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introduction there is a prevailing view that women are less tolerant of shift work than men ie female shift workers tend to report greater effects of shift work on sleep fatigue accident risk and health although the evidence is mixed 1 a commonly discussed source of genderspecific effects of shift work is gender roles 2 women in employment commonly experience a double burden of having to cope with the demands of their job while at the same time undertaking more work at home particularly if they have children or other adults to care for 3 4 5 for example female shift workers may be more likely than their male counterparts to forgo recovery opportunities to undertake childcare activities clissold et al 6 reported that female nurses felt unable to use their later starting afternoon shifts as an opportunity to repay the sleep debt incurred in the night shift opting instead to use their free time to engage in domestic chores and childcare one of the few studies to compare males and female shift workers doing the same job found that females up to 50 years of age had shorter sleeps were drowsier on shift more chronically fatigued and reported poorer health compared to their male colleagues 7 however the gender difference was reversed after the age of 50 which may reflect the lessening of the females double burden as their children grew up and eventually left home 2 shift work affects workers health wellbeing and safety through three pathways disturbance of circadian rhythms and the body clock shortened and disturbed sleep and disturbed family and social life 8 these pathways are moderated by individual differences and situational factors the current study examines whether gender and the presence of children at home moderate the second and third of those pathways ie whether the combination of being a shift worker and having young children at home affects the sleep fatigue and workfamily conflict experienced by women more than it affects men methods data were drawn from the swedish longitudinal occupational survey of health slosh is an open cohort survey of an approximately nationally representative sample of the working population followups have been conducted every second year since 2006 all labour market sectors and occupations are represented and the number of men and women is approximately equal baseline data and followup data were drawn from five waves of slosh additional data concerning previous exposure to shift work were obtained from the 2008 wave participants were classified as being either dayworkers shift workers who did not work nights or shift workers who did work nights see below for work schedule category definitions the process of categorizing participants with respect to their work schedule is illustrated in figure 1 if a participant reported in any of the five waves 201018 working something other than either daywork shift work with nights or shift work without nights their responses for that wave were excluded from the analyses we then identified all participants who indicated being shift workers in any of the five waves 201018 when all shift workers in the dataset had been identified the sample of dayworkers was drawn from the remainder who had not been categorized as a shift worker at any time we sought to limit selection effects 9 by excluding responses of dayworkers with prior or subsequent exposure to shift work this was to ensure that the shift workers were not being compared with dayworkers whose health may have been affected by prior exposure to or a subsequent transfer to shift work hence two additional exclusion criteria were applied to respondents classified as dayworkers participants classified as dayworkers were excluded if they had either indicated in response to a question in the 2008 survey that they had previously worked night shifts for a year or more or if they had not answered the question or reported working any schedule other than daywork in any of the six waves 200818 the final sample after exclusions was n 8938 baseline data were based on responses from the first survey in which the respondent indicated being a dayworkershift worker while their outcome data were based on their responses at baseline and in the subsequent two waves ethical approvals for slosh and the current study were obtained from the regional research ethics board in stockholm work schedule was ascertained by asking respondents about their normal working hours response options were daywork evening work nightwork key learning points what is already known about this subject • shift work has negative effects on workers sleep and consequent fatigue due in large part to the disruption of circadian rhythms it can also increase workfamily conflict as a result of the need to work unsocial hours • some studies have found that shift work impacts womens sleep fatigue and certain other aspects of their wellbeing more negatively than it does men • women tend to undertake more unpaid domestic work at home including childcare and this increased burden has been proposed as a reason for them suffering more problems with shift working what this study adds • while shift work negatively impacts sleep fatigue and workfamily conflict there is no evidence from the current findings that childcare exacerbates those effects either for women or for men • the current study did not show that women were more negatively affected by shift work than men with respect to sleep fatigue or experience of workfamily conflict what impact this may have on practice or policy • shift working parents of young children may not be at greater risk of impaired sleep greater consequent fatigue or workfamily conflict than their nonshift working counterparts • the findings should be interpreted in the context of the data having been obtained in sweden a country with high levels of gender equality and state subsidized childcare provision gender was obtained from registers linked to questionnaire responses by means of the unique swedish 10digit personal identification numbers presence of children under 13 years at home was determined from a series of items asking about the number and ages of any children at home from which participants were categorized as having either at least one child at home under 13 years or as none age was also obtained from registers educational level was determined from registers indicating the respondents highest level of education attained categorized as 3 years of higher education or ≥3 years of higher education employment status was selfreported with participants categorized as working either fulltime or parttime sleep disturbance mental fatigue and sleep insufficiency were measured with items from the karolinska sleep questionnaire which assesses sleep problems experienced in the last 3 months 1011 sleep disturbance was calculated as the mean of four items assessing the frequencies of difficulty falling asleep disturbed sleep premature awakening and repeated awakenings while a fifth item measured the frequency of experiencing mental fatigue sleep insufficiency was based on a single item asking whether the respondent felt that they got enough sleep workfamily conflict was calculated as the mean of four items assessing the frequency with which work negatively affects life at home adapted from fisher et al 12 mixed linear regression models with random intercepts examined the combined effects of work schedule gender and childcare status on sleep insufficiency sleep disturbance fatigue and workfamily conflict across up to three measurement occasions in each analysis an initial model was implemented with three betweensubject predictors and one withinsubject predictor a second model additionally included a set of interaction terms that were relevant for the purposes of the current enquiry lastly a full model was implemented that additionally included the four covariates interactions were explored with pairwise comparisons using sidak adjustment for multiple comparisons mixed model analysis has the advantage of being flexible in handling missing data in longitudinal studies and is superior to imputation methods 13 results descriptive statistics for the final sample by schedule are presented in table 1 the main findings are summarized below and a full account is presented in supplementary material table 2 presents the results from the third models that included interaction terms and covariates in the analysis of sleep insufficiency greater sleep insufficiency was predicted by shift work without nights 00410125 t 390 p 0001 shift work with nights 349 p 0001 presence of young children at home 1126 p 0001 and female gender 432 p 0001 in the second and third models there were no significant interactions involving the combination of schedule gender and childcare status in the analysis of sleep disturbance greater sleep disturbance was predicted by shift work without nights 437 p 0001 shift work with nights 344 p 001 absence of young children at home 481 p 0001 and female gender 1221 p 0001 in the second model there was a significant threeway interaction between schedule gender and childcare status 584 p 001 see figure 2 among respondents without young children females in all schedule groups reported more sleep disturbance than their male counterparts whereas among respondents with young children at home there was only a significant gender difference for dayworkers the same interaction was observed in the third model in the analysis of fatigue greater fatigue was predicted by shift work without nights 403 p 0001 presence of young children at home 558 p 0001 and female gender 1530 p 0001 in the second and third models there were no significant interactions involving the combination of schedule gender and childcare status in the analysis of workfamily conflict greater workfamily was predicted by shift work without nights 724 p 0001 shift work with nights 516 p 0001 presence of young children at home 441 p 0001 and female gender 978 p 0001 in the second model there was a threeway interaction between schedule gender and childcare status 348 p 005 see figure 3 among respondents without young children females in all schedule groups reported more workfamily interference than their male counterparts whereas among respondents with young children at home there was only a significant gender difference red horizontal lines represent pairwise comparisons between subgroups withand without young children at home blue horizontal lines represent male and female subgroups solid horizontal lines represent significant differences dashed horizontal lines represent significant differences for those working shifts without nights the same interaction was observed in the third model discussion shift working was associated with shorter and more disturbed sleep greater fatigue and greater workfamily conflict in accordance with the model of barton et al 8 however the results provided no support for the contention that having young children exacerbates these effects of shift work either in men or in women females were more likely than males to report insufficient sleep disturbed sleep fatigue and workfamily conflict however there was little indication that females were more negatively affected by shift work than males irrespective of childcare status while this is inconsistent with the prevailing view of women being less tolerant of shift work 1 it is consistent with previous findings of limited genderspecific effects of shift work on health found in slosh 1415 moreover recent evidence from metaanalyses suggest that genderspecific effects of shift work may not be as pervasive as previously suggested at least with respect to sleep 1617 cardiovascular disease 18 and cancer 19 similarly a recent largescale study found no genderspecific effects of shift work on accident risk 20 however other recent metaanalyses have shown that the links between shift work and metabolic disorders 2122 and between shift work and mental illheath 23 are stronger in women than in men there was little or no indication of an accumulation of negative effects across successive measurement occasions this is perhaps unsurprising as the anticipated effects were likely to be relatively acute while the presence of children in combination with a demanding schedule could be expected to affect sleep and workfamily conflict there is little reason to anticipate these problems getting worse with prolonged exposure indeed the opposite could be argued on the assumption that the effects might diminish as children get older and become more independent a sensitivity analysis found that changing the cutoff age for the definition of young children from 13 years to 6 years made no substantive difference to the patterns of results obtained the strengths of the current study include a prospective design based on multiple repeated measures that consider the timevarying nature of the studied effects the analytic approach accounts for missing values making it possible to draw upon a large heterogeneous and broadly representative sample of the working population in sweden the current analysis sought to limit selection effects by excluding from the day working sample any respondents with a history of working night shifts this was to ensure that shift workers were not being compared with dayworkers whose health may have been impaired due to previous exposure to nightwork as a result of which they may have transferred into daywork 9 however selection effects cannot be completely ruled out it was only possible to exclude dayworkers reporting prior exposure to nightwork in 2008 but not those who worked shifts that did not include nightwork it could be suggested that the failure to find the expected pattern of results reflect insensitivity of the outcome measures particularly as two of the four were based on singleitem measures however counter to that suggestion it is notable that all four outcome measures did show negative effects of shift work but that these effects were not exacerbated by either gender childcare status or a combination of the two nevertheless the majority of measures were selfreport which introduces the possibility of reporting bias or recall error as well as bias due to commonmethod variance 24 the measure of shift work exposure was crude with no possibility to account for variations in schedules such as the sequence of shifts intensity of nightwork etc it is possible that female shift workers who primarily work in healthcare settings where selfscheduling is common had more possibilities than male shift workers to adapt their schedules to having young children eg by limiting nightwork the measure of workfamily interference does not focus specifically on children which limits its sensitivity in the current context the measure of parttime working lacked a definition in terms of weekly work hours which may limit its sensitivity given that parttime working in sweden can involve working as much as 35 hours per week while the analysis excluded dayworkers who subsequently changed to shift work during followup it remains a possibility that some shift workers may have transferred out of shift work during followup which could have reduced the apparent effect of shift work female and male shift workers tend to work in different occupational sectors and so it is often argued that gender comparisons of the effects of shift work are confounded by occupation the current study did not adjust for occupation as we have found that in the slosh sample at least differences in the occupational characteristics of female and male dominated occupations do not account for gender differences in associations between shift work and sleep disturbance or health 15 it could be argued that with such a relatively large sample the statistical power of the current study design may have contributed to the finding of effects that though relatively small were statistically significant it is notable however that the observed significant main effects were in accordance with previous findings of associations between shift work and sleepfatigue 25 between shift work and workfamily conflict 26 between gender and sleepfatigue 27 and between gender and workfamily conflict 34 the current findings offer no basis for treating women and men differently with respect to work scheduling or the provision of support for those working nonstandard hours however while we failed to observe the predicted pattern of interaction between schedule gender and childcare status it should be noted that these data were collected in sweden where there is universal subsidized childcare for children from a very early age which may serve to mitigate the double burden of demanding work hours and childcare responsibilities moreover sweden has high levels of gender equality which may mean that the added burden of childcare is relatively evenly distributed between the sexes such that neither experiences excessive disruption of sleep and family life thus caution is advised when attempting to extrapolate from these findings to other countries with different sociopolitical contexts an alternative explanation for the absence of predicted interactions is that the women in this study did experience greater strain as result of a higher double burden compared to the men but that they were able to adopt effective strategies to cope with or compensate for it 28 in conclusion shift work female gender and presence of young children at home were all associated with negative effects on sleep fatigue and workfamily conflict however contrary to expectations neither female gender nor presence of young children exacerbated the effects of shift work it remains to be seen whether these three factors act synergistically upon other more chronic aspects of health competing interests none declared

background shift work may impact women more negatively than men due to the increased burden of coping with demanding work schedules while also undertaking more of the domestic chores including childcareto examine whether the combination of shift working and caring for children affects the sleep fatigue and workfamily conflict experienced by women more than it affects menusing data from a survey of the swedish working population mixed linear regression models examined work schedule daywork shift work with nights shift work without nights gender and presence of children 13 years at home as predictors of sleep insufficiency sleep disturbance fatigue and workfamily conflict over up to three successive measurement occasions adjustments were made for age education fullparttime working and baseline yearin fully adjusted models n 8938 shift work was associated with insufficient sleep p 001 disturbed sleep p 001 fatigue p 005 and workfamily conflict p 0001 interactions in the analyses of sleep disturbance p 0001 and workfamily interference p 005 indicated that among participants with no children females reported more disturbed sleep and more workfamily conflict than their male counterparts irrespective of schedule while among participants with children female dayworkers reported more disturbed sleep than their male counterparts and females working shifts without nights reported more workfamily interference conclusions having young children did not exacerbate negative effects of shift work in either men or women this may reflect high levels of gender equality and childcare provision in sweden

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introduction a greenway is a unique linear green open space with ecological value transportation value and historical and cultural preservation value the crossconnection of greenways to form a staggered and integrated green network is of great significance to improve the relationship between people and nature safeguard the ecological environment and improve quality of life 12 greenways serve a variety of purposes including those related to the environment tourism history culture economic value and so forth the cultural role of greenways has also drawn more attention from academics in recent years 3 regional culture encompasses both material culture and spiritual culture in a broad sense it is made up of all the material and spiritual accomplishments that a community has made via physical and mental work over the course of longterm historical development which have been steadily gathered developed and sublimated 4 regional culture which also refers to local peoples behavior and mind patterns is spatially bound there are distinctions in regional culture because of the various geographical environments which also affect peoples behavior patterns and ways of thinking 5 a greenway can be used to convey regional culture reflecting the distinctive elements of regional culture in the design of the greenways landscape which can gather information about local historical occurrences folklore and other aspects turning the abstract information into concrete design elements and enhancing the excursion 3 diverse research on the cultural manifestation of greenways have been conducted by academics sharma 6 suggested a method to make the design syntax or materials of greenway design culturally diverse in order to create landscape variability and unique local 2 of 15 characteristics in greenways keith 7 proposed to increase the diversity of place landscape and slow walking facilities along greenways to increase social interaction opportunities and cultural benefits in order to generate collective memory and increase public engagement and vibrancy some experts also suggested scheduling some cultural festivities and other activities in the public space of greenways or other unused public buildings 8 many greenways landscape designs place a high value on the expression of details in terms of practical investigation utilizing local resources to the fullest extent slowmoving infrastructure designs such as benches railings ground paving signage and interpretive signs also incorporate regional cultural traits into the design of landscape nodes to ensure consistency in the cultural expression of greenways 8 9 10 11 12 the satisfaction level of tourists with the cultural expression of the greenway reflects the quality of the regional culture construction of the greenway and the satisfaction influence factor reflects the perception and experience of tourists with the greenway therefore the investigation of tourists satisfaction and the influencing factors is of positive significance to improve tourists visiting experiences increase regional cultural awareness and enhance the social influence of the greenway regarding cultural perception altunel mc et al 13 argued that tour quality and satisfaction in cultural tourism affect tourists engagement and promotion intention liu tao 14 used a structural equation model to investigate tourists perceived quality of red cultural landscape and came to the conclusion that the perceived quality and overall image of red cultural landscape affects tourists satisfaction and willingness to revisit hultman et al conducted an empirical study on the interrelationship between destination attributes and tourist satisfaction and tourist destination perceptions 15 wu t e et al conducted a tourist satisfaction study on theme product and design as the three major factors affecting the attractiveness of salt heritage tourism on the southwest coast of taiwan 16 ramseookmunhurrun p et al used tourists to mauritius as a research sample to verify the island destinations as influencing factors of tourist satisfaction and loyalty 17 chen c et al studied the interrelationship between tourist satisfaction and tourism place resources attractiveness and competitiveness in kinmen island taiwan province china 18 while most of the relevant studies focus on parks and scenic areas this paper explores the interrelationship between tourists experiences of cultural expressions of greenway landscape construction and satisfaction and loyalty with a view to improving the quality of tourists experiences and providing reference for the promotion and construction of pingtans regional culture there is limited research on the cultural expression of coastal greenways among studies on the cultural functions of various types of greenways by utilizing their unique natural terrain islands may fully realize their tourism potential through the building of greenways islands are cut off from the mainland therefore their cultural traits exhibit both strong ties to the mainland and unique qualities 19 the zigzag coastline 20 which is a part of the urban open space has a greenway created along it the coastal greenway should be built with urban culture mountain and sea qualities in mind and it should make effective use of these features spatial characteristics to promote and influence local culture 21 the creation of the coastal greenway provides a wonderful opportunity to showcase and pass along the intangible and folk cultures of the region the islands historical culture can be protected and improved through the mix of tourism and exchanges 22 in order to make recommendations for the growth of the regional cultural tourism industry this study uses the northern pingtan greenway as the research object it explores how tourists perceive and are satisfied with the cultural landscape construction of the coastal greenway by building a structural equation model materials and methods study area pingtan is situated in fujian provinces eastern sea at 119 • 32 120 • 10 e and 25 • 15 45 25 • 25 45 n the entire region is the largest island in the fujian province and the fifth largest island in china with a land area of 371 km 2 and a sea area of 6064 km 2 by the end of 2013 the total number of households in the area was 11831 with a total population of 418391 23 the people of pingtan migrated from the motherland and have been under the jurisdiction of fuqing and fuzhou since the tang dynasty therefore the living habits of pingtan people such as clothing food housing transportation and festival customs are very similar to those of fuzhou but some of the ancestors from eastern fujian central fujian and southern fujian still retain some of their ancestral customs while integrating into the regional culture of fuzhou 23 the unique marine geography and climate environment also created many pingtan folk customs with strong island flavor 23 in 2015 pingtan was awarded the title of fujian provincial geopark pingtan geopark is a comprehensive island geopark with rich typical sea erosion landforms sea accumulation landforms and prominent sea erosion relics supplemented by granite landforms and volcanic landforms and is a comprehensive island geopark with both marine cultural relics and humanistic landscapes such as stone alley communities in recent years the government of fujian province has proposed to actively explore crossstrait regional cooperation establish a regional platform for closer crossstrait cooperation and exchange set up the pingtan comprehensive pilot zone and strive to build pingtan into a demonstration area for exploring new modes of crossstrait cooperation 23 as the external gateway of pingtan island the construction of the pingtan northern greenway is conducive to building an internationally competitive tourist destination in pingtan compared with other domestic islands the policy support for the construction of pingtan island is stronger and its regional culture is simpler and more distinctive which is more attractive to domestic and foreign tourists an essential link in the creation of pingtan international tourism island is the northern pingtan greenway which is situated in pingtan fujian province the three national openness and development strategies of 21st century maritime silk road free trade zone and the development of marine economy to establish a strong marine state may all be implemented in pingtan thanks to its construction the project is designed to turn the island of pingtan into a livable and visitable worldwide tourism destination by utilizing the benefits of nearby tourism resources such island scenery beaches bays and sand views sea erosion landforms and fujiantaiwan culture the cultural resources in this region are abundant and they include archeological sites wharf culture the history of the spread of christianity the culture of seaside fishing etc the cultural and historical values are exceptional according to the estimation the total length of the planned greenway in the long term is about 375 km the total area of the greenway is 1123695 m 2 the per capita land index is 10 m 2 person the instantaneous capacity is 11236 people the average passenger turnover rate is 22 and the passengers are expected to be about 25000 per day 23 however as development has progressed it has more served as a means of transportation and the manifestation of ancient culture is still absent relevant studies show that tourists can relax and cultivate themselves by understanding and feeling the regional culture in the process of visiting tourist places so tourists pay more attention to the construction of regional culture in tourist places an urgent issue that needs to be resolved in this study is how to better promote area culture and incorporate regional cultural components into the greenway landscape design structural equation modeling influence factors in order to examine how visitors perceive cultural expressions in the landscape design of the northern pingtan greenway this study analyzes red cultural landscapes using liu tao′s conceptual paradigm of perceived qualityperceived valuesatisfactionloyalty 14 tourists from various cultural backgrounds have different perceptions of the landscape 24 and cultural landscape perception is the process of sensory experience and cognition of environmental material elements based on people′s own cultural literacy and way of thinking when they are in a specific cultural atmosphere 25 perceived quality cognitive image and perceived value are the three key factors this study focuses on from a landscape gardening perspective visitor satisfaction is influenced by the visitor′s perception of multiple dimensions and these factors interact with one another additionally the perceived dimensions have a direct or indirect impact on the gardening components 26 which are the tangible items through which visitors can most readily experience the local culture the quality of the landscape and the quality of cultural services are determined to be the two main influencing factors of tourists′ perceptions of the site′s quality in this study along with the site′s unique circumstances the quality of the landscape primarily comprises two elements slow walking facilities and cultural perception of landscape points the perceived worth is primarily demonstrated by the sense of relaxation and enjoyment that visitors to the island′s natural and cultural setting experience according to kyoungshin et al 27 visitors′ perceptions of the healing feelings associated with cultural heritage tourism sites have an impact on their satisfaction and propensity to return and the sites′ vibrant cultural milieu soothes visitors′ bodies and minds the tourists′ assessment of the island′s historical and cultural development is mirrored in the cognitive image according to studies visitors who are openminded and in awe of the surrounding natural and cultural environment will form an impression of the tourism destination 14 numerous tourists are drawn to the island for travel vacations relaxation and stress relief because of its distinctive regional culture and stunning natural surroundings the experience of traveling is influenced by how people perceive the local culture loyalty affects a visitor′s inclination to return and promote a destination to others whereas satisfaction is the perception and appraisal of the consequences of the difference structural equation modeling influence factors in order to examine how visitors perceive cultural expressions in the landscape design of the northern pingtan greenway this study analyzes red cultural landscapes using liu taos conceptual paradigm of perceived qualityperceived valuesatisfactionloyalty 14 tourists from various cultural backgrounds have different perceptions of the landscape 24 and cultural landscape perception is the process of sensory experience and cognition of environmental material elements based on peoples own cultural literacy and way of thinking when they are in a specific cultural atmosphere 25 perceived quality cognitive image and perceived value are the three key factors this study focuses on from a landscape gardening perspective visitor satisfaction is influenced by the visitors perception of multiple dimensions and these factors interact with one another additionally the perceived dimensions have a direct or indirect impact on the gardening components 26 which are the tangible items through which visitors can most readily experience the local culture the quality of the landscape and the quality of cultural services are determined to be the two main influencing factors of tourists perceptions of the sites quality in this study along with the sites unique circumstances the quality of the landscape primarily comprises two elements slow walking facilities and cultural perception of landscape points the perceived worth is primarily demonstrated by the sense of relaxation and enjoyment that visitors to the islands natural and cultural setting experience according to kyoungshin et al 27 visitors perceptions of the healing feelings associated with cultural heritage tourism sites have an impact on their satisfaction and propensity to return and the sites vibrant cultural milieu soothes visitors bodies and minds the tourists assessment of the islands historical and cultural development is mirrored in the cognitive image according to studies visitors who are openminded and in awe of the surrounding natural and cultural environment will form an impression of the tourism destination 14 numerous tourists are drawn to the island for travel vacations relaxation and stress relief because of its distinctive regional culture and stunning natural surroundings the experience of traveling is influenced by how people perceive the local culture loyalty affects a visitors inclination to return and promote a destination to others whereas satisfaction is the perception and appraisal of the consequences of the difference between the visitors expectations prior to the visit and the experience afterwards 2829 tourists propensity to return and recommend visited locations can increase their attractiveness and highlight local traits the landscape design of the tourist destination and the tourists spiritual satisfaction are both considered in this studys evaluation of satisfaction cultural experience satisfaction model a multivariate statistical model called a structural equation model may deal with complex interactions between many variables and provide solutions for variables that are difficult to directly observe the model which has been extensively employed in the social sciences and other sectors 30 permits both the independent and dependent variables to contain measurement errors in comparison to conventional statistical methods the goal of this study is to better understand how tourists perceptions of the perceived value perceived quality and cognitive images of the coastal greenways landscape relate to their satisfaction and loyalty creating the five sets of hypotheses listed below then use the structural equation model to verify their validity tourists′ propensity to return and recommend visited locations can increase their attractiveness and highlight local traits the landscape design of the tourist destination and the tourists′ spiritual satisfaction are both considered in this study′s evaluation of satisfaction cultural experience satisfaction model a multivariate statistical model called a structural equation model may deal with complex interactions between many variables and provide solutions for variables that are difficult to directly observe the model which has been extensively employed in the social sciences and other sectors 30 permits both the independent and dependent variables to contain measurement errors in comparison to conventional statistical methods the goal of this study is to better understand how tourists′ perceptions of the perceived value perceived quality and cognitive images of the coastal greenways′ landscape relate to their satisfaction and loyalty creating the five sets of hypotheses listed below then use the structural equation model to verify their validity figure 2 questionnaire design before distributing the questionnaire the researchers conducted a field trip to the northern pingtan greenway to obtain a preliminary understanding of the design of the landscape on the greenway and also talked deeply with the tourists to understand their visiting preferences mainly including 6 aspects whether you pay attention to the cultural expression of the landscape design on the greenway whether you pay attention to the cultural experience of visiting on the greenway whether you think the cultural experience of visiting on the greenway how much do you know about the traditional culture of pingtan island and whether the cultural expression of the greenway landscape construction helps you understand the history and culture of pingtan island compared with the natural scenery of the island do you think that the inculcation of regional culture helps to relax to a large extent compared with other islands do you think the history and culture of pingtan island are simpler and have a greater sense of history the preliminary research results show that most of the visitors are very concerned about the cultural expression of the landscape construction of the northern pingtan greenway and the history and culture of pingtan island and they show great interest in it based on the results of the preliminary research this questionnaire was designed two sections make up the questionnaire study in the first section which examines the h5 satisfaction is positively correlated with loyalty questionnaire design before distributing the questionnaire the researchers conducted a field trip to the northern pingtan greenway to obtain a preliminary understanding of the design of the landscape on the greenway and also talked deeply with the tourists to understand their visiting preferences mainly including 6 aspects whether you pay attention to the cultural expression of the landscape design on the greenway whether you pay attention to the cultural experience of visiting on the greenway whether you think the cultural experience of visiting on the greenway how much do you know about the traditional culture of pingtan island and whether the cultural expression of the greenway landscape construction helps you understand the history and culture of pingtan island compared with the natural scenery of the island do you think that the inculcation of regional culture helps to relax to a large extent compared with other islands do you think the history and culture of pingtan island are simpler and have a greater sense of history the preliminary research results show that most of the visitors are very concerned about the cultural expression of the landscape construction of the northern pingtan greenway and the history and culture of pingtan island and they show great interest in it based on the results of the preliminary research this questionnaire was designed two sections make up the questionnaire study in the first section which examines the demographics of tourists we learn about their fundamental features such as gender age level of education and country of origin the second part is the satisfaction evaluation factors of the northern pingtan greenways cultural expression which includes 26 measurement items and covers 7 major areas including the perception of slow walking facilities the greenways landscape regional cultural services perceived value and satisfaction and loyalty the five point likert scale is used in the research scale distribution of viewpoints 69 regional characteristics of ancient villages 33 viewpoint geographical appreciation perspective 34 view the regional cultural atmosphere of the site 69 native plant landscape creation 35 cultural service quality greenway cultural activities enrichment 83637 types of transportation to reach various cultural attractions on the greenway 38 distribution of food and beverage on the greenway 39 questionnaire survey the questionnaire survey was conducted in a combination of online and offline methods the offline survey was selected for june and july 2022 mainly during the peak tourism period of pingtan island from 300 pm to 700 pm the number of tourists was high during this period and the new crown epidemic was effectively controlled during this period so the questionnaires were distributed more efficiently there were five researchers all of whom had engaged in social surveys related to greenway planning and were more experienced in interviewing tourists both survey methods took the form of questionnaire interviews before filling out the questionnaires information on four aspects of the visitors gender age education and place of origin is known which mainly takes into account that different groups have different comprehensions of regional culture and the subsequent research results also show this offline survey five people randomly distributed questionnaires to tourists at various spots on the greenway before conducting the survey the consent of tourists was firstly obtained to understand the degree of tourists knowledge about the history and culture of pingtan island to ask tourists interest in the history and culture of pingtan to focus on this category of people for questionnaire distribution and to provide necessary explanation and clarification of the survey content to ensure the respondents understanding of the purpose of this survey and the questionnaire content a total of 329 questionnaires were distributed offline and 308 valid questionnaires were collected after eliminating the invalid questionnaires that were filled out repeatedly to ensure effective online questionnaire distribution visitors were also asked about their use of wechat during the offline research process the results showed that the interviewees all used wechat as their main communication software which facilitated online research online survey an online survey through questionnaire star was used and wechats two platforms were used to issue the questionnaires wechat is a free application that provides instant messaging services for smart terminals supporting the rapid delivery of free voice messages videos pictures and texts over the internet across communication carriers and operating system platforms as well as the use of profiles via shared streaming content before issuing the questionnaire we first confirmed whether the survey respondents have visited the destination and have familiarity with the destination to confirm this point in the questionnaires photos and videos were used to help respondents recall the study site overview and explain the meaning of the relevant factors of the questionnaire one by one a total of 123 copies were distributed online there were some tourists that could not recall the status of the relevant attractions so this part of the questionnaire was excluded and 109 valid questionnaires were collected a total of 452 questionnaires were distributed in both ways and 417 valid questionnaires were returned for an effective rate of 9226 the sample size was in accordance with the required sample size in the structural equation modeling study spss 190 and amos 240 were used for data processing and conceptual model validation analysis the study followed the basic procedures and principles of scale development in designing the questionnaire construct validity was mainly expressed as convergent validity and discriminant validity the cronbachs coefficient of the questionnaire was greater than 07 indicating good stability of the measure the sem was evaluated based on theoretical perspectives and quality criteria the maximum likelihood method was used to estimate the parameters of the structural model results demographic characteristics the questionnaire survey results in the northern pingtan greenway show that the respondents were mainly concentrated in the age range of 18 and 40 years and the education of people with a bachelors degree or above was dominant there were more visitors who were local residents and relatively few foreign visitors and there were more visitors who were male than female using an independent sample ttest in spss 190 the impact of gender on the accuracy of cultural perception was examined the quality of cultural perception is significantly influenced by gender as shown in table 3 and women have a significantly higher level of cultural perception than men age factor the results of the oneway anova test for the impact of age on cultural perception quality revealed a statistically significant impact of age on the variability of cultural perception quality tourists under the age of 18 years and those over the age of 40 years have significantly different cultural perceptions from those groups of travelers and those between the ages of 18 years and 40 years and those over 40 years have significantly different cultural perceptions as well the group of travelers between the ages of 18 years and 40 years has the strongest perception of regional culture the visitors over 40 years had the worst perception while the visitors under 18 years had the secondbest perception education factor the findings of the oneway anova test for the influence of different educational backgrounds on the quality of cultural perceptions reveal that there is a substantial difference in how tourists with only a high school diploma and those with a bachelors degree or above perceive the local culture the perspective of local culture is stronger the more education one has measurement model analysis reliability and validity analysis using spss 190 the results of the 417 questionnaires that were gathered were examined for consistency and reliability the findings demonstrated that the questionnaires reliability was high with the overall scales cronbachs coefficient of 0989 and the cronbachs coefficient being less than 0989 after removing any question item the findings of bartletts sphericity test and kmo value analysis on the survey data indicated that the scales kmo sampling appropriateness was 0984 bartletts sphericity test and kmo analysis results revealed that the sample data were appropriate for exploratory factor analysis because the kmo sampling suitability quantity was 0984 the bartletts sphericity tests approximate chisquare distribution was 15977054 and the significance probability value of p 0000 0001 reached a significant level the validation factor analysis of the fictitious model using amos 240 revealed that the standard factor loadings of each item ranged from 0742 to 0944 the construct reliability and average variance extraction tests were used to detect the convergent validity of the test variables all of which were greater than 0500 the average variance extracted was greater than the standard value of 0500 indicating that each observed variable could explain the corresponding latent variable more effectively and the combined reliability was greater than 0800 the fact that all three sets of data satisfy the minimal standard criterion suggests that the questionnaire is very reliable structural equation model goodnessoffit analysis using the great likelihood method for parameter estimation through amos 240 software the structural model was examined for its structural relationships table 6 displays the comparison between the calculated results and the standard fitting coefficient values the measurement model has a good fit degree as evidenced by the measurement models root mean square error of approximation of 0069 goodness of fit index of 0862 normative fit index of 0947 and the other indicators all falling within the range of the fitting criteria further evidence that the model has strong discriminant validity comes from the fact that the root values of each latent variable in the judgment matrix are higher than the correlation coefficients between the latent variables and other latent variables path hypothesis testing the results of the path hypothesis test were obtained in this study using the significance level of p 0050 as the test standard to test and analyze the hypothesis path the outcomes demonstrated that the five path coefficients were all less than 005 supporting the validity of the path hypothesis figure 3 displayed the final hypothesis model discussion perceived quality perceived value and cognitive image the standardized path coefficient from perceived quality to cognitive image is 098 as seen in the final model diagram the greenway landscape the cultural design of the facilities and the regional cultural services all have a direct impact on how tourists perceive and comprehend the local culture rising by 098 units for every unit increase in perceived quality while the standardized path coefficient from perceived quality to perceived value is 036 and the standardized path coefficient from cognitive image to perceived value is 065 respectively this suggests that the perceived value of regional culture or the restorative experience of regional culture obtained by tourists is more difficult to the standardized path coefficient from perceived quality to cognitive image is 098 as seen in the final model diagram the greenway landscape the cultural design of the facilities and the regional cultural services all have a direct impact on how tourists perceive and comprehend the local culture rising by 098 units for every unit increase in perceived quality while the standardized path coefficient from perceived quality to perceived value is 036 and the standardized path coefficient from cognitive image to perceived value is 065 respectively this suggests that the perceived value of regional culture or the restorative experience of regional culture obtained by tourists is more difficult to obtain directly through the regional landscape and requires a certain cognitive base of regional culture before the perceived value of regional culture can be attained this outcome is mostly driven by the demographics of visitors many of whom are from outside the area and are not wellversed in the local culture visitors also have varying levels of education age and other cognitive abilities these make it difficult for visitors to understand the value of the local culture directly from the greenway landscape which necessitates accurate interpretation to comprehend the regions historical changes and to recognize the restoration of physical and mental health during the perception of history according to kaplan 43 research findings also demonstrate that the constructed environment has restorative qualities similar to those of the natural environment pingtan is very reminiscent of a restorative environment which influences travelers experiences while they are there this is due to its extensive history and rich culture as well as the beautiful island scenery perceived value satisfaction and loyalty from perceived value to satisfaction the standardized path coefficient is 098 according to research satisfaction rises by 098 units for every unit increase in perceived value demonstrating a relationship between the pleasure and physical and mental relaxation that may be attained through cultural tourism and satisfaction with the tourist destination the standardized path coefficient from satisfaction to loyalty is 096 meaning that for every unit increase in satisfaction loyalty increases by 096 units indicating that a persons level of satisfaction with a particular aspect of the culture of a coastal greenway influences their propensity to return and recommend the studys findings concur with those of wu jing 44 and gu yaqing 45 in that loyalty is largely influenced by satisfaction which in turn is largely influenced by perceived value the perceived importance of the island greenways cultural expression among visitors also strengthens their bonds with the tourist location resulting in greater destination loyalty conclusions this study investigates how tourists cultural perceptions of the northern pingtan greenway are now holding up and comes to the following conclusions tourists of different genders ages and educational levels have very different perspectives on the culture of the coastal greenway in general women have a stronger perception of regional culture than men those between the ages of 18 and 40 have a stronger perception of regional culture the elderly and children are less likely to feel the regional culture the higher the education the wider the experience the stronger the perception of culture and the older the tourist the less likely they are to feel the regional culture tourists cognitive image and perceived value are favorably impacted by how well they perceive the island culture on the perceived quality the three factors barely differ the architecture of the coastal greenways slowwalking facilities vistas and cultural service conditions thoroughly reflects the regional culture of the area tourists perceptions of the local culture are somewhat influenced by the designs excellence which both directly and indirectly influences perceived value tourists assessed the value of the coastal greenway as a cultural manifestation is strongly correlated with contentment tourists contentment with the coastal greenways cultural expression has a favorable impact on their loyalty the protection and promotion of the islands natural and cultural landscape should be highlighted by the coastal greenway a type of recreational linear open space on the basis of fulfilling the general greenways role as a green infrastructure function the following recommendations for greenway development are made in light of the studys examination of tourists opinions of cultural manifestations in coastal greenway landscape design make the landscape nodes of coastal greenways more diverse in terms of their cultural themes choose to place landscape nodes at the best vantage point for ornamental and distant views so that tourists can appreciate the stunning natural scenery of the island appropriately add artificial facilities the material color shape and other design elements fully integrating into the regional culture presenting different regional theme characteristics enrich the public space of the landscape by including a range of basic service facilities along the greenway such as food and beverage distribution cultural exhibitions entertainment bars etc additionally introduce social and cultural activities to foster communication between people by increasing the opportunities for social interaction and the benefits of culture on the other hand the islands ecological environment needs to be protected so that the ecological and cultural functions of the greenway can be more clearly demonstrated the topography and native vegetation of the site should not be altered during the planning and design of attractions enhance the greenway landscape designs science education and interpretation framework the previous study demonstrates that tourists perceptions of the cultural expression of the landscape are influenced by age gender educational attainment and other sociocultural factors and that there are differences in how various groups view regional culture regional characteristics can be promoted through voice broadcasting staff interpretation video interpretation and other means virtual reality technology can also be used to create digital interactive experiences virtual scenes and other means to further tourists historical and cultural knowledge enhancing their understanding of the regions history and culture without requiring indepth cultural knowledge make cycling a part of the coastal regional culture traits many visitors come to the island for sightseeing because of its stunning natural surroundings utilize the creation of the greenway to build a cycling segment with a cultural theme using coastal features such as sea silk culture fishing folklore island village landscape and other elements while it is advisable to choose lots with undulating terrain that can easily lead to cycling risks and to concentrate on the construction of pedestrian and vehicular paths it is not advisable to place shared bicycles electric bikes and other cycling transportation and parking spots to provide convenient cycling conditions increase the greenways usage rate while lowering risk and meeting a variety of access demands this enables visitors to take in the local natural beauty and appreciate the local culture giving them both physical and mental fulfillment reasonable modification of the ratio of commercial inventive and spaces for cultural experiences the coastal greenways construction intends to give visitors somewhere to unwind and a little amount of commercial activity can meet some of their recreational needs however it should not go overboard it should primarily construct private leisure and cultural experience spaces in the greenway experience to feel the islands natural landscape experience the islands historical and cultural changes and escape the hustle and bustle of urban life data availability statement the project has not yet been completed and the research data are not yet available

the islandtype greenway should emphasize the role of maintaining and promoting the island cultural landscape as it serves the function of a general greenway green infrastructure while also having a unique landscape appearance the northern greenway of pingtan is used as an example in the paper to illustrate how regional culture is perceived the first part of the analysis looks at how demographic factors affect the quality of cultural perception the study reveals that from a gender perspective women are more likely than men to perceive regional culture from an age perspective people between the ages of 18 and 40 are more likely to perceive regional culture older people and children are less likely to perceive regional culture and from a level of education perspective the higher the education the stronger the perception the relationship between tourists perceived quality cognitive image perceived value satisfaction and loyalty to the cultural expression of the greenway landscape is then analyzed by building a structural equation model according to the findings visitors perceptions of the islands cultural quality have a positive impact on their cognitive images and perceptions of value while their satisfaction with the cultural expressions along the coastal greenway has a positive impact on their loyalty

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introduction the 1948 universal declaration of human rights states that everyone has the right to education education shall be free at least in the elementary and fundamental stages elementary education shall be compulsory technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit a number of further declarations restated the ideas that education is a right and education shall be compulsory enshrining these in international law and reinforcing the international communitys will to make it good in the past few decades this has gained a new impetus through the education for all movement which is officially sponsored by unesco but also supported by a number of development agencies and nongovernmental organizations meetings held in jomtien dakar brasilia beijing cairo and oslo amongst others urged governments to prioritize investment in basic education achieve inclusion and gender parity in education and aim at providing primary elementary schooling by 2015 needless to say these targets were not achieved because of a lack of investment and commitment by parties the problem is compounded by the fact that understanding education as a right implies an interconnection between this right and other rights that is the requirement for there to be a right to education rights in education and rights through education this demonstrates the complexities involved in this issue and the mammoth task faced by educationists 1 further i note that there is a tension between right and compulsory in article 26 of the 1948 declaration and this has been a source of contention for commentators discussing issues such as understanding education as schooling and turning schooling into something compulsory compulsory education and infringement of other rights especially in connection with social segregation indoctrination and class inequalities or perhaps even more telling making elementary education compulsory but not education in general especially adult education or higher education 2 mccowan has noted the tension a right to something is an entitlement and not an obligation but there is a counterfactual aspect to rights in the sense that it is important that one has the right to freedom of religious worship even if one does not actually exercise it at the same time it is argued that human rights are inalienable for example one cannot voluntarily give oneself up into slavery nevertheless even if one cannot voluntarily give up the right to say healthcare one can choose not to exercise that right in a particular moment the reasons why education is an exception to the rule are never explained by mccowan or by other commentators they seem to take it for granted that education is indeed a right perhaps because it is stated in the 1948 universal declaration of human rights and other such documents in this article i wish to turn the problem on its head and take issue with the idea that education should be understood as a right my argument is rather that education should be understood as a duty an obligation that all human beings have towards themselves and their communities in order to do this i will refer to the works of johann gottlieb fichte the german postkantian idealist whose works in education have been long neglected and forgotten however they are of great help to us in trying to make sense of education not as a right but as a duty i will argue that such understanding dissolves the tension present in article 26 between right and compulsory and that perhaps a reframing of our understanding of what education is needs to occur not just at the individual but also at the societal level fichte and education fichte developed his understanding of education in several of his writings in both his early and later philosophical phases 3 however fichtes views on education remain fairly unappreciated by contemporary philosophers of education perhaps because of hegels and schellings assessment of these as being somehow secondary to his purely philosophical writings that said this was not always the case and this is better appreciated if we acknowledge that wilhelm von humboldt whose plans for changes in the german education system were implemented between 1809 and 1910 was very much influenced by fichtes ideas for both fichte and humboldt education is to be democratic in nature and universal and compulsory in application it is the very lifeblood of the state because t he individual is not only an individual he is at the same time a member of a community and as such must be educated to take his place in it otherwise the future of that community is doomed these views would later influence changes in many other countries including the usa and japan despite hegels and schellings assessment i note that fichtes views on education remained intrinsically connected to his wider philosophical project the wissenschaftslehre project the project encompasses some 17 writings reworking some of the most important themes of kantian philosophy dealing with issues connected with the possibility of consciousness the subjectivityobjectivity relationship and the attainment of knowledge these issues are used as a foundation for his wider philosophical views including those on education and political philosophy the connections between these various aspects of fichtes thought will come to the fore as this article unfolds is education a right in the foundations of natural right fichte presents his argument for the emergence of natural rights following on from the tradition of the wissenschaftslehre project the text begins with an account of consciousness leading fichte to argue that the rise of selfconsciousness can only occur through a meeting with external reality which mirrors kants view in critique of pure reason 4 his argument proceeds in three stages and is outlined in very fine detail firstly selfconsciousness requires that a rational entity posits itself as an individual that is different from the rest of reality 5 to use fichtean terminology this means that the i posits a noti secondly fichte comments that when an entity posits itself as rational it necessarily posits itself as a free entity and in doing so it infers that there are other entities like itself in the world in fichtean terms this means that the i perceives other is in the noti as such freedom is established as something shared by all rational entities in reality the third and final stage of fichtes argument is that originally the conception of freedom referred only to a power and it was only this power that rational entities ascribed to each other that is the phenomenon of rationality necessarily requires that it is not caused externally however when entities move into the social sphere the conception of freedom is further developed freedom requires that an outcome of the thinking activity be perceived tangibly in reality in the external world this is to say that freedom necessitates that an entitys will be effective in the world but if other free rational entities are present in the world and thus interfering and opposing each other freedom as the implementation of the is will is only possible when these entities restrict their causality by setting up some limits to freedom this means that they must divide the world amongst themselves so as to avoid conflict and the notion of rights emerges as a form of entitlement at first this limitation is not imposed from the outside and all free rational entities chose to limit themselves making it a rule not to disturb the freedom of other entities with whom they share reciprocal relations this is what ends up giving rise to society to the commonwealth the influence of kants second formulation of the categorical imperative is quite evident demonstrating the kantian influence on fichtes thought act in such a way that you treat humanity whether in your own person or in the person of any other never merely as a means to an end but always at the same time as an end but this situation can only continue to occur in an ideal setting in a utopia because some human beings will not abide by it ultimately fichte was a pessimist about human nature this can be seen in his first book attempt at a critique of all revelation 6 where he discusses in great detail the nature of revelation as well as theology and natural and revealed religion fichte understands that evil is ingrained in human nature and thus by and large human beings are bound to diverge from the moral law 7 as a consequence of this the commonwealth decides that any disturbance to an is sphere of freedom such as a coercion or a crime is dealt with in such a manner that the disturbingi gets exactly the opposite of what it desires ultimately it loses its social freedom for this to happen rules and obligations are created externally by the commonwealth and all individuals must abide by them i note that fichtes account of freedom has connections with berlins notion of positive freedom in 1957 berlin delivered his paper two concepts of liberty his inaugural lecture for the chair of social and political theory at the university of oxford where he comments on the notions of positive and negative freedom berlin did not create the terms negative and positive freedom however his characterization has become a classic in the canon of political philosophy berlins essay was written during the cold war years and it associates negative freedom with the kind of freedom in liberal democracies whereas positive freedom is connected with that of communist societies ultimately berlin is very critical of positive freedom the notion of negative freedom is associated with the liberal thought of hobbes locke mill and tocqueville who argued that a minimum negative freedom is required and essential for human wellbeing as it is the area within which a man can act unobstructed by others thus a person is free in the negative sense when he or she is not prevented by human act or omission from doing what he or she may wish to do in short negative freedom is freedom from constraints contrasting with this is the notion of positive freedom which is founded on the individuals desire to control his or her own life from the wish on the part of the individual to be his own master however this kind of selfcontrol can be diminished by both the interference of other individuals and by ones own faulty character or lack of control over ones own passions this notion of freedom can be traced as far back as the stoics 8 and plato who discussed selfmastery and the case of false pleasures 9 positive freedom is freedom to control ones own life berlin is critical of positive freedom as he understands that in some cases it might lead to authoritarianism inverting the conception of liberty into its very opposite this happens because the kind of philosophy behind positive freedom usually understands the self as divided into two halves a higher part associated with reason and a lower part connected with passions and emotions and once this is presumed the higher part needs to conquer the lower part reason must dominate the passions crowder notes that the slippery slope happens when dictators suppose they know the requirements of the true self better than the individual concerned the doctrine of the divided self does not guarantee authoritarianism but it offers authoritarianism aid and comfort 10 it might be clear to the reader by now that fichte was a staunch defender of positive freedom in the foundations of natural right and this was noted by berlin in freedom and its betrayal berlin traces fichtes standpoint and his critique of positive freedom and the inverted thesis to rousseau who understood that liberty is social cooperation and right action the vulgar idea of liberty as negative noninterference refers merely to an amoral animal liberty consistent with acting wrongly but to act wrongly is to depart from the standards of the inner better more real self which necessarily seeks the good berlin 2002a 46 truly human liberty entails the liberation of that which is distinctively human namely a persons capacity for selfdirection in accordance with moral rules the will of the true self for rousseau the lower part of the self needs to be conquered by the higher part of the self and this can only be done in a commonwealth where all individuals seek a common good this opens the door for individuals to be forced to be free because the commonwealth believes it knows what is best for the members of the group hence freedom is inverted and becomes mere obedience to the commonwealths will berlin concluded that rousseau was one of the most ardent and passionate lovers of human liberty who ever lived but also one of the most sinister and most formidable enemies of liberty in the whole history of human thought the same could be said of fichte since he followed in rousseaus footsteps in the foundations of natural right arguing that obligations must be created externally by the commonwealth and all individuals must abide by them some years later fichte added a nationalistic tinge to this in addresses to the german nation where he talks about complying to the spirit of the nation and for germans to the german nation 11 but what does this have to do with the understanding that education is a right and shall be compulsory it is arguable that the 1948 declarations understanding of education as a right and as compulsory follows the school of thought that defends the notion of positive freedom a right to something is an entitlement and not an obligation but education became an exception to this characterization because the international community the established commonwealth understands that it knows what is best for individuals as such education became something compulsory and no longer an entitlement that all human beings have in order to fulfil their humanity and something they can choose to subscribe to if and when they wish education became an obligation that all human beings have to conform to because the commonwealth understands that it is important that all its members are educated this is at the very heart of the philosophical tension between right and compulsory the original idea of right as freedom not to be interfered with and to choose and implement ones will is still used with reference to education in speech and documents related to education but it has become secondary to the ideas of compulsory and obedience to the law this is a prime example of the inverted thesis discussed by berlin in connection to this it is perhaps worth ending this section by referring to foucault who also noted how a system of rights can be imposed on all members of the commonwealth by those who are in control of the community i will come back to this point when i discuss the aristoi and the pseudoaristoi lechner says a ccording to kants classical definition the law the agency guaranteeing individual rights is made up of the whole of conditions under which the freedom of choice of the one can coincide with the freedom of choice of the others according to a general law of freedom foucault argues in discipline and punishment that disciplinary power constitutes a counterlaw by invoking insuperable asymmetries and excluding reciprocities for this purpose disciplinary power establishes coercive relations between individuals that essentially digress from the formally sanctioned contractual relation in which the idea of universal rights is embedded disciplinary power thus renders both the volitionality of the contractual relation and the contract itself fictitious therefore foucault summarizes i t would be hypocritical or naive to believe that the system of rights was made for all in the name of all it would be more prudent to recognize that it was made for the few and that it was brought to bear upon others is education a duty in order to resolve the philosophical tension between right and compulsory i wish to propose a different understanding of education that is not as a right but as a duty that all human beings have towards themselves and their communities i will turn to fichtes writings again and look in detail at some lectures concerning the scholars vocation fichte and the rousseauian school of thought might have generated the problem through their defence of positive freedom but i believe fichte might also provide us with the solution to the problem fichte arrived in jena in 1784 just before the start of the summer semester to take up his appointment as professor of philosophy he had spent the previous months perfecting his new philosophical system the wissenschaftslehre project and preparing his private lectures on this fichte however did not want to use his newly appointed position to teach his system to a handful of students rather he wished to have a more profound influence on the whole of the university community it is for this reason that fichte devised a series of public lectures in addition to his private lectures which were entitled morality for scholars and the first five of these were published as some lectures concerning the scholars vocation he did the same thing but on a larger scale in addresses to the german nation with the aim that his interaction with the wider public would spread the message even further in this connection dimic´notes fichte is the first philosopher after plato and aristotle who in his philosophical practice made a difference between exoteric and esoteric lectures as they were called in platos academy that is lectures for all interested citizens ie the broad public and highly specialised lectures for professional philosophers prior to fichtes efforts during this period philosophy and science scarcely reached common people and he was keen to realize the ideal of the school for everybody not just in theory but also in practice this was based on a new understanding of education advocating that it would become available to absolutely everybody and not only the circle of the educated and rich the influence of fichte on humboldt is quite evident here and triggered significant changes in the german education system soon after as previously discussed in my introduction fichtes motivation for choosing the topic morality for scholars in his public lectures is explained in the following passage of another text his concerning the concept of the wissenschaftslehre fichte says the sciences as you all undoubtedly realize were not invented as an idle mental occupation to meet the demand for a refined type of luxury were they no more than this then the scholar would belong to that class to which all those belong who are living tools of a luxury which is nothing but luxury indeed he would be a contender for first place in this class all our enquiries must aim at mankinds supreme goal which is the improvement of the species to which we belong and students of the sciences must as it were constitute the centre from which humanity in the highest sense of the word radiates every addition to the sciences adds to the duties of its servants it thus becomes increasingly necessary to bear the following questions seriously in mind what is the scholars proper vocation what is his place in the scheme of things what relation do scholars have to each other and to other men in general especially to the various classes of men how and by what means can scholars most expeditiously fulfil the duties which they incur through these relationships and how do they have to develop the skills which this requires these are the questions which i shall be trying to answer in the series of public lectures which i have announced under the title morality for scholars further the word gelehrter in the original title of morality for scholars einige vorlesungen u¨ber die bestimmung des gelehrten which is usually translated as scholar requires explanation the word scholar is meant to refer here not only to academic professionals researchers and teachers but also to someone who is educated who spends their life pursuing knowledge and who is concerned with sharing any gained knowledge with the rest of humankind because they understand that knowledge is the central pillar in humanitys continuous pursuit of selfimprovement commenting on fichtes understanding of gelehrter fichte notes thus it is the especial responsibility of the scholar to supervise and to regulate human progress toward perfection and in order to do this he must at least strive to be the ethically best man of his time let me now look in detail at these lectures in his first lecture fichte aims to answer the question what is the vocation of man as such the answer is given at the end of the lecture mans final end is to subordinate to himself all that is irrational to master it freely and according to his own laws this is a final end which is completely unachievable and must always remain so so long that is as man is to remain man and is not supposed to become god it is part of the concept of man that his ultimate goal be unobtainable and that his path thereto be infinitely long thus it is not mans vocation to reach this goal but he can and he should draw nearer to it and his true vocation qua man that is insofar as he is a rational but finite being lies in endless approximation to his final goal now if as we surely can we call this total harmony with oneself perfection in the highest sense of the word then perfection is mans highest and unattainable goal his vocation however is to perfect himself without end he exists in order to become constantly better in an ethical sense in order to make all that surrounds him better sensuously and insofar as we consider him in relation to society ethically as well and thereby to make himself ever happier human nature or the vocation of man qua man implies according to fichte that human beings are in a constant pursuit of selfimprovement selfimprovement towards perfection presumably fichte understands that by perfecting oneself one becomes a better and wellrounded individual one overcomes ones inherent evil and as such becomes a better moral agent 12 moreover fichte understands that the path towards selfimprovement is endless and eternal and this is so because human beings are finite and as such they can never achieve perfection because perfection requires infinity and only god is infinite and perfect fichte is making reference here to the ontological argument for gods existence that is the predicate perfection is not part of the concept of the human being but is part of the concept of god hegel took issue with fichtes understanding of the human condition and some of my readers will be in agreement with him i quote harris the infinite progress in morality which fichte accepted as the destiny of humanity was for hegel an endless treadmill of internalised slavery it placed man in the situation of sisyphus or tantalus it deprived him even of the rational possibility of a real selffulfilment that could be known and enjoyed i believe that such criticisms are unfounded and fichte would reply that if one fulfils ones nature one must feel some sort of selffulfilment it would be something paradoxical if one followed ones nature and did not enjoy it did not feel some sort of selffulfilment the process is what is important not the final goal each achievement is a conquered milestone leading to another and as such a sense of selffulfilment is gained with every conquest in the second lecture fichte poses the question what is the vocation of man within society in doing so fichte puts forward an account of human beings social nature and their drive towards the improvement of society one of mans fundamental drives is to be permitted to assume that rational beings like himself exist outside him he can assume this only on the condition that he enter into society with these beings consequently the social drive is one of mans fundamental drives it is mans destiny to live in society he ought to live in society one who lives in isolation is not a complete human being he contradicts his own self the true vocation of man within society is unification a unification which constantly gains in internal strength and expands its perimeter but since the only thing on which men are or can be in agreement is their ultimate vocation this unification is possible only through the search of perfection we could therefore just as well say that our social vocation consists in the process of communal perfection that is perfecting ourselves by freely making use of the effect which others have on us and perfecting others by acting in turn upon them as upon free beings in this lecture fichte presumes that there is a state of nature a presociety and establishes that human beings are social beings craving the encounter with other rational and free beings and hence forming societies for fichte not to do so is to diminish oneself as a human being and go against ones very nature after establishing this fichte reinstates his argument that human beings aspire to achieve a state of perfection through the powers of pure and practical reason that is the human being tries to achieve a state of absolute unity and harmony with himself however this is something that it is impossible to achieve leading to an everlasting struggle to achieve the impossible the infinite quest for improvement of the human being qua human being fichte concludes that human beings do not only aim at their personal and constant selfimprovement towards perfection but they also as social beings aim at the constant improvement of their societies 13 in this respect it is arguable that selfimprovement is something inescapable a duty and that it is also a duty to improve ones society 14 now that fichte has dealt with the issues of the vocation of man qua man and the vocation of man within society he is in a position to deal with his main concern in the lectures that is the vocation of the scholar this is done in the fourth lecture we have already shown that the purpose of all human knowledge is to see to the equal continuous and progressive development of human talents it follows from this that the true vocation of the scholarly class is the supreme supervision of the actual progress of the human race in general and the unceasing promotion of this progress thus since the role and duty of the scholarly class within society is to supervise direct and promote the development of human beings talents it has a prominent position in humankinds continued pursuit of selfimprovement towards perfection this means that the scholar has a duty to encourage and facilitate human progress on the eternal and endless road to perfection moreover every scholar must strive to promote and facilitate progress within his own class fichte places a heavy weight on the shoulders of the scholarly class as it must promote and facilitate the improvement of its own class as well as supervise direct and promote the betterment of the other classes but this does not mean that all human beings need to become scholars and as such fichtes argument might appear to bear some elitist overtones and to resemble platos argument in the republic it thus has implications for sociopolitical thought and particularly for education the platonic idea of society and citizenship is fundamentally based around the concepts of the aristoi and the pseudoaristoi and it is in direct contrast to aristotles which is centred on the concept of a polis white comments on this as follows the aristotelian idea of citizenship which combines at once ruling and being ruled forming a polis is not however the only model on offer the platonic version of citizenship for instance draws a sharp distinction between rulers and ruled or the aristoi and the pseudoaristoi as will become clear later in this section fichte did not envisage the commonwealth as divided between the aristoi and the pseudoaristoi in a platonic fashion in fact i would argue that he strongly defended a republican aristotelian conception of society and citizenship based on the idea of a polis however with regard to the point about him being elitist i believe this is not the case and he was merely being realistic about the possibilities of human societies fichte commented the scholar is especially destined for society more than any other class his class insofar as he is a scholar properly exists only through and for society the scholar should now actually apply for the benefit of society that knowledge which he has acquired for society he should awaken in men a feeling for their needs and should acquaint them with the means for satisfying these needs this does not imply that all men have to be made acquainted with those profound inquiries which the scholar himself has to undertake in order to find something certain and true for that would mean he would have to make all men scholars to the same extent that he himself is a scholar and this is neither possible nor appropriate this brings us to the fifth and final published lecture where fichte discusses the claim that education and culture have corrupted and not improved human beings he does not mention rousseau by name but this view is usually attributed to him and his prizewinning essay of 1750 a discourse on the moral effects of the arts and sciences 15 in truth rousseaus position is much more subtle than that demonstrated by fichte but this does not stop fichte from exploring the internal contradictions and external limitations of such a position this leads him to conclude that rousseaus ideal of harmony between reason and sensibility is something that lies ahead of not behind us it is an ideal we should infinitely approximate not a natural state from which we have fallen 16 by doing so fichte emphasizes the idea that we as human beings are in a constant and eternal pursuit of perfection advocating that education and culture play a pivotal role in this thus although fichte like kant was an admirer of rousseaus writings and influenced by them as we saw in the previous section where i discussed the issue of positive freedom fichte was also very critical of rousseau taking issue with his position on education and culture fichtes argument in favour of education and culture leads him to claim that within the commonwealth the individual is at the same time a teacher and a student in constant interaction with others and permanently exchanging these roles fichte was not defending a version of platonic citizenship because there is no division between the aristoi and the pseudoaristoi between an educated class and a pseudoeducated one but something much more aristotelian democratic and egalitarian and ultimately poliscentred i note that fichtes views contrast with contemporary developments in the field of education and the move from traditional republicanism based on aristotles views to modern liberalism founded on platos thought it is perhaps worth quoting the following passage from ignatieff who instantiates this by contrasting both positions the one defends a political the other an economic definition of man the one an active participatory conception of freedom traditional republican and the homos politicus the other a passive acquisitive definition of freedom modern liberal and the homos consumus the one speaks of society as a polis the other of society as a marketbased association of competitive individuals indeed i would argue that fichtes views on education seem to be very supportive of traditional republicanism and could be used as a defence against modern liberalism and the dangers for education institutions and democracy that come with it fichtes framework suggests that we are in a constant pursuit of selfperfection and the improvement of our societies as well as constantly exchanging the role of teacher and student and as such it is very much a form of traditional republicanism based on democratic egalitarianism and the polis however fichtes version of republicanism does not happen just because we agreed to a social contract specifying it rather there is something more fundamental to it as it occurs because it is part of our very essence as human beings this means that we should not try to escape from our human condition but embrace it the vocation of the human being qua human being is to educate oneself in a constant personal and social pursuit of perfection as human beings we have a duty to improve ourselves and our societies through education conclusion when the 1948 universal declaration of human rights was being drafted some parties manifested their uneasiness about some of its wording for instance the american anthropological association warned that the declaration could become a statement of rights conceived only in terms of the values prevalent in western europe and america and that values are culturally dependent in connection to this and as i have previously argued the declaration at least insofar as article 26 on education is concerned could be viewed as a prime example of the kind of authoritarianism that is based on positive freedom this is because it conceives of education as a right but also understands that people cannot be trusted to take up this right turning it into something compulsory bergstro¨m commented on this last point whilst noting the tension between right and compulsory by the end of the nineteenth century education was not only elementary and free it departed from laissezfaire and became compulsory the word compulsory could be justified on the grounds that the free choice is a right only for matured minds that children are naturally subject to discipline and that parents cannot be trusted to do what is in the best interest of their children it is such distrust in parents ability to do what is in the best interest of the child that invoked among the delegates on the un united nations drafting committee a fear of totalitarianism authoritarian governments and political paternalism thus the meaning of the word compulsory became an issue the concept of compulsion appeared contradictory to the statement of a right this problem is compounded by the rise of a platonic conception of commonwealth and citizenship dividing society into the aristoi and the pseudoaristoi neoliberalisms hegemonic rise in the past decades has only made matters worse by turning education into a market tool and something to be consumed the consequence of this is that the aristoi the elites have access to the most valuable highly prized educational commodities whilst the pseudoaristoi the masses by and large need to content themselves with educational commodities of lesser value thus creating an untenable division that is difficult to overcome within the commonwealth this situation can be traced back to plato because he conflated state and individual public and private politics and psychology on the foundation of civil society and theory of the state this is at the centre of many of the problems faced by modern societies including that of marketization in education and the deterioration of the homos politicus into the homos consumus i would argue that this makes it easier for the aristoi to maintain their privileged position over the pseudoaristoi in society because in an educational market they have access to more valuable cultural social and economic capital leading them to possess more knowledge and knowledge itself is power furthermore the aristoi can make use of education as a disciplinary mechanism and power so as to normalize and discipline individuals pretending to protect empower and stimulate their personal development this setup turns teachers into technicians of behavior engineers of conduct orthopaedists of individuality and through this atmosphere of surveillance and observation the conduct of pupils is directed and coordinated while in the mean time a stock of knowledge about the individual students is being built up in this way discipline is formed which produces enslaved subjects and at the same time generates reliable knowledge about them this means that t he objective of the educational system is to produce productive effective and obedient subjects that is the pseudoaristoi fichtes position represents a rejection of all this and a recovery of the aristotelian conception of commonwealth citizenship and education it can be argued that fichtes framework and its traditional republicanism advocates that the unity of the commonwealth is as bauman argued in liquid modernity achieved daily anew by confrontation debate negotiation and compromise between values preferences and chosen ways of life and selfidentification of many and different but always selfdetermining members of the polis this is the republican model of unity of an emergent unity which is a joint achievement of the agents engaged in selfidentification pursuits a unity which is an outcome not an a priori given condition of shared life a unity put together through negotiation and reconciliation not the denial stifling or smothering out of differences therein lies the importance of education for traditional republicanism that is it can only be achieved if individuals understand that to educate themselves is a duty to themselves and their communities and something that is achieved through a constant exchange of roles between teachers and students further the commonwealth must recognize that it can only continue to exist if it provides its members with the opportunity to fulfil this duty this means that investment in education at all levels from child to adult education should be an absolute priority for any commonwealth because t he individual is not only an individual he is at the same time a member of a community and as such must be educated to take this place in it otherwise the future of that community is doomed this also means that the relations between teachers and students in education must be conceived in less asymmetrical and more egalitarian terms because the line between teacher and student and teaching and learning is a very fine one in fichte perhaps he could even be understood as a visionary and a forerunner sowing the seeds of what would become critical pedagogy finally by understanding education as a duty the tension between right and compulsory is dissolved and discussions about how to understand compulsory in education become nonsensical notes 1 progress has been made slowly in this direction and certain parts of the world such as latin america have made good progress developments in this area are not always driven by governments but by grassroots movements such as the landless movement in brazil which implemented a large network of primary schools early years provision and teacher education and adult education courses with the aim of equipping people to be valuable members of the community and to fight for social justice 290 2 by definition one cannot speak of a right in degrees that is either one has a right to something or one does not because a right is something absolute for instance one has a right to vote to get married or not to be tortured and these are absolute one cannot cast half a vote get married partially or be tortured a little bit to defend ones right to elementary education whilst arguing that higher education is a privilege seems to be inconsistent and arbitrary 3 it is generally agreed by fichte commentators that his philosophical development can be divided into three phases his first phase is the kantian phase and it encompasses his earlier writings such as the attempt at a critique of all revelation the second phase is usually referred to as the jena period in which fichte develops his wissenshaftslehre project and includes his more popular writings such as some lectures concerning the scholars vocation the third phase is normally referred to as the berlin period which is also known by commentators as the eclipse of fichtes career and includes texts such as addresses to the german nation written in 1808 during the napoleonic occupation 4 this position can be explained through a simple example imagine a human being devoid of all interaction with physical reality and other human beings from the very moment of birth could we conceive that this human being can say i certainly not this insight is something that permeated german postkantian idealism 5 in a very insightful and innovative way fichte introduces the idea of anstoss the challenge and obstacle posed by reality to the activity of the i as an important aspect for the rise of selfconsciousness this was something that kant had neglected to discuss in detail in his writings fichte defines anstoss as follows the anstoss occurs to the i insofar as it is active and is thus an anstoss only insofar as the i is active its possibility is conditioned by the activity of the i no activity of the i no anstoss and vice versa the is activity of determining itself would in turn be conditioned by the anstoss no anstoss no selfdetermination moreover no selfdetermination nothing objective once one cuts through fichtes philosophical jargon the same thesis defended by kant in the critique of pure reason is established that is to say selfconsciousness is dependent on ones contact with reality 6 the story of the publication of this work is perhaps better known than the work itself since it was written as a sort of selfintroductory note from fichte to kant kant thought the text was a wellwritten piece of work and suggested that fichte should sell it to kants own publisher the first edition had very strange omissions the title publisher city and date appeared as usual but fichtes name and signed preface were missing whether this was due to a true printing mistake or a cunning ploy by the publisher one will never know the second and subsequent editions corrected these errors and acknowledged fichtes authorship however by the time this was done the book had already proven to be a huge success partly because it was assumed by book reviewers and readers to be yet another of kants works the written style the terminology the fact that it was published by kants own publisher and the fact that it had been widely expected that kant was soon to publish a critique of religion led to the conclusion that kant was the author 7 fichtes views have a clear foundation in the christian belief of original sin contrasting to fichtes views are schellings who understood that evil has a metaphysical foundation in reality because both satan and jesus were begotten by god and as such these two forces are always at play in reality and are not something ingrained in human nature as a condition bestowed on humanity by adam and eves original sin in this first work fichte also argues that theology is not enough and religion especially revealed religion is necessary to reconnect individuals to morality the root of the word religion is the latin religare which is translated as to reconnect in english 8 available at 9 available at 10 mills account of higher and lower pleasures in his version of utilitarianism is another classical example of this school of thought 11 crowder notes that the section on fichte ends with berlin citing a series of quotations from heine who warns the french against underestimating the destructive potential of the ideas emerging in germany armed fichteans will come whose fanatical wills neither fear nor selfinterest can touch a drama will be performed in germany in contrast with which the french revolution will seem a mere peaceful idyll berlin 2002a 72 for berlin this is a genuine vision of the doom to come berlin 2002a 72 12 fichtes argument seems to have been influenced by aquinas summa theologica where he argues against ignorance it is evident that whoever neglects to have or do what he ought to have or do commits a sin of omission wherefore through negligence ignorance of what one is bound to know is a sin whereas it is not imputed as a sin to man if he fails to know what he is unable to know consequently ignorance of such like things is called invincible because it cannot be overcome by study for this reason such like ignorance not being voluntary since it is not in our power to be rid of it is not a sin wherefore it is evident that no invincible ignorance is a sin on the other hand vincible ignorance is a sin if it be about matters one is bound to know but not if it be about things one is not bound to know 13 fichtes views seem to mirror the jewish concept of tikkun olam this is a hasidic and kabbalistic aspect which understands that the shards or sparks of the divine remain contained in the material world and that rightful deeds by the pious will help in releasing this divine energy it is not possible however to ascertain if fichte was familiar with this concept 14 it must be noted here that one must seek to perfect society according to the moral law or acting in accordance with practical reason one cannot seek to perfect oneself and society without taking this into account not to do so would be unreasonable to kant and fichte incurring a whole range of criticisms such as relying on emotions or moral luck 15 available at 16 as already mentioned rousseaus position is much more subtle than fichte portrays this is noted by osterwalder in emile the pupil is educated in unity with and for himself as well as in unity with the whole with an order like the absolute moral order manifested in nature in which humanity ought to live beyond the decadent reality of the existing society in emile the education culminates in the educators confessed commitment to an absolute moral order beyond the order or rather disorder of a decadent society

the 1948 universal declaration of human rights states that everyone has the right to education and it shall be compulsory i note that there is a tension between right and compulsory in the declaration because by definition a right is an entitlement and not an obligation the reasons why education is an exception to the rule have not been explored in detail and efforts seem always to concentrate on the compulsory side of the tension in trying to understand exactly what it would entail and fail to direct attention to the right element of the problem in this article i wish to turn the problem on its head and take issue with the idea that education should be understood as a right the argument is rather that education should be conceived as a dutyan obligation that all human beings have towards themselves and their communities in order to do this the author refers to the works of johann gottlieb fichte 17621814 the german postkantian idealist whose works in education have been long neglected and forgotten nevertheless they are of great help in trying to make sense of education not as a right but as a duty i argue that such understanding dissolves the tension between right and compulsory and that a reframing of an understanding of what education is needs to occur not just at the individual but also at the societal level

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introduction according to metaanalysis of research studies clinical depression and subclinical depressed mood were associated with higher body mass index in adults 1 4 several mechanisms explain how psychological distress influences obesity first depressive symptoms may promote fat storage in the body by increasing cortisol levels 5 another explanation is that negative emotions may lead to the consumption of highcalorie meals and binge eating 67 in addition peoples sadness and hopelessness might decrease their motivation to exercise thus contributing to higher bmi 8 10 the influences of sociodemographic factors on the association between depressive symptoms and higher bmi are not well understood 1241011 research on the influence of sociodemographic factors such as raceethnicity may inform the development of effective interventions mental health interventions that provided services to a specific racialethnic group were four times as likely to be effective in alleviating depressive symptoms compared with interventions that targeted people of different racialethnic groups in metaanalysis of 76 studies 12 since weight gain was a late consequence of depressed mood in a metaanalysis of longitudinal studies 4 implementing timely strategies based on the cultural context of the participant to prevent and manage psychological distress may help reduce depressive moods and subsequently obesity research on the influence of sociodemographic factors on the association between depressive symptoms and obesity had conflicting findings 1241011 female gender either had no influence 4 or was a greater risk factor 12 in the relationship between depressed mood and obesity some reasons for the gender difference in the association between depressed mood and obesity may include disparities in genetic predisposition to both depressed mood and obesity stigmatization access to care and choice of providers 1 educational attainment had no influence on the association between depressive symptoms and obesity in most 1410 but not all studies 11 one study on racialethnic differences reported a more pronounced association between depression and obesity among latinas 1 two other studies found no racialethnic differences 1011 people of lower educational attainment and latinas may have reduced access to mental health care the depressive symptoms of people of lower educational attainment and latinas thus may remain untreated for longer periods of time which subsequently could lead to reduced exercise and increased bmi these prior studies with conflicting findings had important limitations a metaanalysis of nine longitudinal studies found that depression increased the likelihood of becoming obese it found no differences in the association by gender and age limitations of the metaanalysis included a small number of publications a statistically significant trend of publication bias and the inclusion of only age and gender as covariates 4 in another metaanalyses of 17 studies which also only focused on gender and age differences the association between depression and obesity was especially pronounced among females the relationship did not differ by age 2 three studies focusing on racialethnic differences in the association between depressive symptoms and obesity were identified in an investigation of 4651 us middleaged females in a health plan in washington and northern idaho raceethnicity age and educational levels were not risk factors in the association between depression and obesity the study consisted primarily of middle class and white women 10 a study of 4162 us adults aged 65 years and older found that being african american was not associated with having comorbid depressionhigh bmi 11 lower education was however related to having such comorbidity 11 the findings of this study which was administered in five counties in north carolina may not be applicable to other parts of the us and to adults younger than 65 11 the third study focusing on racialethnic differences performed analysis in a subset of the 2001 behavioral risk factor surveillance survey participants in the usa 1 among 44 800 subjects being latina was a risk factor in the association between depressive symptoms and obesity 1 one limitation was that the study sample was not representative of the brfss because the particular question on depressive symptoms during the past 30 days for about how many days have you felt sad blue or depressed was administered in a limited number of states 1 given these conflicting findings and the limited research on racialethnic influences we investigated the sociodemographic differences in the association between depressive symptoms and bmi we conducted the crosssectional research in a demographically representative sample in genesee county michigan usa the sociodemographic determinants included age gender raceethnicity and education the participants completed a survey which included items on depressive symptoms methods setting genesee county and its most populous city flint have experienced significant economic and population declines in part due to the closure of automobile manufacturing plants 13 the unemployment rate in the county more than doubled from 41 in december 2000 to 98 in december 2011 14 the countys population decreased by 10 351 people from 415 439 in 2000 to 425 790 individuals in 2010 15 between 2000 and 2012 the rate of violent crime increased by 9 in genesee county 16 crosssectional design to monitor and assess residents health and health needs a committee composed of academicians and community members developed the prevention research center of michigans speak to your health survey 17 19 previous manuscripts provided details on the speak to your health survey 17 19 the survey was administered among residents aged 18 years and older across all residential census tracts in genesee county mi random samples of households were drawn from these tracts to represent all areas of genesee county in this crosssectional study three waves of survey data were combined into a sample of 3381 adults a total of 4585 completed the survey in 2007 2009 and 2011 these 4585 participants were part of the complete sample of them 3381 had complete data on all variables these 3381 participants were part of the analytic sample included in the present analysis the complete and analytic samples were similar in terms of age education in years gender and bmi participants were asked if they had previously taken the survey and if so in what year they had completed the survey no participant reported to have previously taken the survey selfreported measures and data analysis bmi a continuous variable was calculated using the respondents reported height and weight sociodemographic variables included age gender raceethnicity and education ethnicity was categorized as nonlatino white and african american participants were asked for their highest level of education completed depressive symptoms were assessed with brief symptoms inventory items 20 composite scores were calculated using these brief symptoms inventory items a two independent samples ttest was conducted to compare the mean bmi between african americans and nonlatino whites the bivariate pearsons correlation coefficients between variables were calculated stepwise linear regression was used to determine the unique predictors of bmi in stepwise regression predictor variables are determined by an automatic procedure in the form of a sequence of ttests 21 in this study bidirectional elimination was used in which a combination of forward selection and backward elimination was carried out to test for variable to be included or excluded at each step 22 forward selection begins with no variables in the model tests the addition of each variable and adds the variable that would improve the model the most backward elimination starts with all variables tests the deletion of each variable and deletes variable that would improve the model the most by being deleted the standardized regression coefficients in the stepwise regression were calculated because the coefficients in the b column are all in the same standardized units they can be compared to determine which one has a stronger effect the ultimate goal of stepwise regression is to identify the regression model that best predicts the outcome 2122 bmi was the dependent variable in stepwise linear regression in model 1 the stepwise linear regression identified the about how much do you weigh without shoes enter weight in pounds influence of age gender raceethnicity education depressive symptoms and the interaction terms for demographic variables with depressive symptoms on bmi model 2 included all predictors as those in model 1 in addition to the variable year year was added as a predictor in model 2 to account for including three waves of survey data age education year and depressive symptoms composite scores were continuous variables in the linear regression statistical significance was defined as p 005 the statistical analyses were conducted using spss results most participants were nonlatino white and female the mean age of participants was 55 years the mean years of education among participants were 12 the mean bmi was higher in african americans than in nonlatino whites specifically the mean bmi among african americans was 2982 and that among nonlatino whites was 2865 the chronbachs alpha of the depressive symptom items was 089 as depressive symptom scores increased bmi increased as well in model 1 gender and the interaction terms of raceethnicity â depressive symptoms and gender â depressive symptoms uniquely predicted bmi once these factors were accounted for no other demographic characteristic or interaction term explained a significant proportion of the variance in the association between depressive symptoms and bmi in model 2 increasing year was a significant unique predictor of higher bmi gender and the interaction terms of raceethnicity â depressive symptoms gender â depressive symptoms remained statistically significant in model 2 in both models therefore women had a higher bmi than men and depressive symptoms were more strongly associated with bmi among african americans and women than among nonlatino whites and men the interaction term depressive symptoms â race had the largest standardized coefficient among all statistically significant predictors discussion main findings of this study a more pronounced relationship between depressive symptoms and obesity among african americans existed the presence of a gender difference in depressive symptoms and obesity is consistent with most prior research 2 the lack of age and education differences in the association between depressive symptoms and obesity in the present study also supports most prior research 1410 the correlation between depressive symptoms and bmi was positive and statistically significant however the correlation was relatively weak such weak correlation may imply that factors other than depressive symptoms contribute to higher bmi increasing survey year was associated with higher bmi what is already known on this topic an african american individual may gain more weight than a nonlatino white individual suffering from the same depressive symptoms the reasons for the greater weight gain in african americans may be their stronger stigma related to having depression reduced likelihood to seek mental health services and lower quality of received mental healthcare services compared with nonlatino whites stigma defined as the perception of having a spoiled identity 23 and undesirable traits 24 is an obstacle to seeking mental health care 25 the us department of health and human services identified reducing stigma as a major goal in increasing mental health care 26 african american patients reported greater stigma related to depression than nonlatino whites in prior research 2728 as a result of such stigma african americans are less likely to seek mental health services than nonlatino whites 2930 once african americans do seek mental health services they receive lower quality of care than nonlatino whites 2930 as a result of these disparities african americans depressive symptoms may remain untreated or undertreated while nonlatino whites depressive symptoms may be successfully managed african americans experiences of stigma and lower access to adequate and quality mental health care may exacerbate their risk for having untreatedundertreated depressive symptoms and subsequently obesity the gender difference in the association between depressive symptoms and obesity may be explained by the stronger genetic predisposition to depressed mood and obesity in women than in men a significant increase in anxiety and depression scores for females homozygous for certain genes existed in one study 31 a statistically significant association between bmi and homozygosity for these genes for females but not males was present 31 the study concluded that genetic factors played significant roles for obesity and psychological distress particularly in females 31 in addition females depressed mood may persist over time due to social factors such as greater peer pressures during adolescence and lower wages and reduced career opportunities in adulthood compared with men 32 these social factors may contribute to the stronger association between depression and obesity among females future research should investigate the reasons for the racialethnic and gender differences in the association between depressive symptoms and obesity what this study adds the findings have implications for intervention research interventions to reduce obesity are much needed in areas such as michigan the rate of obesity increased from 20 in 2000 to 313 in 2012 in the state 33 only four other states specifically west virginia alabama louisiana and mississippi had higher obesity rates than michigan in 2012 33 the obesity rate in genesee county was even higher than that in michigan the rate of obesity was 359 in genesee county in 2012 34 most interventions to decrease obesity rates in michigan do not target the pathways from depressive symptoms to obesity the michigan nutrition physical activity and obesity program for example enhanced public parks and improved walking trails 35 it initiated the planting of neighborhood and school gardens and the creation of farmers markets the faithbased initiative through partnership with african american churches increased access to fresh fruits and vegetables and places for physical activity 35 such programs are much needed but cannot fully succeed in decreasing obesity rates if peoples depressive symptoms prevent them from consuming healthy meals and engaging in exercise and outdoor activities the findings on the racialethnic and gender difference in the association between depressive symptoms and obesity support the development of tailored interventions among african americas and females compared with nonlatino whites african americans have expressed lower acceptability of antidepressant medication 36 greater preference for professional counseling 37 and increased interest in counseling from clergy 38 future research should assess the effectiveness of quality improvement programs in physician offices offering a choice of mental treatment options that consider preferences of african americans interventions to prevent and treat mental health problems among females may be especially important in adolescence the higher prevalence of depression in females compared with males first emerged in puberty in prior research 39 the most effective interventions to reduce depression in adolescent girls provided cognitivebehavioral therapy others were multifaceted interventions targeting negative stress responses and family conflict 40 yet different effective programs provided coping classes teaching adolescent girls how to overcome unconstructive thoughts and behaviors 40 future research should assess the effectiveness of these interventions on healthy weight maintenance decreasing stigma related to having depressive symptoms may be another viable intervention among females women who had familyfriends with depression felt less stigmatized than women without familyfriends with the condition in a study of 3047 adults 41 in the same study females who were completely in agreement with their physicians on the treatment for their depression reported less stigmatizing attitudes than women not in complete agreement therefore programs seeking to increase social support and improve patientphysician communication on the appropriate treatment may decrease obesity rates by improving mental health care among women residents increases in weight over the years may be attributed to the worsening economic situation in genesee county future studies should investigate pathways that may explain how peoples health may have changed over the years one hypothesis is that people may be discouraged to exercise in their neighborhood because of the worsening crime thus contributing to increased bmi over the years limitations of this study the survey response rate was 25 the results may not be generalized to all us areas all measurements were selfreported people tend to overestimate their height and underestimate their weight 42 no question on participants income was asked in the 2007 2009 and 2011 surveys because there was a high refusal rate to the household income question in earlier survey waves we used the education variable to assess socioeconomic status another limitation is that the results of this study cannot be generalized to clinical depression they may be better generalized to individuals experiencing subclinical depressive mood who are at risk for depression the full depressive symptoms scale was not used however the four items used to assess depressive symptoms exhibited a high reliability with a chronbachs alpha of 089 causal and temporal associations could not be assessed in this crosssectional study the direction of the association between depressive symptoms and obesity may be opposite to that reported in this study stigma is attached to obesity particularly among nonlatino whites and people of higher socioeconomic status 43 46 studies on the influence of obesity on depressive symptoms had mixed findings in the third national health and nutrition examination survey obesity was related to depression primarily among individuals with severe obesity 44 in the national comorbidity survey obesity was associated with major depression the association was more pronounced among nonlatino whites and college graduates 45 in a representative sample of 2020 adults there was no influence of obesity on depression however being overweight increased the likelihood of depression among the more educated adults 46 future studies should investigate sociodemographic differences in the bidirectional relationship between depressive symptoms and obesity interventions to reduce obesity rates in the usa as a whole and in michigan in particular are much needed depressive symptoms were stronger predictors of bmi for african americans and women than for nonlatino whites and men interventions to prevent and manage physiological distress among african americans and females may decrease obesity rates in addition clinicians may consider monitoring weight gain among patients with depressive symptoms over time

the study investigated the sociodemographic differences in the association between depressive symptoms and higher body mass index bmi in genesee county michigan random samples of households were drawn from all residential census tracts the speak to your health survey was administered among adults aged 18 years and older in these households to conduct this crosssectional study data from three waves of survey data collection 2007 2009 and 2011 were combined resulting in a sample of 3381 adults selfreported height and weight were used to calculate bmi depressive symptoms were assessed with brief symptoms inventory items sociodemographic factors included age raceethnicity gender and education results using stepwise linear regression gender b ¼ 004 p ¼ 002 and the interaction terms of raceethnicity â depressive symptoms b ¼ 015 p 0001 and gender â depressive symptoms b ¼ 005 p ¼ 001 uniquely predicted bmiwomen had a higher bmi than men and depressive symptoms were more strongly associated with bmi among african americans and women than among nonlatino whites and men tailored interventions to alleviate depressive symptoms in african americans and females may help decrease racialethnic and gender differences in depressive symptoms and obesity

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introduction in 2016 the united nations reported that safe access to drinking water sanitation and hygiene was fundamental to improving standards of living across the world but it was felt that there were large disparities in wash globally particularly in marginalised groups improving access to clean water sanitation and hygiene facilities is central to achieving sustainable development goals 6 3 and 10 and also indirectly related to other goals such as 1 2 5 and 12 with competing demands on water from population growth in some of the most vulnerable countries along with increased industrial and agricultural demands there is a need for greater investment of time activities and finance to reduce water pollution and ensure equitable access to water hygiene and sanitation facilities data for malaysia from whounicef showed that around 99 of malaysians live in modernised housing and communities with direct household access to water sanitation electricity and utilities such as electricity and a gas supply the remaining 1 of the population does not have access to such facilities this group would include the indigenous orang asli orang asli are the oldest indigenous inhabitants of peninsula malaysia there are around 95 subgroups with their own distinct language or dialects and culture in johor they mainly comprise jakun people orang kuala orang kanaq and orang seletar historically most earned a living in agriculture fishing or through trade but most live in rural areas a recent un study looking at the orang asli population found that their health situation was significantly poorer than the rest of the malaysian population with a higher prevalence of parasitic infections often related to water supply a recent systematic found that orang asli communities were often excluded in governmental national surveys and recorded wash data may not be representative the systematic review found that orang asli suffered from a greater number of tropical diseases and noncommunicable diseases and had poorer nutritional status than the general population often related to socioeconomic factors common illnesses related to untreated water included stunted growth acute diarrhoea illness and chronic enteric infection most studies looking at disparities of health in indigenous communities in malaysia have been taken in selangor perak and pahang to our knowledge no studies have been undertaken on wash facilities for orang asli living around the johor river basin in johor state the aim of this study was therefore to evaluate wash provision for residents of the johor river basin and evaluate the disparity in facilities between indigenous orang asli and more modernised communities methods following ethical approval and informed consent from newcastle university residential communities around the johor river basin were contacted through village heads and housing associations to seek participation in the study in each community a data collector was appointed from the village by the village head to collect the questionnaires digitally from the community between october 2021 and june 2022 questionnaires were completed and collected using the arcgis survey123™ platform with data anonymously uploaded to a secure cloudbased database a copy of the questionnaire adapted from the united nations childrens fund and world health organization questionnaire is shown in the supplementary information appendix a data were analysed with descriptive statistics using spss 2 software comparisons between orang asli and more modernised communities were undertaken using chisquare analysis tests for the normal distribution of data were undertaken with a kolmogorovsmirnov test results demographics of the populations eight hundred and ninetynine respondents completed questionnaires in this study comprising 799 from more modernised communities and 100 from indigenous communities data were not normally distributed in this study in the indigenous community 63 of respondents were male but there was a more even gender balance in the modernised communities in the indigenous community 91 were under 55 years of age compared to 807 in the modernised community most commonly 46 people lived in around 60 of households in both communities unemployment affected 38 of respondents in the indigenous community and 362 of the modernised communities with regard to the personal income of respondents more than half of the indigenous community had no fixed monthly income when compared to 329 for more modernised communities the differences in mean personal income between the communities were statistically significant with the modernised communities earning significantly higher amounts for household income which included household contributions from people other than the respondent there was again a significant difference in earnings between the two communities with 58 of indigenous households having no fixed monthly income but only 116 of modernised communities having no fixed income the most commonly reported household income for the indigenous group was less than rm 1000 when compared to the modernised community where 432 of people reported earning between rm 2000 and 20000 regarding the level of education there were significant differences in education level between the indigenous group and modernised populations about 98 of indigenous respondents were educated up to the end of secondary school with 2 having achieved diplomas whereas 742 were educated up to secondary school in the more modernised community and 257 acquired diplomas andor a university degree water use and sanitation facilities a significant difference existed in access to toilets between the indigenous group and the modernised communities as summarised in table s2 almost all of the indigenous community used buckets and only one respondent had a mechanical toilet in the modernised community 389 used a mechanical toilet with a flush that drained to a piped sewer system 262 used a bucket and 244 used toilets with mechanical sewage leading to a septic tank when asked about using shared toilet facilities all indigenous respondents shared their toilet facilities with people outside of their household whereas only 249 of the modernised respondents shared their toilet facilities with outsiders on a daily basis unsurprisingly there was also a significant difference in the number of toilets in each household between the indigenous and the modernised communities 98 of the indigenous people had only one toilet in the household and 2 of them had two toilets compared to the modernised group where 878 had more than two toilets in the household when asked about toilet and sewage systems in the household 52 of the indigenous people did not know where flush toilets are connected to compared to 409 of respondents from modernised communities when asked about the condition of the toilet in the household almost all of the indigenous population did not know the condition of the toilet basement in their households the other 8 said that their facilities are in very good condition for the modernised population most think that their toilets were in very good condition followed by 352 who do not know the condition of their toilets 6 have damaged plumbing that needs repair and the remaining 19 have damaged and leaking toilet facilities regarding the main source of drinking water for household members while all houses had a tap with water this water was not necessarily considered safe to drink table s2 compares the water usage between the indigenous and modernised community about 62 of the indigenous respondents depended on their spouse to bring drinking water in the household either as bottled or boiled drinking water from the tap but this responsibility was taken on by all family members for 190 of the indigenous households for the modernised group 567 relied on their spouse to bring drinking water to the household 204 relied on parents and 53 relied on children for cooking and washing there was a significant difference in the main source of water for household usage between indigenous and the modernised groups about 96 of the indigenous population had tap water as the main source of water which may have come directly from the river a local pond or public water supply for the modernised community 862 used tap water from the municipal water supply as the main household water source there was a significant difference in the recent household water supply shortage between indigenous and modernised groups about 15 of the indigenous community said there had been household water supply shortages in the past month for the modernised population 228 had experienced a household water supply shortage there was a significant difference in handwashing between the indigenous and the modernised communities in the indigenous community 97 used a kitchen sink for the modernised population 98 used either kitchen sinks bathroom sinks or both to wash their hands regarding the use of soap for handwashing there was a significant difference in the routine use of soap and detergent between the indigenous people and the modernised people about 18 of the indigenous people did not use soapdetergent when washing their hands compared to 58 of the modernised community respondents for showering or bathing 92 of the indigenous people showered two times per day but for the modernised population 621 showered two times per day and up to 368 showered three times or more each day as a matter of routine there was a significant difference in showering time between the indigenous and the modernised communities about 78 of the indigenous people said that they would take a quick shower and the remaining 13 showered within 1020 min however for the modernised group 501 showered within 1020 min 459 showered for less than 10 min and up to 4 of them showered more than 20 min at a time there was a significant difference in the frequency of weekly household laundry undertaken between the indigenous group and the modernised communities about 70 of the indigenous people did laundry 14 times per week and 300 did laundry 58 times per week for the modernised group 592 of laundry was undertaken 14 times per week followed by 287 doing laundry 58 times per week the remaining 121 said that they did laundry 912 times per week when asked about car washing 62 of the indigenous community found this question not applicable because they did not own a car about 18 of the indigenous people answered once a week 1 answered once every 23 weeks and the other 19 answered once a month for the modernised community car owners 141 washed their cars once a week 230 washed their car once every 23 weeks and 307 washed their car once a month when asked how water was stored in this study 89 of indigenous respondents boiled their water from the tap which may have come from the municipal supply or the river about 9 of the indigenous community did not treat their water at all from the tap or river and the remaining 2 used an electronic water filter in the modernised communities 457 boiled tap water and 343 used an electronic filter the difference in water storage methods was significantly different between the two communities given the greater water usage by the more modernised community it is perhaps not surprising that there was a significant difference in monthly water bills between the indigenous group and the modernised group in the indigenous community 91 of respondents paid less than rm 100 per month compared to the modernised community where only 81 paid less than rm 100 per month a comparison of wash practices related to income status irrespective of community type is presented in table s3 this study showed that a greater proportion of households with lower household incomes lived within walking distance of the johor river basin than those requiring transport to get into the river basin whereas a greater proportion of higherincome households lived at a distance from the johor river basin requiring transport this difference was significant at the p 0001 level there was not much of a difference between lowerand higherincome households with respect to the main source of household drinking water in both groups the majority of respondents had tap water in the house there was a similar small difference in the main source of water for household water in both the lower and higherincome groups tap water was used for household water requirements interestingly in the lowerincome households female spouses were more often responsible for ensuring that there was clean drinking water in the house in the higherincome group a greater proportion of parents were enlisted to ensure clean drinking water for the household compared to the lowerincome group in all cases these differences however were nonsignificant there was no significant difference in the experience of water shortage between lowerand higherincome households in this study with regard to water storage both household income groups stored water most commonly in open buckets and plastic bottles to store water and the refrigerator a greater proportion of lowerincome households however used glass containers to store water this study showed that higherincome households had higher water bills than the lowerincome households with 473 paying less than rm 50 per month versus higherincome households with 518 paying rm 51100 monthly health risks and perception of risk when asked about health concerns of contaminants in drinking water a significant difference existed between indigenous and modernised communities with regard to the nature of the concerns indigenous respondents were most concerned about metals polluting water whereas modernised communities were more concerned about chemicals such as arsenic and petrochemicals only 1 of indigenous respondents were concerned about bacteria or sewage contamination whereas 9 of the modernised community were concerned about bacteria concern for bacteria however was significantly higher within the modernised community group for respondents with higher educational levels chemical concern was conversely higher in those with lower levels of education ie primary or secondary school level these patterns were also reflected in the household income level compared with those of no fixed income and less than rm 1000month concerned primarily about chemicals and the higher earners concerned about bacteria interestingly the predominant health concern in both communities was diarrhoea and both communities felt those under five years old were most vulnerable in both communities the lack of access to water and the contamination of water were said to affect mood but a greater number of the modernised community respondents felt that water contamination was a health concern compared to only 78 of indigenous respondents when asked where they mostly received information from regarding water pollution the indigenous community mostly relied on television programmes whereas the modernised communities mostly received information from the internet and then from television with the remainder getting information from newspapers the community advertisements and friends this difference between the two community types was significant additional questions and responses are tabulated as supplementary information discussion the communities involved in this study provided a proportionally representative sample of people living in the johor river basin while the study did not capture every village and riverside community access provided by village heads and the johor orang asli association allowed the study to be undertaken with a relatively large sample size there is a disparity in sample sizes between the modernised and orang asli communities but this is reflective of the relative population ratios of people living in the area of the river basin sampled more men were proportionally higher respondents in the orang asli communities than women this is compared to a more equal divide in the modernised communities it likely this is because the village head of the orang asli communities were male as were the data collectors and sampling was probably more convenient than random in those communities based on where data collectors decided to undertake their questionnaires women were often at home while men were sitting out in social areas in the modernised communities due to the larger population it was easier for data collectors to sample equal numbers of men and women the electronic questionnaire used in this study was beneficial in the sense that it could be used by data collectors in the community to obtain information and data could be uploaded to secure cloudbased storage minimising contact between the researchers and vulnerable communities during and immediately after the covid19 pandemic data collectors found the electronic questionnaire easy and convenient to use this study has shown significant differences between orang asli and modernised communities in almost all variables measured in this study in the second malaysian plan in the 1970s the malaysian government attempted to reduce the disadvantage to orang asli communities by making plans to increase educational standards and job opportunities they also made plans for upgrading basic facilities such as utilities clean water access and sanitation facilities attempts were made to improve medical facilities and health too but the plan involved resettlement programmes and only 07 of orang asli were willing to move and live in the urban or semiurban community as a consequence many orang asli are still living without basic facilities that are reflected here in the johor river basin water usage was considerably lower in the indigenous communities with the less frequent use of mechanical or flush toilets showering and car washing while this questionnaire has not examined every possible use of water in a household it gives an indication of the differences in community water usage for common activities in general the indigenous communities tended to be more conservative about using household water for everyday tasks which may reflect lower personal and household incomes to pay water bills indigenous communities handwash laundry using river water or tap water but electric washing machines were commonplace in more modernised communities while the ministry of rural and regional development has implemented a rural electricity supply programme to serve remote rural areas of peninsula malaysia and borneo there is no universal provision and communities who do not want to live in resettlement areas still do not have a reliable electricity supply regarding drinking water it is interesting to note that more of the indigenous community did not treat their water prior to drinking several studies have reported increased higher rates of parasitic infection and diarrhoea infection in orang asli populations while the current study showed awareness of unclean water causing diarrhoealrelated illnesses this has not necessarily translated to a behaviour change in terms of maintaining high levels of sanitation in this study the orang asli community was more worried about chemical contamination in their water supplies chemical pollution is episodic and frequently reported in local newspapers or in television so awareness of chemical pollution is likely to be more common in this group who rely on television more than internet sources for news and information in addition it affects more highly populated modernised communities too so journalists are more willing to report on such issues bacterial contamination is a longstanding problem affecting a minority of the population so may not be considered to be newsworthy a striking difference between the two communities was toilet facilities all but one indigenous respondent was using a single bucket for the whole family and all were sharing their bucket toilet facilities regularly with their communities this was in contrast to the modernised communities who shared toilet facilities much less frequently and most households had more than one toilet due to the smaller size of the indigenous community dwellings and the ability to use toilets in neighbouring properties it is perhaps not surprising that indigenous communities felt that they did not need more than one toilet despite having a similar number of people in the household as the modernised communities in this study toilets were felt to be in a better condition in the more modernised communities than the indigenous homes and while not specifically asked about in this study it is possible that more of the modernised community homes were owneroccupied and thus responsibility for maintenance and function was with the owner while many of the indigenous respondents were homeowners who had purchased basic homes on a government scheme these homes only included very basic toilets as standard sanitation facilities without adequate connection to any sewage treatment plant such responsibility falls to the homeowners the current practice is either a selfprepared underground wood storage box to contain the sewage or sewage is directly released into open water without proper drainage and sewage management it is unlikely that the indigenous communities will install such toilets now or in the future when wash data were compared between highand lowincome households irrespective of community it was found that more households with a higher monthly income were located away from the river this may be a reflection of the types of employment in these communities those in modernised communities were commonly employed in service industries and factories whereas those living near the river were mainly dependent on retail and fishing for household incomes which are consistent with findings from masron et al interestingly female spouses were responsible for ensuring clean drinking water supplies in the lowerincome communities a behaviour consistent with findings from other lowincome communities in lowand middleincome countries in this study water storage did not differ greatly between higherand lowerincome households but the use of the refrigerator was more common in the higherincome households and water was probably less likely to be contaminated since the refrigerator is a sealed compartment lowerincome households did not use the refrigerator due to lack of electricity while most of malaysia has electricity readily available pockets of rural areas have unpredictable access unsurprisingly the lowerincome households had lower water bills than the higherincome areas but this may be not only a reflection of budgeting but that they use the river water to carry out laundry and washing practices rather than a washing machine or a shower facility bathrooms with handwashing facilities were more common in higherincome households but in both higherand lowerincome households there was adequate access to soap and detergent most of the time less time was spent showering in this study in lowerincome households but individuals in these households were showering more frequently so water usage may have been similar for showering while laundry practices did not vary greatly between lowerand higherincome households there were higher levels of car ownership and consequently car washing which will have affected water use in higherincome households water availability to indigenous communities in malaysia has been the subject of a long debate wook discussed the case of orang asli plaintiffs from a fishing village in southern johor wanting exclusive land and water rights in their settlements where they had lived for more than 50 years land reclamation and development had removed resources that communities had previously depended on meaning that livelihoods were being threatened along with water provision unfortunately the high court ruled that orang asli had nonexclusive rights to this land and water through common law as such there would not necessarily be any legal protection from these resources being further removed in the future from this study it is clear that there are differences in the perception of risk between the two community types as such public health education programmes would need to be tailored to the community in question future public health education programmes for the indigenous communities should also be directed towards educating communities about the importance of improving sanitation and hygiene both communities had some awareness of bacterial contamination of their water supplies but did not fully understand the consequences simple handwashing hygiene and water preparation information targeting various age groups in the communities are the next step in trying to improve wash facilities and practices in the johor river basin for indigenous communities in modernised communities there is also work to be done explaining the risks to health with water contamination while wash facilities are generally good in this community knowledge of health risks is variable so public health education in these areas will be better directed to the health consequences of water contamination changing behaviours on water treatment and usage is difficult when many of these behaviours have been lifelong and may be cultural or learned from previous generations further study into why water is used and treated or not treated will allow investigators to work with communities to modernise some behaviours to improve sanitation and hygiene in vulnerable communities conclusions this study confirms the statement by whounicef that in malaysia those living in marginalised communities and stateless individuals indigenous or otherwise may not have access to basic drinking water and sanitation significant differences exist between indigenous and modernised communities in their water access and sanitation facilities further study is required not only to understand behaviours but also to educate populations on relevant potential health risks from water contamination in the johor river basin data availability statement all relevant data are included in the paper or its supplementary information conflict of interest the authors declare there is no conflict

water access sanitation and hygiene wash data for malaysia suggest that almost 100 of the population have access to basic sanitation and basic drinking water but this data may not include marginalised communities and stateless individuals indigenous or otherwise the aim of this study was to evaluate wash provision for residents of the johor river basin and evaluate the disparity in facilities between indigenous orang asli and more modernised communities questionnaires were distributed to eight communities in total 899 questionnaires were completed including 100 from indigenous communities and 799 from more modernised communities significant differences existed between communities with regard to education levels p 0001 occupation p 0001 household income p 0001 type of toilet sewage and sanitation facilities p 0001 and perception of health risks and concerns p 0001 there is a significant difference in access to water and sanitation facilities between indigenous and modernised communities further study is now required to understand behaviours and educate riverbased communities on relevant potential health risks from water contamination in the johor river basin

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introduction in 2011 at the height of the euro crisis the european union imposed strong austerity programs on portugal as well as on other european countries in portugal specifically the measures designed by the troika have profoundly affected citizens lives the gdp fell significantly between 2010 and 2014 unemployment also significantly increased and many people emigrated in addition to the poverty rate rise taxes increased wages decreased and the investment in health care and education was greatly reduced the measures imposed by the troika have brought intense suffering increased social inequalities and have been an issue of intense political and economic debate nationally and internationally how did the portuguese citizens react to this economic crisis did they consider themselves responsible for their social and economic misfortune research on the psychosocial variables affecting the reaction of populations during the last global economic crisis has been scarce christandl and papastamou et al are exceptions especially those associated with ingroup blame for its own suffering this paper intends to fill this gap by investigating how belief in a just world and national identity predict portuguese citizens ingroup blame previous research has shown that when confronted with a victim of injustice individuals need to preserve their perception that the world is just so that they can maintain their confidence in the future and guarantee their mental health the preservation of the bjw when facing injustice can be done through various ways such as the engagement in actions perceived as effective in reestablishing justice or through secondary victimization ie blaming or derogation of the victims whether the victims are other people or the actual individual this process of cognitive restoration of justice only happens when the suffering is ongoing and it is not possible to alleviate that suffering importantly recent studies have shown that the more people believe in a just world and the more identified with the victims group they are the higher their need to reestablish the perception of justice when threatened by ingroup victimization indeed those individuals showed higher secondary victimization of an ingroup victim or of many members of the ingroup and possibly they themselves nevertheless research has not investigated whether this pattern occurs when individuals themselves are victims simply due to belonging to a given group and when the victimization takes place in an intergroup international context based on a national probabilistic sample this study intends to test whether the bjw and national identification of portuguese citizens jointly predict the victims reactions to the suffering inflicted by the economic measures imposed by the troika national identification belief in a just world and victimization of ingroup members according to social identity theory when people categorize themselves as members of social groups they define themselves more in terms of their group rather than their personal characteristics therefore sharing a common identity with a victim of injustice is a potential cause of threat to ones bjw especially when individuals strongly identify with their own group as previously assumed by the social identity approach the degree of internalization of or the identification of a category with an ingroupoutgroup membership is a major determinant of accessibility of a category this happens because there is a convergence between the belief that good things happen to good people while bad things happen to bad people and the motivation for positive distinctiveness arising from the categorization between us the good ones and them the bad ones a nonthreatening situation occurs when bad things happen to the outgroup or when good things happen to the ingroup on the other hand a threatening event occurs when bad things occur to good people ie when the ingroup is victimized in such a situation individuals are motivated to solve the threatening incongruence by restructuring the situation in order to perceive it as just and legitimate furthermore within the framework of the system justification theory research has shown that the need for system justification can lead individuals of disadvantaged groups to blame themselves and their group for their own disadvantage although apparently paradoxical the costs of internalization of inequality at a personal and group level are compensated by the benefits at the system level that ones outcomes are predictable and controllable which reduces the threat caused by the ingroup misfortune indeed after results such as those of novak and lerner where victims who were perceived as being more similar to the observer were subject to greater avoidance correia et al showed that an innocent ingroup victim is more of a threat to the bjw than an innocent outgroup victim one other study additionally showed that the ingroup victim was also more secondarily victimized in a nonobtrusive or implicit derogation measure than an ingroup nonvictim however these previous studies did not differentiate between participants who strongly and weakly endorsed the bjw nor between participants who strongly and weakly identified with the group the introduction of these measures allowed for findings on explicit derogation measures it was found that when the identity of the victim and the victimization situation are not necessarily related the positive relationships between bjw and victims derogation and between bjw and psychological distancing were significant for strongly identified participants but not for weakly identified participants furthermore the same result was found when there is an intrinsic relation between being an ingroup member and being a victim in the latter case the measure of reaction toward victims was the legitimation of wife abuse therefore both when the identity of the victim and the victimization situation were and were not related there was an association between bjw and secondary victimization for strongly identified participants but not for weakly identified participants this means that the relationship between bjw and secondary victimization of a specific target perceived as an ingroup member is moderated by the extent to which the perceiver identifies with this ingroup these previous studies analyzed the victimization of particular individuals in a group but not the victimization of the group as a whole the current paper goes further by proposing that victim blaming is a more general phenomenon affecting the entire ingroup when it is under suffering specifically we test whether bjw and identification also interact to predict secondary victimization when the group as a whole is a target of misfortune in this particular case provoked by the economic austerity measures imposed by the troika we may then predict a twoway interaction between bjw and ingroup identification on ingroup blaming so that the impact of bjw should be stronger in more identified individuals when the ingroup is victimized because only negative events occurring to the ingroup are threatening to bjw when the ingroup suffering is lower more identified individuals will no longer be motivated to blame the ingroup because their ingroup is no longer being victimized in such a situation ingroup identification should not moderate the impact of bjw on ingroup blame accordingly it is likely that the interaction between bjw and ingroup identification should occur when the ingroup is a target of a misfortune but not when the ingroup is no longer victimized we may then predict a threeway interaction between bjw ingroup identification and the victimization context if this is the case this paper represents an important contribution for the literature about justice motivation in terms of intergroup relations for the first time secondary victimization produced by a threat to bjw will be shown not to be specific to individuals who suffer life misfortunes but a wider phenomenon that also has a groupbased identity function according to the bjw theory this happens because blaming of the ingroup when facing victimization is a protective mechanism for people to continue to believe that they as ingroup members are protected from injustices so that they can continue to delay gratification and to invest in the future hoping that they will be fairly rewarded overview of studies using representative probabilistic samples of portuguese citizens we carried out two studies aiming to address how national identification and bjw jointly predict secondary victimization of an ingroup as a whole when there is a threat to bjw caused by externally imposed austerity measures and when this threat is lower because those austerity measures have finished we conducted study 1 in 2014 at the height of the portuguese financial crisis during the intervention by the troika study 2 was conducted 3 years later when the troika had already left portugal as we already mentioned this external intervention was accompanied by a profound deterioration of economic activity with extremely negative consequences for the lives of the population indeed there was the deep economic recession resulting from the troikas financial intervention which produced an environment of continued social and psychological suffering that affected almost the entire portuguese population this scenario at the time of study 1 provided us with a unique opportunity to analyze secondary victimization in a realistic context when the measures finished at the time of study 2 there was a period of some social enthusiasm due to returning economic growth allowing us to see the social environment in which the study was carried out as one of less suffering compared to that of study 1 together these two studies allowed us to test the hypothesis that bjw is positively associated with ingroup blaming for its own suffering and that this association is moderated by national identification and by threat produced by ingroup suffering specifically we predicted that because an environment of ingroup suffering is more threatening of the bjw of more ingroup identified individuals bjw would be positively associated with ingroup blame in highly identified portuguese participants ie individuals degree of national identification should moderate the effect of bjw on secondary victimization additionally we predicted a different pattern of results when the suffering caused by social environment decreased when external intervention was concluded and the countrys socioeconomic situation improved ingroup suffering should be less salient for national identified individuals and so the association between bjw and secondary victimization should not be moderated by individuals national identification study 1 in this study we aimed to address the articulation between national identity and bjw on ingroup blame for economic suffering during externally imposed austerity measures more specifically as regards to ingroup blame we predicted that only for highly identified portuguese participants bjw would be positively associated with ingroup blame because the bjw motivates the reestablishment of justice in the world when the victim shares a common identity with the perceiver additionally in order to better test our hypotheses several control variables were introduced in the regression models these variables have shown to be correlated with bjw in previous studies see correia for a revision and consequently may contribute to explain the dependent variable ingroup blame this is even more probable if we take into account that the study is crosssectional and the sample is representative of a countries population we also predict that european identification may foster ingroup blame therefore it should be controlled so that a stronger test of our hypothesis that bjw and national identification predict ingroup blame over and above those control variables can be done materials and methods participants and procedure a national representative probabilistic sample was used for the present study we only considered data from participants who were portuguese citizens of these participants 779 matched all measurements and therefore constitute the final sample of the present study data were collected between september 2014 and january 2015 as part of the portuguese module of the international social survey program these data were collected by trained interviewers the interviews were face to face and carried out in the participants home participants consent was obtained prior to the beginning of the study in accordance with the declaration of helsinki the protocol and questionnaire were approved by the issp general assembly according to their ethics statement except the item that measured ingroup blame and the items that measured belief in a just world that were part of the portuguese module of the issp the data and further information about documentation and data collection can be found at and at portugalsav measures religiousness we measured this construct with one item asking people without counting special occasions such as weddings funerals and baptisms how frequently do you participate in religious services in an eight point scale from 1 several times a week to 8 never the answers to the items were recoded so that higher scores indicate stronger endorsement of the construct subjective social status we measured this construct with one item asking people in a general way some people are at the top of our society and others are at the bottom this scale represents the top and the bottom at which point of the scale do you think you are at this time of your life in a 10point scale from 1 bottom to 10 top belief in a just world we measured this construct with threeitems taken from the general belief in a just world scale ranging from 1 to 5 the answers to the items were recoded so that higher scores indicate stronger endorsement of the construct we computed a global score for this scale by averaging across items ingroup identification we used two items to measure ingroup identification in a fourpoint scales ranging from 1 to 4 the answers were recoded so that higher scores indicate stronger endorsement of the construct we computed a global score for this scale by averaging across items european identification we used one item to measure identification with europe in a fourpoint scales ranging from 1 to 4 the answers to the item were recoded so that higher scores indicate stronger endorsement of the construct ingroup blaming we measured this construct with one item regarding the impact of the measures imposed by the troika in portugal portuguese people are partly to blame for the suffering they are going through with fivepoint scales ranging from 1 to 5 the answers were recoded so that higher scores indicate stronger endorsement of the construct sixty percent of the participants said they agreed or totally agreed with that sentence only 26 disagreed or strongly disagreed results and discussion preliminary analysis table 1 presents descriptive statistics and zeroorder correlations between all variables some results are important for a better characterization of the context in which the study was carried out besides serving as baseline for comparisons with study 2 both national and european identification were strongly higher than the midpoint of the response scale and respectively mean scores of bjw were slightly below the midpoint of the scale in turn ingroup blaming was substantial being scored significantly above the midpoint of the scale concerning the correlations bjw and national identification were both positively correlated with ingroup blame additionally ingroup blame was positively and significantly correlated with identification with europe and years of schooling and negatively correlated with age main analysis we then tested whether national identification moderated the relationship between bjw and ingroup blame while controlling for the effects of european identification as age years of schooling social status and religiousness correlated significantly with the main predictor variables as well as with the criterion variable they were also introduced in the regression we thus conducted a multiple regression analysis in a first block we entered the sociodemographic and the control variable in a second block we entered bjw and national identification in a third block we entered the product between bjw and social identification in the current and in the subsequent study all the predictor variables were centered before analyses the results are shown in table 2 in the final model ingroup blame was explained by years of schooling european identification national identification and bjw all these associations were positive furthermore a significant twoway interaction between bjw and social identification significantly predicted ingroup blame this significant effect obtained in the third model was over and above the effects of other variables included in the model estimated in block 1 and block 2 in accordance with our hypothesis simple slope analyses showed that for portuguese citizens higher in national b unstandardized coefficients for all measures scores were computed by averaging across items with higher scores indicating stronger endorsement of the construct for sex 0 male 1 female p 005 p 001 p 0001 identification bjw was positively associated with ingroup blame b 032 t 400 p 0001 also as we predicted for portuguese citizens lower in national identification bjw was not significantly associated with ingroup blame b 006 t 074 p 0461 the pattern of results we found is the first evidence for the key role played by national identification in understanding the association between bjw and secondary victimization of an ingroup as a whole especially in a social environment in which the national ingroup is under ongoing suffering imposed by an external outgroup according to our rationale this occurred because the more identified participants are the more they are sensitive to social and psychological consequences of the economic austerity measures which may have threatened their bjw indeed a bad thing was happening with good people ie with their own beloved and valued ingroup our rationale also assumes that the social environment plays a key role in victimization specifically if the impact of national identification depends on the social environment where the victimization occurs we can predict that a change in the social context that led to victimization should also impact the association between bjw and ingroup victimization of more national identified individuals specifically if the social environment is less threatening to the ingroup the need to restore justice should not be so prominent among the most identified individuals which may mitigate the role of identification in the relationship between bjw and victimization this possibility will be tested in study 2 study 2 this study aimed to analyze the moderating role of national identification on the relationship between bjw and ingroup blame in a social context where externally imposed austerity measures were not present anymore study 2 was conducted in 2017 when the troika intervention program had already finished and the portuguese social environment was regaining some enthusiasm due to returning economic growth therefore the study was conducted in a social context of less victimization compared to that of study 1 because of the decreased victimization it is possible that threat to ingroup had been removed and therefore national identification no longer played a role in the relationship between bjw and ingroup blame thus we predict that national identification should not moderate the bjw effect moreover study 2 allows us to overcome some important limitation of the first study the results we obtained in study 1 were based on a measure of the dependent variable accessed with only one item which weakens the accuracy of the estimated parameters and limits the power of inference on the studied phenomenon the current study addresses this aspect by considering more items to measure ingroup blame as well as by using different forms of accessing it the study also tested the proposed hypothesis by taking into account the role played by relevant controlling variables in crosssectional representative surveys materials and methods participants and procedure we used the national portuguese database from the european social survey round 8 the sample is composed of 1270 individuals who are representative of the portuguese population of them 1140 indicated they were born in portugal have portuguese nationality and are over 18 years of age and so we considered them eligible for the current study because we had the possibility to carry out the study with a large and diverse sample it was possible to extend the test of our hypothesis by using two different versions of the ingroup victimization measure which allowed us to increase the scope of generality of the proposed effects therefore when the portuguese specific items of the ess8 were applied half of respondents answered a version of victimization items while the other half responded to a different set of victimization items subsample a is composed of 551 participants aged between 18 and 90 years old being 224 male and 327 female subsample b is formed by 589 participants the participants were randomly allocated either in subsample a or in subsample b at the moment they were answering the ingroup victimization items the two different scales of ingroup blame are presented below participants consent was obtained prior to the beginning of the study in accordance with the declaration of helsinki and the protocol and questionnaire were approved by the ess research ethics committee the data and further information about documentation and data collection can be found at and at measures belief in a just world we asked the participants to answer the same threeitems we used in study 1 to measure bjw the scores were recoded and averaged so that higher values indicate stronger endorsement of the bjw ingroup identification we also used the same two items of study 1 for measuring national identification we computed a global identification score by averaging across items that vary from 1 to 4 ingroup blaming as we indicated above participants were randomly located into two subsamples according to the set of items we used to measure ingroup blaming the participants in subsample a indicated the extent to which they agreed with the following two items by using a fivepoint answer scale regarding the impact of the measures imposed by the troika in portugal portuguese people are partly to blame for the suffering they went through and regarding the impact of the measures imposed by the troika in portugal portuguese people are partly responsible for the suffering they went through we recoded the answers so that higher scores indicate stronger ingroup blaming the participants in subsample b used a fourpoint answer scale to indicate their agreement with the following two items regarding the impact of the measures imposed by the troika in portugal how much do you think the portuguese people are to blame for the suffering they went through regarding the impact of the measures imposed by the troika in portugal how much do you think the portuguese people are responsible for the suffering they went through we also recoded the answers so that higher scores indicate stronger ingroup blaming in both versions each set of items showed have strong internal consistence subsample a subsample b controlling variables besides some relevant participants sociodemographic characteristics we also included three controlling variables religiousness subjective income leftright political positioning varying from 0 to 10 european identification how close to or identified do you feel with europe coded from 1 not at all identified to 4 very much identified results and discussion preliminary analysis table 3 shows descriptive statistics and bivariate correlations between all variables the mean scores of our key variables are substantially different from those we obtained in study 1 which denote a less threatening social environment for example in both samples of the current study the national and european identifications were higher than in study 1 similarly bjw in both study 2 subsamples was stronger than in study 1 t 510 p 0001 d 028 and t 560 p 0001 d 027 respectively importantly ingroup blaming was significantly lower in subsample a of study 2 than in study 1 t 629 p 0001 d 035 1 regarding the correlations in each subsample bjw correlated positively with ingroup blame the correlation was substantially stronger in subsample a in this sample only bjw and european identification are associated with ingroup blame in subsample b besides the association with bjw ingroup blame was positively correlated with participants years of schooling subjective income and identification with europe and negatively with age national identification did not correlate with ingroup blame in any sample which points in the direction of our hypothesis according to which ingroup identification plays a less important role in a social context where the victimization is little salient despite these preliminary results indicating weak associations between ingroup blame and the controlling variables we included them in the regression analysis when testing our hypotheses main analysis table 2 presents the estimated parameters for the regression analysis we used to test our prediction in each subsample the results indicate very consistent results across samples the more the participants bjw the more they blamed portuguese people for the troika intervention importantly this main effect of bjw was not moderated by national identification this means that the association between bjw and ingroup blame occurred not only over and above individuals ingroup identification but it is equally positive both in more and less identified participants moreover the bjw remained a significant predictor even taking identification with europe into account which was a controlling variable associated with more ingroup blame the pattern of results we found in the current study is in accordance with our prediction that the association between bjw and secondary victimization is not moderated by individuals national identification in a social environment where ingroup suffering is not salient as was the case when the study was conducted 2 this was at the time the troika intervention was completed and the countrys socioeconomic situation started to get better in sum the results are in accordance with our prediction that bjw is positively associated with ingroup blaming for its own suffering and that this association is moderated by national identification and by the environmental social context where the ingroup blaming means between study 1 and 2 by using only the common item across the two studies results demonstrate that effectively ingroup blaming was significantly lower in study 2 than in study 1 t 639 p 0001 d 04 moreover ingroup blaming does not reach the midpoint of the scale in study 2 while it was significantly above this midpoint in study 1 additionally the reduction of ingroup blaming from study 1 to study 2 is more evident when we take into account the percentage of participants who agreed with the ingroup blaming indicator while in study 1 about 60 of them scored above the midpoint of the scale in study 2 this percentage decreases to only 46 2 because in study 1 we had not an indicator of leftright political placement the nonsignificant interaction in study 2 could be due to control for this variable in order to address this possibility we reestimate the regression model without leftright as a controlling variable results showed very similar effect to those presented on table 2 in fact the interaction effect was not significant in subsample a nor in subsample b thus the nonmoderating effect of national identification in study 2 cannot be explained by controlling for individuals leftright political placement secondary victimization occurs that is the moderating effect of national identification should in fact occur in study 1 but not in study 2 in order to carry out a more rigorous test of this hypothesis we conducted a new analysis in which we assembled the databases of the two studies by focusing on the measures that fully matched between the two time points we then estimated a regression model taking ingroup blame as the dependent variable the year when data were collected bjw national identification and interaction terms as predictors results showed a reliable main effect of the year of study confirming that ingroup blaming was lower in 2017 than in 2014 as expected we found a reliable main effect of bjw and a marginal effect of national identification importantly we obtained a threeway interaction between the year of study bjw and national identification as we predicted and verified before in each study the decomposition of this interaction indicated a reliable two way interaction between bjw and national identification in 2014 but not in 2017 the pattern of interaction follows those already depicted in figure 1 these results represent strong evidence for our hypothesis that the moderating role played by national identification in the relationship between bjw and ingroup blame depends on the social environment where the victimization occurs 3 general discussion this study addressed for the first time the relation between national identity and bjw on ingroup blame for externally imposed economic austerity measures by the troika that lead to suffering of the population and was perceived as a victimization imposed by an outgroup using probabilistic representative samples of portuguese citizens we found a consistent pattern of results across the two studies the more participants endorse bjw the more they blame the ingroup as a whole for their suffering importantly in a social environment characterized by ongoing suffering caused by an outgroup intervention the association of bjw with ingroup blame was moderated by national identification this result is in accordance with our prediction that bjw is positively associated with ingroup blame only for highly identified portuguese participants in a social context of victimization by an outgroup importantly 3 years later when the victimization was less prominent national identification did not play a role in ingroup blaming in sum the results were in accordance with our proposal that in terms of intergroup relations the moderating role of ingroup identification in the relationship between bjw and secondary victimization depends on the existence of a threatening social context where the ingroup is victimized theoretical implications results we found provide new insight into the role played by national identification on the relationship between bjw and secondary victimization establishing a new frontier for understanding the conditions under which ingroup identification favors the relationship between bjw and ingroup blaming from a theoretical point of view the results support the generalizability of the relation between the degree of endorsement of bjw and social identification in the reaction to ingroup victims either the ingroup victim is an isolated victim and there is no relation between the nature of the victims group and the victimization that happened or there is an intrinsic relation between being an ingroup member and being a victim or as in the present study when people are victimized just because they belong to a given group the same result was found it is also important to stress that these effects have already been obtained with different forms of secondary victimization victim derogation and psychological distancing from the victims and legitimization of the victimization the present research advances prior research on the psychological effects of victimization since the moderating role played by ingroup identification occurs when the group as a whole is in continuous suffering but not when the act of victimization by the outgroup was removed beyond advancing the literature on secondary victimization the present paper also contributes to the understanding of the social consequences of intervention imposed by a powerful outgroup and therefore studies the phenomenon at an intergroup relations level of analysis our results suggest that the blaming of the ingroup is a way to deal with bjw threat and consequently to maintain confidence in the future indeed to believe that the misfortunes occurring with the ingroup are not random and are to some extent deserved as a consequence of its own misbehavior may be psychologically and socially functional in other words it can contribute to maintaining the fundamental illusion that the events occurring to us are predictable stable and controllable this possibility is in line with theorizing and research about the sociopsychological consequences of the legitimation of social inequality see costalopes et al for a review from a social identity perspective individuals are motivated to value their ingroup by differentiating it from outgroups in order to maintain positive selfesteem individuals who are members of minority groups have their selfesteem threatened when their ingroup is under victimization imposed by a high status outgroup one possible way to maintain selfesteem is by perceiving victimization as illegitimate and ingroup boundaries as impermeable which motivates them to engage in collective actions for instance when members of minority groups can attribute their misfortune to prejudice they increase identification with the minority group which leads to enhanced wellbeing especially those who already have higher ingroup identification furthermore highly identified members may deviate from the ingroup members internalization of the disadvantage willing to improve the ingroup situation a different reaction can occur when individuals view victimization as legitimate and group boundaries as permeable in this case it motivates them to disidentify with the ingroup which leads to the outgroup favoritism effect that can have pervasive harmful consequences for the individuals own ingroup the current research shows that individuals can follow a third way in solving the ingroupvictimization problem they can actively tend to legitimize their situation through ingroup blaming when their ingroup identity is under threat indeed the selfprotective role of national identity motivating a coping process when facing a threat of injustice by an outgroup perpetrator has never been studied and this paper constitutes a first step in that direction that possibility is in accordance with the system justification theory that predicts a justice motive to legitimize the existing social order whose function is to reduce dissonance especially in disadvantaged groups accordingly the results of the present research not only extend previous research within the framework of bjw literature but also contribute to illuminate the functionality of bjw in legitimizing the suffering observed in the social system as a whole it is also in line with recent research that showed at an interpersonal level that random and uncontrollable bad outcomes increase beliefs about deserving bad outcomes our research contributes to this literature by showing that legitimization also depends on the existence of threats resulting from the macro social environment limitations and further directions the fact that the constructs were assessed with few items represents a weakness however in study 2 we found the same results with two different measures of ingroup blame nevertheless the results obtained are according to the theoretical predictions which lessens this issues potential impact moreover the size and representativeness of the present study sample allows the hypotheses to be tested on individuals who are very diverse in terms of age gender economic status etc we must also not forget that the correlational design of this study limits the nature of the conclusions that can be drawn about the causal and sequential relations among bjw national identification and ingroup blame future studies should experimentally manipulate the motivation to reestablish the bjw and the strength of national identification to check their joint impact on ingroup blame future studies should also include measures related with the perception of efficacy to change the ingroup situation or of support of collective action so that it is possible to compare high and low identifiers on their perceived efficacy to change the ingroup disadvantaged situation the reliability of bjw in study 2 was low the measures of bjw have been mostly used with adult participants with a medium to a high level of education in our representative sample we have participants with a comparatively lower education level than in most samples furthermore we only have a threeitem scale all these reasons may explain the lower reliability of the bjw scale even so the findings were according to the theoretical predictions methodologically the main strength of this paper is the analysis of the same population over time where it is possible to study the impact of threats resulting from the macro social environment on the relation between bjw national identity and ingroup blame future studies could also measure the impact of ingroup blame on wellbeing in fact if ingroup blame is used to reduce threat to bjw it is expected that its use can have positive consequences for the wellbeing of the individuals on the downside it also legitimizes the status quo and contributes to its passive acceptance and therefore to social injustice conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

using representative probabilistic samples of portuguese citizens and framed by an intergroup perspective we carried out two studies aiming to address how national identification and belief in a just world bjw jointly predict secondary victimization of an ingroup as a whole specifically ingroup blame we conducted study 1 n 779 in 2014 at the height of the european austerity policies imposed on portugal by an institutional outgroup specifically the troika the european union the european central bank and the international monetary fund study 2 n 1140 was conducted after the troika intervention an environment of ongoing ingroup suffering caused by an outgroup is more threatening for the bjw of individuals who are more identified with the ingroup we therefore predicted and found that bjw was positively associated with ingroup blame in participants higher in national identification when the victimization provoked by an institutional outgroup was higher study 1 however when the suffering caused by the outgroup decreased the association between bjw and secondary victimization was not moderated by individuals national identification study 2 indeed a threeway interaction was found between bjw national identification and social context high vs low victimization these results are an important contribution for the literature about justice motivation in terms of intergroup relations because they show that secondary victimization produced by a threat to bjw has a groupbased identity function

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introduction breast cancer is the second leading cause of cancerrelated death among women with notable differences by raceethnicity in breast cancer burden 12 for example compared with white women women of color are more likely to be diagnosed with metastatic breast cancer and die from the disease 3 such inequities in the distribution of metastatic disease are concerning as they have negative financial implications for women whose treatment regimens may be more complex and costly due to indefinite treatment duration financial toxicity or the financial burden and distress that cancer patients experience is now considered a significant adverse effect of cancer care 4 affecting more than 30 of cancer patients 5 financial toxicity has been linked to lower healthrelated quality of life and higher mortality among cancer patients 67 moreover patients reporting cancerrelated financial burden are more likely to engage in costmanagement behaviors such as delayingdiscontinuing treatment forgoing medical care and filing for bankruptcy 5 8 9 10 although racialethnic disparities in financial barriers to care are welldocumented 11 research on racialethnic differences in financial burden has been limited one recent prospective cohort study of black and white women with breast cancer found that compared with whites black women were more likely to report income loss health carerelated financial barriers health carerelated transportation barriers job loss and loss of health insurance 12 however no study to our knowledge has examined racialethnic differences in employment status and financial coping among women with incurable metastatic disease moreover little is known regarding the extent of financial coping in less studied racially ethnically diverse populations including hispanicslatinas asianspacific islanders and american indiansalaskan natives such understanding can help inform the development of future interventions aimed at addressing financial toxicity with a bend towards equity using data from a national survey of diverse patients with metastatic breast cancer we examined racialethnic patterns in employment changes and financial coping due to cancer specifically we assessed racialethnic differences in cancerrelated changes in work for pay and costmanagement behaviors among nonhispanic whites nonhispanic blacks hispanicslatinas asianpacific islanders and american indiansalaskan natives methods outcomes changes in work for payto assess changes in work we combined survey items from several prior studies that assessed changes in work status among cancer patients and survivors 9 12 13 14 specifically participants were asked since being told you have metastatic or stage iv breast cancer which changes if any have you made in your work for pay participants could select multiple responses in eight dimensions including stopping work completely reducing hours taking paid leave taking unpaid leave retiring early or changing jobs as a result of their cancer financial copingcostmanagement behaviorswe define our financial coping measures according to the framework developed by altice and colleagues where cancer financial coping behaviors are defined as those behaviors that patients adopt to manage their medical care while experiencing increased household expenses duringfollowing cancer care 15 consistent with the altice and colleagues definition we use the terms financial coping and costmanagement behaviors interchangeably throughout this paper to assess costmanagement behaviors we combined survey items from several prior studies that assessed financial coping behaviors among cancer patients and survivors 5131617 specifically we asked which of the following have you done to manage the cost of your cancer costmanagement behaviors included discontinuing care due to cost skipping vacations or other activities withdrawing money from savings filing for disability avoiding treatment for other medical problems skipping payment of nonmedical bills and applying for or receiving financial assistance covariates the primary variable of interest was raceethnicity as defined by selfreport individuals could select more than one racial category but nearly all individuals identified as only one race all those who identified as more than one race identified as white and another race and were categorized into the nonwhite group individuals who identified as having hispanic ethnicity are classified as hispanic regardless of racethe majority of these individuals are white hispanics the sample size was sufficient to report on nonhispanic white nonhispanic black hispanic asianpacific islandernative hawaiian and american indianalaskan native participants control variables were divided into clinical characteristics and socioeconomic characteristics clinical variables included age at the time of the survey and years living with metastatic disease socioeconomic variables included insurance coverage marital status whether any dependents are present in the household total household income educational attainment and whether women were employed at the time of the survey statistical analysis first we evaluated racialethnic differences in participant sociodemographic and clinical characteristics using chisquared tests comparing each racialethnic group to nonhispanic whites next we calculated unadjusted prevalence rates of each outcome by race using chisquared tests to report statistically significant differences between each racialethnic group and nonhispanic whites lastly we estimated modified poisson regressions predicting each outcome as a function of raceethnicity adjusting for patient clinical and sociodemographic characteristics differences are presented as risk ratios and each group is compared to nonhispanic whites using a wald test statistical tests were twosided with significance assessed using an alpha value of 05 all analyses were performed using stata 15 results participant characteristics survey participant characteristics are displayed in table 1 the study sample included 660 nonhispanic whites 90 nonhispanic blacks 66 hispanics 101 asianspacific islandersnative hawaiians and 83 american indiansalaskan natives mean age for the sample was 423 years compared with all other racialethnic groups nonhispanic whites were more likely to report living with metastatic breast cancer for less than a year possessing insurance and being married or living with a partner most participants reported having dependents and education nonhispanic blacks were most likely to be currently employed unadjusted comparisons figures 1 and 2 display unadjusted comparisons of outcomes by raceethnicity with nonhispanic whites as the reference group for chisquared comparison tests regarding changes in work for pay stopping work completely was the most commonly reported change in work for pay across all racialethnic groups with participants of color reporting higher rates of work discontinuation relative to nonhispanic whites retiring early and changing jobs were least commonly reported across the entire sample but relatively more common among participants of color than nonhispanic whites with respect to costmanagement behaviors stopping or refusing treatment was the most commonly reported costmanagement behavior for nonhispanic blacks asianspacific islandersnative hawaiians and american indiansalaskan natives while borrowing money from friends was most commonly reported for hispanics and skipping a vacation was the most commonly reported costmanagement behavior for nonhispanic whites of note very few participants applied for and received financial assistance for their cancer care with no statistically significant differences by raceethnicity adjusted comparisons results from the adjusted modified poisson regression analyses are reported in figures 3 and4 in adjusted analyses comparing nonhispanic whites with nonhispanic blacks on changes in work for pay blacks were more likely to report taking unpaid leave of note nonhispanic blacks exhibited the highest prevalence of unpaid leave in the entire sample hispanics were more likely than whites to report reducing work hours taking paid leave highest prevalence group 686 and changing jobs asianspacific islanders native hawaiians were also more likely than nonhispanic whites to report stopping work and taking paid leave moreover compared with nonhispanic whites american indiansalaskan natives were more likely to report stopping work completely and reducing work hours racialethnic differences in costmanagement behaviors were also observed in adjusted analyses specifically nonhispanic blacks were more likely than nonhispanic whites to report stopping or refusing treatment hispanics were more likely than whites to report borrowing money from friends and filing for disability but were less likely to report skipping a vacation and using savings asianspacific islandersnative hawaiians were more likely than nonhispanic whites to report stopping or refusing treatment and skipping other medical bills but less likely than nonhispanic whites to report borrowing money from friends and using savings finally american indiansalaskan natives were more likely than nonhispanic whites to report stopping or refusing treatment skipping a vacation and skipping nonmedical bills and skipping other medical bills to cope with cancer care costs discussion women with metastatic breast cancer experience a range of changes in work for pay and engage in a wide variety of costmanagement strategies to cope with the costs of their cancer care we observed racialethnic differences in the prevalence and types of work changes and costrelated coping behaviors reported by participants in our study specifically women of color were more likely than their nonhispanic white counterparts to report adverse changes in their employment status due to the burden of their cancer care furthermore stoppingrefusing treatment was the most commonly reported costmanagement behavior among patients of color while using savings and skipping a vacation were the most common financial coping practices reported among nonhispanic whites these findings highlight the need for an equity prioritization lens in efforts aimed at addressing financial burden among cancer patients higher prevalence of adverse changes in work for pay among women of color likely reflects racialethnic differences in the types of jobs held by persons of color relative to their white counterparts national data indicate that on average blacks and hispanics are more likely than whites to be employed in service transportation and manual labor positions but less likely to hold management professional and related positions 18 as such racialethnic differences in employment categories have implications for racial variations in changes in work for pay as individuals in service transportation and manual labor positions generally have less flexibility and autonomy in determining their work roles and schedules as well as less job security relative to persons employed in managementprofessional positions 1920 furthermore given the persistent physical side effects of metastatic cancer treatment and the physical demands of many service transportation and manual labor positions individuals in these positions may face additional barriers in performing their job duties that can affect job retention more research is needed to further elucidate associations between raceethnicity job type and changes in work for pay among cancer patients as well as identify strategies for addressing the disproportionate burden of work discontinuation and other adverse effects of cancer treatment on employment among persons of color indeed past research suggests that increasing employer support for employees with cancer including accommodating alternative work schedules and responsibilities is critical to work continuation and return 21 such practices are also consistent with employmentrelated nondiscrimination policies such as the american disabilities act which requires employers to provide reasonable accommodations to employees or job applicants with a disability 22 additionally ensuring equitable access to physical and occupational therapy may help mitigate the abovementioned barriers to job performance and retention in patients of color similarly early identification of individuals at highrisk of adverse work changes and creating systems of support for these individuals can help offset the negative impact of cancer care on work status racialethnic disparities in cancer patient survival are welldocumented and partly attributable to racialethnic differences in treatment completion 2324 in this study treatment refusaldiscontinuation was the most commonly reported costmanagement behavior among patients of color suggesting that financial burden over and above socioeconomic status is a potential key driver of racialethnic inequities in survival among metastatic breast cancer patients as such supportive cancer care services that address financial burden particularly among patients of color hold much promise for helping to mitigate racialethnic inequities in cancer care outcomes interestingly very few patients in our study reported that they applied for and received financial assistance for their cancer treatment costs in a recent study of oncology navigators perceptions of financial burden and financial assistance resources our team identified several barriers to patients obtaining financial assistance including lack of financial assistance resources at hospitals limited knowledge about available resources and complexduplicative application processes 25 thus to improve equitable access to financial assistance services it will be important to establish systems within cancer hospitals that enhance transparency regarding available financial resources and coordination for patients seeking these resources it is also worth noting that the costmanagement strategies most commonly reported among nonhispanic whites included using savings and skipping a vacation yet most of the patients of color in this study were more likely to report other costmanagement behaviors such as stoppingrefusing treatment borrowing money from friends and skipping payments on nonmedical bills these racialethnic differences in the types of coping behaviors employed likely reflects broader national trends in wealth and access to economic reserves for example prior research has shown that for every dollar of wealth that whites possess blacks have 6 cents and latinos have 7 cents 2627 these longstanding wealth inequalities need to be taken into account in broader discussions related to addressing financial toxicity particularly among patients with metastatic disease who are more likely to face prolonged financial strain due to their ongoing need for cancer treatment there are limitations to this study that are worth noting first this study cohort is a convenience sample of patients with metastatic breast cancer who were members of a metastatic breast cancer support network and willing to complete an online survey thus participants in this study may be a more engaged patient population and may differ from the broader population of patients with metastatic breast cancer in ways that are meaningful to our study outcomes consistent with this notion we found that participants in this study were relatively younger than the general population of women living with metastatic breast cancer in the us 28 prior research suggests that younger and workingage cancer survivors are at great risk for financial burden 1029 thus additional research is needed to assess racialethnic variations in financial coping across age subgroups of patients with metastatic breast cancer moreover given our focus on metastatic breast cancer findings from this study may not generalize to other cancer types or disease stages despite these limitations this study has several strengths that make it a novel and important contribution to the literature such as our large and racially ethnically diverse sample that included understudied groups of patients of color additionally our intentional focus on patients with metastatic disease provides insight into the distinct financial challenges faced by a group of patients with indefinite treatment trajectories conclusion women with metastatic breast cancer experience substantial financial burden as a result of their cancer treatment importantly our study suggests that patients of color experience more adverse changes in work for pay and financial coping than their white counterparts given the negative impact of financial strain on patient wellbeing and treatment decisionmaking as well as longstanding disparities in cancer outcomes equity must be a guiding principle in strategies aimed at addressing financial toxicity in cancer patients supplementary material refer to web version on pubmed central for supplementary material bars represent 95 confidence intervals analysis adjusted relative risk of each behavior relative to nonhispanic whites after adjusting for clinical characteristics and socioeconomic characteristics significance assessed using a wald test includes only those who applied for financial assistance analysis adjusted relative risk of each behavior relative to nonhispanic whites after adjusting for clinical characteristics and socioeconomic characteristics significance assessed using a wald test

ms sellers reports payment as a consultant with pfizer which was unrelated to the submitted work none of the other study authors have any conflicts of interest to disclose beyond receiving independent grant funding from pfizerall procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional andor national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standardsthe experiments conducted in this study comply with the current laws of the country in which they were performedinformed consent was obtained from all individual participants included in the study

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background modern family planning methods have become more broadly accepted and used as a replacement for traditional methods and as one of the interventions to most empower women women empowerment as an important goal for achieving national development goals needs to be strengthened and sustained to ensure that women exercise their responsibilities and enjoy their human rights 1 2 3 women status and empowerment have been found to be associated with longer birth interval lower rate of unintended pregnancy and lower fertility rate 3 through fp programs women have been given access to modern contraceptives allowing them to better meet their fertility preferences and to avoid unwanted pregnancies and their potential complications 4 5 6 7 nonetheless even in highly developed countries such as the us unintended pregnancies remain high 8 and constitute a health and socioeconomic burden for women and their partners 910 an obvious explanation is that there remain sociocultural barriers and perceived health risks associated with the use of new fp methods 11 12 13 previous research has shown that the main challenges facing women and preventing them from using modern contraceptive methods include the social pressure on women to prove their fertility immediately after marriage and the fear of side effects and negative consequences of modern fp methods 14 15 16 in a recent qualitative study involving 42 focus group discussions with jordanian and syrian young couples there was a strong belief among participants that most modern fp methods can have serious side effects that could harm womens health including bleeding hypertension diabetes foetal abnormalities and cancer 17 these concerns often drive married couples to use less effective but safer methods such as withdrawal and condoms womens personal experiences knowledge and perceptions of how a fp method might impact their quality of life can influence fp decisions among women while different fp methods may have varying degrees of impact on womens healthrelated quality of life 18 there yet remains no consensus on the relationship between modern fp methods and the qol of women most of the previous research has focused on either single or limited types of contraceptives and on only one or two qol domains 19 20 21 22 23 24 25 for instance it has been found that combined oral pills statistically decreased general wellbeing among healthy women and reduced three of the six dimensions of the psychological general wellbeing index namely positive wellbeing selfcontrol and vitality 19 the authors concluded that even a modest reduction in general wellbeing could be of importance and could explain the high incompliance rate and irregular use of oral contraceptives 19 similarly sadatmahalleh et al observed lower sexual function and qol in women who had undergone tubal ligation than in women who had not hence concluding that tubal ligation is not a safe fp method 26 in contrast intrauterine contraception has been shown to significantly improve hrqol 20 on the other hand a recent systematic review by worly et al revealed that the available studies do not support a clear general association between progestin hormonal contraceptives and depression levels or incidence of depression diagnosis 25 modern fp use among jordanian women although the total fertility rate in jordan has declined steadily in recent decades to reach 35 in 2014 it has not changed significantly during the last few years 27 jordan has made some progress in meeting fp needs such that the use of modern contraceptives increased by 15 from 1990 to 2012 28 however the use of both modern and traditional fp methods has declined from 42 to 37 and from 19 to 14 between 2012 and 20172018 respectively among currently married women adopt a modern method of fp the most commonly used method is the intra uterine devices followed by the pill and the male condom 2829 the majority of modern contraceptive methods are accessible to women through the primary and comprehensive healthcare centers of the ministry of health oral contraceptives etonogestrel implants depo provera contraceptive injections male condoms and iuds are offered free of charge and there are some facilities for female sterilization the process of choosing fp methods in jordan is primarily influenced by the husbands decision and preference about 85 of women currently using contraceptives report that the decision to use any fp method was a shared decision with the husband additionally two thirds of those who report not using any method say that the decision not to use was also a mutual decision with the husband regardless of the education level women reported that they first discussed fp and the likelihood of using contraception with husbands doctors and midwives and friends oral contraceptives and iuds were the two most common methods suggested by those advisers when women decide to start using contraception physicians were the most sought person to give advice as they are highly trusted by women 2930 however a lack of comprehensive understanding of the impact of modern fp methods continues to exist among jordanian couples to date research addressing the impact of different modern fp methods on womens qol remains limited 31 32 33 34 a study found that women who had undergone tubal ligation and those who used injectable contraceptive were less likely to have average or better physical hrqol than women who used combined hormonal contraceptives and that women who used injectable contraceptive were also less likely to have average or better mentalhrqol 18 another study showed that women who had undergone tubal ligation had significantly worse physical functioning but better general health perceptions than women whose partners used condoms 32 to this end the primary aim of this study was to examine the relationship between the use of common modern fp methods and qol among jordanian women also identifying main predictors of qol was another aim of the study methods study design and setting a crosssectional household survey in two cities in jordan was conducted from april to december 2017 each city was stratified into 5 sectors based on geographical location and density of population housewives from each sector were visited in their houses and working women who were unavailable during the morning were visited in the afternoon an initial screening was first conducted to ensure that each woman was eligible and that she consented to participation in the study the screening questions included information on age health status medical history and whether the participant was pregnant if the woman was eligible the female interviewers explained to her the objectives of the study and assured her of the confidentiality of the interview before commencing with the interview itself talking about family planning methods is a sociocultural sensitive issue in jordan especially among young women many jordanian women usually feel embarrassed to discuss family planning methods and this led to a low response rate of around 15 of the household survey for this reason nonpregnant women who visited the obstetrics and gynecology clinic of king abdullah university hospital for contraceptive advice and followup consultations were also included kauh is a teaching referral hospital that provides a wide range of services ethical approval was sought and obtained from the institutional research committee of jordan university of science and technology after full clarification of the study aims and ethical considerations any woman who showed interest in participating and gave consent was included since contraception is a culturally sensitive issue in jordan willingness to participate voluntarily was a main inclusion criterion and thus a convenience sampling method was applied data collection and measures according to the latest national survey about 30 of jordanian women discontinued using the method within 12 months the most common reason for discontinuations was the desire to become pregnant followed by complaints that the method was inconvenient to use 29 consequently nonpregnant women of child bearing age who had been using a modern contraceptive method for the past year were interviewed through facetoface structured interviews three female researchers were trained to conduct the interviews where each one was responsible for conducting the interviews in a particular geographical locationarea a structured interview questionnaire guide composed of four main sections was used for data collection the sociodemographic data form included questions about the womans age number of living children age at marriage and religion the first section also included statements on socioeconomic status including educational attainment employment class monthly income housing tenure and the number of dependents the second section included questions on birth spacing and on the type duration of use and previous information of the modern fp methods used as well as previous knowledge of their side effects another questionnaire namely the arabic version of world health organization quality of lifebref was used as the measuring instrument for qol in the current study the whoqolbref is a cross cultural well validated generic questionnaire that has been employed in various clinical conditions in different countries around the globe 31 35 36 37 according to the who report 38 the whoqolbref serves as an adequate alternative instrument to the evaluation of domain profiles using whoqol100 with a total of 26 questions the instrument contains four domains namely physical health psychological social relationships and environment these questions use a five point likert response scale there are also two questions in the whoqolbref that are evaluated separately the first question asks about the participants overall perception of their qol and the second about the participants overall perception of their health 39 while the whoqolbref examines respondents perceived qol and can thus provide an overview of the participants perceived effects of disease and health interventions it is not supposed to act as an objective tool for measuring symptoms and disability therefore the whoqol is an assessment of a multidimensional concept incorporating the individuals perception of health status psychosocial status and other aspects of life 38 as per the who guidelines the mean score of questions within each domain is used to calculate the score of the domain means are multiplied by 4 and subsequently transformed into a 0 to 100 scale 38 the domain scores are comparable with the scores used in the whoqol100 and the mean score in each domain reflects womens perceptions of and satisfaction with each aspect of their quality of life the higher the score the better the response a permission to use the whoqolbref was obtained from the information evidence and research department the world health organization geneva the last section of the interview guide contained questions about side effects of modern fp methods and bleeding patterns at the end of each interview the participating woman was asked to read and check the filled data for accuracy and then she was voluntarily asked to sign the filled questionnaire each interview lasted about 20 min data analysis data was analyzed using r statistical computing software version 343 descriptive statistics including means standard deviations and percentages for collected data are presented qol scores for the four domains were calculated individually for each participating woman and then the total scores for each domain were summarized finally predictors of quality of life scores were identified through multiple linear regression and stepwise selection a 5 significance level was assumed throughout the analysis results five hundred fortyeight women aged between 18 and 49 participated in the study the participating women had been using a fp method for an average of 517 years discontinuously the results show that the average time from marriage to first pregnancy was 331 months and the average number of children per family was 379 the mean duration of spacing between births was 278 years detailed information on the participants is provided in table 1 around one third of the participants had a graduate or postgraduate academic degree around 33 had a family income less than 400 jds and 585 resided in rented accommodation in jordan there is no clear official definition of the poverty line however when taking into consideration the latest available data and reports an estimated family income of per month can be considered as the poverty line 4041 in accordance with the national figures about 95 of the participants were smokers 42 and only 1186 were employed 43 the results also show that about 952 of the participating women used a fp method without a doctors prescription unfortunately about 8066 of the women had no previous knowledge of the possible side effects of using fp methods and only 4672 of them had had enough information about fp methods before starting to use them as for the types of contraceptive methods used 4161 of the participants used iuds 2318 used oral contraceptives 1478 used implant and injectable hormonal contraceptives 62 used sterilization and 1423 reported that their husbands used condoms as a fp method only about 50 rated their qol as being good or very good and about 4088 were satisfied with their health status womens responses to qol related questions of the whoqolbref tool are summarized in table 2 based on these responses scores for the four qol domains namely physical health psychological social relationships and environment were calculated for each woman a summary of these domain scores along with the fp method used is shown in table 3 from highest to lowest average scores for the social relationships psychological physical health and environmental domains were 1332 1297 1294 and 1281 respectively on a scale of 420 women who used iuds had the highest qol average score for the physical health domain while those whose husbands used condoms had a much higher average qol scores for the psychological social relationships and environment domains than other womens groups multiple linear regression in combination with the stepwise selection method was used to identify the significant predictors of the domain scores and to identify the effect of fp methods on the qol of the participating women as the effect of the fp method used might be confounded with other variables such as the socioeconomic status and age all collected variables were used in the regression model to adjust for the effects of the fp methods significant predictors along with the model coefficients for the four domains are shown in table 4 multicollinearity among used predictors was assessed through variance inflation factors values for vif were all less than 10 indicating no multicollinearity issues significant predictors of physical health scores were level of education income residency employment status birth spacing side effects type of contraception quality of life rating and satisfaction with health in comparison to women who used ocs women who used iuds for family planning had the highest probability of good physical health scores followed by women who use implants and injectable hormonal contraceptives whereas those who used sterilizations were more likely to score low in the physical health score level of education number of children birth spacing side effects contraceptive method and qol rating were the significant predictors of the psychological domain scores similar to the physical health scores a negative effect was observed for sterilization while positive effects were observed for iuds and male condoms for the social relationships domain age income occupation birth spacing contraceptive method and satisfaction with health status were identified as the significant predictors in comparison to women who used ocs women who used iuds or implants and injectable hormonal contraceptives and those whose husbands used condoms were more likely to have better scores while those who used sterilization were more likely to score low in the social relationship finally age income smoking occupation period of contraceptive use birth spacing contraceptive method quality of life rating and satisfaction with health status were the significant predictors of the environmental domain scores for the environmental domain women who used iuds and those whose husbands used condoms as fp methods reported higher scores than women who used ocs however women who had received permanent sterilization had the worst environmental scores among all of the family planning methods to further investigate the effect of fp methods on qol multinomial logistic regression was used to identify significant predictors of side effects frequency bleeding frequency qol rating perceptions and satisfaction with health status rating identified significant predictors are shown in table 5 results indicate that the type of contraceptive method used was a key predictor of side effects bleeding qol perception and health satisfaction table 5 shows that women who had undergone sterilization reported the highest probability of frequent side effects while those whose husbands used condoms had a high probability of experiencing rare or no side effects women who used implant and injectable hormonal contraceptives had a very low probability of never experiencing side effects similarly women who had undergone sterilization and those who used iuds had the highest probability of bleeding results also show that women who used iuds had the highest probability of goodvery good quality of life perceptions while sterilized women had the lowest probability of goodvery good perceptions women who used iuds or implant and injectable hormonal contraceptives and women whose husbands used condoms had the highest level of health satisfaction while women who used oral pills and sterilization had the lowest health satisfaction discussion from social psychological and healthrelated viewpoints fp methods are of great importance in womens lives 4445 this study investigated the relationship between the use of common modern fp methods and qol domains among jordanian women in line with the latest jordanian national survey 20172018 29 our findings observed that the most commonly used modern fp method is the iuds followed by ocs the findings also revealed that about a tenth of jordanian women of reproductive age had previously used a modern fp method without medical prescriptions or advice furthermore more than half of the participating women did not have enough previous information about modem fp methods it has been found recently that the percentage of jordanian women who were not informed about side effects of modern fp methods ranged between 20 to 39 among various methods including pills female sterilization iud implants and injectables 29 nevertheless women who intend to use modern fp methods have the right to know the potential side effects and negative consequences of these methods including emotional psychological physiological and sexual consequences most women in developing countries including jordan prefer to get pregnant immediately after marriage 46 47 48 49 and hence an average time from marriage till first pregnancy of only 331 months was observed among the participating women often this short waiting period is a result of social pressure and reflects the tendency among young women to prove their fertility immediately after marriage regardless of whether they are physically and emotionally prepared 50 51 52 it has also been argued that in some cases jordanian women may use their ability to get pregnant soon after marriage as a way to raise their status and power among their inlaws this provides insight on why fp methods are usually only considered after the first child has been born 5354 based on the whoqolbref scale the overall mean scores of the four domains were found to be average with the social relationships mean score being slightly higher than the other domains and the environmental domain being slightly lower our results also revealed that women who used iuds and women whose husbands used condoms as fp methods had better qol in the four domains than women who used ocs in line with our findings a recent prospective observational multicenter study conducted in spain found that the levonorgestrel intrauterine system has a positive impact in terms of health related qol the results were obtained through conducting a secqol questionnaire at baseline and 12 months afterwards the study demonstrated improved scores in all domains of the secqol including the social menstrual symptoms breast symptoms psychological and sexual domains beside its efficacy as a fp method lngius provided women with additional noncontraceptive benefits 21 similar results were reported by singh from india 55 though iuds may cause mild side effects which may interfere with a womans qol such as irregular bleeding amenorrhea and hormonal disturbances 5657 women who used iuds and those whose husbands used condoms were nonetheless more satisfied than women who used ocs and sterilization the use of female condoms is uncommon among jordanian women and 1423 of the participating women in our study reported that their husbands used male condoms loss of sexual function and pleasure is reported as being the most devastating side effect of using condoms 5859 in consistence with our results a recent randomized doubleblind placebocontrolled trial which assessed the influence of a firstchoice combined oral contraceptive on general wellbeing and depressive symptoms found that contraceptive pills are associated with reduced general wellbeing selfcontrol and vitality among healthy women 19 also in japan it has been reported that ocs can worsen qol if used for contraceptive purpose only 60 on the other hand other studies have reported that ocs have no negative impact on qol especially among first time users 61 zhao et al conducted a prospective cohort study on rural women who used ocs and iuds in a chinese province the study found that oral pills and iuds could significantly improve overall qol 62 the mechanism behind reduction in wellbeing by the use of ocs among healthy women is yet to be discovered however the decrease in free testosterone level induced by ocs use and the direct progestininduced central nervous system effect may be the underlying causes behind reduced wellbeing 19 our results observed that women who had been using implant and injectable hormonal contraceptives have better qol in terms of the physical health and social relationships domains di carlo et al studied the impact of contraceptive implants on qol and sexual function among italian women their results showed that general qol and physical role status of the women improved significantly after use of the implant and that the implant had some positive effect on sexual function 63 in a review of evidence on implant contraindications satisfaction and rate of continuation amico et al found that whilst irregular bleeding was the most common reason for discontinuation of the implant most of the participating women reported an overall reduction in bleeding additionally complications related to its use insertion and removal were rarely reported 64 consistently the short form36 qol questionnaire was employed to evaluate the hrqol changes associated with the use of the depot medroxyprogesterone acetate injection along with its contraceptive efficacy dmpa was linked with improvement in perceived physical health and with no adverse effects on mental health and sexual function 65 to identify predictors of qol for women using fp methods multiple linear regression models were fitted to the scores of the four qol domains common qol predictors such as education level family income employment status and place of living were also identified as predictors of qol for women using fp methods significant method specific predictors were also identified including birth spacing experiencing side effects and type of modern fp method regression results indicated that the more frequent side effects the lower physical health women who used iud as their fp method had higher probability of better physical qol scores compared to women who used other methods those whose husbands used male condoms have shown higher probability of better qol scores for the psychological social relationships and environmental domains the multiple linear regression analysis confirmed that in comparison with women who used oral pills women who had chosen permanent sterilization as their contraceptive method had the lowest qol scores in all of the four domains this is not surprising given the adverse effects and negative consequences that tubal ligation can have on womens overall wellbeing including psychological wellbeing and sense of productivity 66 similarly bahrami et al adopted the to compare the effects of different contraceptive methods on womens qol and found that women who had used sterilization or injectable contraceptive had the lowest level of qol 67 the logistic regression analysis extended our findings and showed that women who had undergone permanent sterilization were more likely to experience side effects and vaginal bleeding than women who used ocs on the other hand women who had been using other types of modern fp methods had less likelihood of experiencing side effects and bleeding a study conducted on women who performed tubal ligation method found that one third of women perceived tubal ligation as a risky procedure that should not be performed whereas the majority of women indicated that they will not advise women to undergo this procedure 68 another study revealed that depression significantly increased after tubal ligation due to several factors including changes in selfimage fear of negative perceptions of other people and most importantly the husbands negative attitude towards the procedure 69 because female sterilization or tubal ligation is a permanent contraceptive method which requires a onetime effort some women still consider it to be the most convenient and effective fp method in an iranian study many of the participating women stated that their main reason for choosing sterilization was to avoid the side effects of other contraceptive methods however the study results showed that the mean total scores of the sf12 and sexual function were significantly lower in the female sterilization group than in the nonsterilization group 20 of the women in the sterilization group regretted their decision 26 the main reason why these women had chosen permanent sterilization was that they felt fully satisfied with their family size 26 however the most widely known biological change after terminating fertility by tubal ligation is the poststerilization syndrome which comprises symptoms such as hormonal disturbance menstrual irregularities and vaginal bleeding 70 71 72 this could explain why an increasing number of women are opting for reversible longacting fp contraceptive methods rather than permanent tubal ligation 73 our multinomial logistic regression analysis showed that women who used iuds and those who had undergone sterilization had a higher probability of experiencing vaginal bleeding than women who used ocs yet women who used iuds had the highest qol it has been argued that dissatisfaction due to bleeding profile is the most common reason for the discontinuation of a fp method 74 previous studies confirm that women who use iuds report higher levels of satisfaction than users of other fp methods 7576 our analysis also demonstrated that women who used ocs and permanent sterilization were less satisfied with their health status than women who used other modern fp methods strengths and limitations the current study has some limitations that need to be acknowledged first the sample collected through a crosssectional household design from only two cities in jordan in which all eligible women were chosen based on a convenience frame the convenience selectivity of the sample limits the generalizability of the findings as there is a possibility that women who agreed to participate in this study differed from those who refused to do so for example women who declined participation could have been unwilling to talk about their experiences with using modern fp methods or share their perceptions for several reasons that could directly impact qol regardless the authors tried to increase representativeness of the sample by stratifying each city into 5 sectors based on geographical location and density of population future research need to conduct a national survey using a randomization process to increase representativeness of the findings to a wider population second qol was selfreported and this might have been associated with false reporting as with all selfreporting surveys there is always a chance with inaccurate answers that overestimate patients responses due to many reasons including courtesy bias 77 recall bias andor social desirability bias 7778 however the whoqolbref is a cross cultural well validated generic questionnaire that has been employed in various clinical conditions including contraceptive use in different countries worldwide 31 35 36 37 67 future studies need to use more objective measures to assess the impact of modern fp methods on womens qol preferably using a longitudinal design to draw causal inferences additionally further research need to design andor use more relevant questionnaires that truly reflect and measure the real perceptions of qol among users of modern fp methods taking into considerations medical history and overall health status of women nonetheless the authors tried to cover some of these aspects in this study by asking women specific questions related to fp methods and qol such as birth spacing the type of method used duration of use and previous information of the modern fp methods used as well as previous knowledge of their side effects finally although we faced several difficulties in recruiting participants and in data collection this study can be considered the first study that attempted to explore the association between modern fp methods and womens qol in jordan implications the current study revealed that the overall average scores of the four domains of qol were relatively low among women who were using modern fp methods this raises an important question about whether jordanian women who are not using modern fp methods have the same low level of qol a national household survey in jordan found that females reported poorer hrqol in comparison with their counterpart males 79 thus more attention to this segment of the population need to be provided to improve all aspects of qol associated with reproductive health not merely those related to fp issues similarly more research need to be undertaken to compare qol levels among jordanian women who use either modern or traditional fp methods versus those who do not in order to establish a baseline for overall hrqol among jordanian women in general simple qol questions could be used by health care professionals as a screening tool for overall health at every medical contact our findings also call for establishing programs to assess qol among women in jordan and other arab countries focusing on the potential impact of modern fp use on overall qol these programs should be widely available for women who need it the most across the country however womens decisions about the best fp options are highly affected by the methods efficacy medical conditions personal subjective experience with side effects or negative consequences and the methods impact on qol 16 80 81 82 jordanian women have some misconceptions in regards to the use and side effects of modern fp methods even worse lack of trust between women and healthcare providers donates to the high percentages of discontinuation andor reluctance to seek alternatives 53 hence women who intend to use modern fp methods have the right to know the potential side effects and negative consequences of these methods including emotional psychological physiological and sexual consequences health care professionals especially trained midwives need to be willing to spend enough time with women especially at maternal and child health medical centers to increase their awareness about the realistic benefits and side effects of each of the modern fp methods in order to change some womens misperceptions in this regard and ultimately increase their adoption of effective methods this is of paramount importance in light of the findings of a recent national survey which found that more than 60 of jordanian women of childbearing age do not use any modern fp methods 29 further the results of this study shed light on the importance of providing effective counselling and education on fp methods to women of reproductive age in jordan and underlines a need to provide couples with premarital counselling on fp and potential risks associated with early pregnancy particularly in rural areas with high fertility rates importantly clinicians need to use a patientcentred approach when providing counselling about all fp methods and support womens reproductive autonomy 6483 this can be achieved by providing and securing various alternatives for women in regards to modern fp methods especially those that are perceived as well tolerated highly effective in controlling blood loss such as iud and definitely a better alternative to hysterectomy for women with heavy menstrual bleeding 55 the current study also found that women who used iuds and women whose husbands used condoms were nonetheless more satisfied and had better qol than women who used ocs and sterilization studies show that women who encounter complications while using a certain contraception method tend to have a lower qol similarly women who experienced side effects reported lower qol scores than those who did not 84 in the case of condom use it is less likely that women experience side effects thus they tend to be more satisfied indicating a need for designing and implementing specific interventions as a part of counseling practice that teach women ways to cope with side effects andor complications with various modern fp methods and evaluating the impact of these methods on both qol and sexual life 84 the relatively higher qol scores observed among women whose husbands used condoms raising the issue of male participation in the use of contraception a study conducted on male muslims in a ghanaian municipality concluded that condom is the most preferred and used modern contraceptive suggesting that male muslims need to be motivated to discuss fp with friends and wives as well as programs should be developed to focus on involving men in the decision of fp with women 85 this is very important given the fact that sociocultural factors could play a vital role in male involvement in fp therefore social support adequate information and shared responsibility can all motivate men to have a more vital role in fp and use of certain contraceptive methods additionally increasing literacy of reproductive health among men to improve their attitude and change their perceptions to better participate in reproductive health services is needed 8687 male participation in fp in turn enhances the status of women a qualitative study on iranian muslim women revealed that participants felt more empowered when shared fp decisions were made with their male spouses based on agreement and support 88 consequently more attention is needed to underpin strategies to encourage gender equity shared decision making shared responsibility and actual participation of men empowering women and to optimize worth of male participation 89 conclusion overall participating women reported relatively poor quality of life particularly those using oral contraceptive bills in comparison to those who use iuds and male condoms when comparing qol across different methods of modern contraceptives we found that women who used oral contraceptives and those who had undergone permanent tubal sterilization were likely to have a lower level of qol than users of iuds and implant and injectable hormones and women whose husbands used condoms also women who used oral contraceptives and women who had undergone tubal sterilization were less likely to be satisfied and had the highest probability of frequent bleeding being able to decide freely whether and when to have children is regarded as a fundamental reproductive health right and is strongly linked to womens health and quality of life qol spanish society of contraception qualityoflife sf12 short form health survey for evaluating qol tfr total fertility rate who world health organization whoqolbref world health organization quality of lifebref abbreviations dmpa depot medroxyprogesterone acetate fp family planning fr fertility rate hrqol healthrelated quality of life ier information evidence and research iuds intra uterine devices jd jordanian dinar kauh king abdullah university hospital lngius levonorgestrel intrauterine system ocps oral contraceptive pills ocs oral contraceptives pgwbi psychological general wellbeing index qol quality of life sd standard deviation secauthors contributions msa and hhh conceived the ideas of this study participated in the study design analysis and interpretation as well as drafted and amended for the manuscripts haa and naa carried out the statistical analysis and wrote the first draft of the results they also contributed in data interpretation da sm sq and sd contributed in study design data collection and interpretation of the results professor ysk critically revised the manuscript he also had a significant contribution to analysis and interpretation of data all coauthors read and approved the final draft competing interests the authors declare that they have no competing interests

background although jordan has made progress in meeting family planning fp needs in last decades recently the use of fp methods has declined significantly womens personal experiences knowledge and perceptions of how a fp method might impact their quality of life qol can influence fp decisions however a lack of comprehensive understanding of the impact of modern fp methods on womens qol continues to exist among jordanian couples therefore this study aimed to investigate the relationship between the use of common modern fp methods and qol among jordanian women methods using the whoqolbref questionnaire along with other questions nonpregnant women of reproductive age were interviewed at their homes through facetoface structured interviews women who visited the obstetrics and gynecology clinic of king abdullah university hospital for contraceptive advice and followup consultations were also included results a total of 548 women aged between 18 and 49 participated in the study based on the whoqolbref scale the overall mean sd scores of the four domains were found to be average our findings show that women who used intra uterine devices iuds and women whose husbands used condoms had better qol in the four domains physical health psychological health social relationships and environment than those who used oral contraceptives ocs women who used implant and injectable hormonal contraceptives had better qol in terms of the physical health and social relationships domains in contrast women who had undergone permanent sterilization had lower qol scores in all of the four domains further analysis revealed that women who had undergone tubal sterilization were less satisfied overall and more likely to experience side effects than women who used ocsthe choice to use contraceptives and decide freely whether and when to have children is regarded as a fundamental reproductive health right and is strongly linked to womens health and qol women who use ocs and women who have undergone permanent sterilization are likely to have lower qol than women who use iuds or implant and injectable hormones and those whose husbands use condoms

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introduction entry into the labor market is an important part of adolescents transitions to adulthood success or discontinuities in schooltowork transitions strongly affect occupational careers and behavior later in life from a developmental perspective transitions to work are influenced by both young peoples active efforts to shape their biographies and the structured set of opportunities and limitations that define pathways into adulthood quite a number of studies have shown that over and above educational attainment young peoples cognitive and noncognitive skills as well as their family resources influence both their continuation of education and occupational career moreover high aspirations have been shown to increase success in labor market entry even for early school leavers existing studies predominantly focused on the us and ukboth characterized by comprehensive school systems and general upper secondary education systems their findings may not apply to countries like germany or switzerland because qualifications are known to be a stronger signal in labor markets in tracked school systems which sort students early by cognitive skills and social origin and apprenticeship systems or occupational labor markets moreover existing research mainly looked at betweengroup differences and did not pay particular attention to individuals with similar school attainment furthermore they looked at entry into jobs as a dependent variable but did not differentiate between adolescents agency that is their application behavior and employer selection as constraints thus the interplay between agentic resources structural constraints and later outcomes is not well understood we therefore investigate the role of agentic resources application efforts and structural constraints on lowachieving school leavers success in the period of schooltowork transitions we thereby examine whether positive characteristics and active efforts can create new opportunities for them in this transition period supporting the integration of lowachieving school leavers into the labor marketor whether they face persistent disadvantage because of their low qualifications lowachieving adolescents are quite heterogeneous in terms of their personal and parental resources these withingroup differences may be associated with differences in adolescents application effort on the other hand we know that lowachieving school leavers face great difficulties in their schooltowork transitions thus agency may not matter for them because for example their early school experiences as lowachievers may result in generally low aspirations despite differences in cognitive or noncognitive characteristics and thereby in less active application efforts moreover the label of having low qualifications may strongly restrict the success of adolescents job application efforts owing to employers screening of applicants based on school certificates as a consequence lowachieving adolescents may have only few or no opportunities to demonstrate their productive cognitive or noncognitive potential in job interviews we study germany and look at entry into regular training positions our german study enables us to investigate how heterogeneous the group of lowachieving school leavers is in a highly tracked school system at the same time the german vocational educational and training system offers valuable opportunities for adolescents to continue their education and to learn an occupation below the level of higher education in this respect the german education system seems to be rather inclusive for lowachieving school leavers however the german training market is highly competitive and serves as entry into the labor market hence lowachieving adolescents who failed to enroll in apprenticeships bear a higher risk of being marginalized not only at the beginning but also throughout their entire worklife the german vocational education system the german school system is highly stratified students are tracked into different school types as early as age 1012 in addition the vast majority of students with disabilities attend specialneeds schools the german school system is also stratified in terms of the schoolleaving certificates that students can obtain at the end of lower secondary education the lower secondary certificate the extended lower secondary certificate and the intermediate certificate students may also leave the general school system without a secondary school qualification these schoolleaving certificates do not correspond precisely to the school types but can be formally obtained at all secondary school types in germany the group of lowachieving school leavers is therefore defined by schoolleaving certificates those who leave the general school system without or with only a lower or extended lower secondary school certificate according to this definition about 25 of the school leavers were classified as lowachieving school leavers in 2012 1 after leaving the general school system lowachieving school leavers are legally eligible to enroll in vocational education and training programs though they are not entitled to enroll in higher education they may enter regular firmbased training programs combined with schoolbased education regular schoolbased programs or prevocational training programs only apprenticeship and regular schoolbased training programs lead to nationally recognized occupationspecific certificates whereas the various prevocational programs do not lowachieving adolescents are free to apply to regular training programs firms and vocational schools however are likewise free to select candidates for their training places school leavers unable to find a regular training place usually contact the federal employment agency and are channeled into prevocational training programs seeking regular employment instead of training is usually not an option for them because vocational education is compulsory until at least the age of 18 in all german states in 2012 27 of the students enrolling in the training system entered prevocational programs the majority of them were lowachieving school leavers theoretical considerations on agency and constraints studies for germany provided inconsistent findings on the impact of lowachieving adolescents cognitive and noncognitive skills on their chances to enter regular training positions protsch and dieckhoff found that for adolescents with lower secondary school certificates only differences in school grades but not in noncognitive skills influenced their likelihood of entering regular training whereas for adolescents with intermediate secondary school certificates conscientiousness but not grades produced withingroup variability in contrast solga and kohlrausch observed that beyond school grades it was conscientiousness and teachers reports on students work behavior that influenced the training opportunities of lowachieving school leavers both studies found that differences in cognitive abilities did not matter in contrast to a swiss study by mueller and wolter they found that belowaverage math test scores reduced the chances of getting an apprenticeship whereas aboveaverage scores did not matter that is they did not increase these chances these studies did not however differentiate between the impact of these agentic resources on adolescents application behavior and the recruitment decisions of employers or vocational schools yet both sides together influence the chances to enter regular training programs in this section we will therefore provide theoretical considerations on why adolescents efforts may vary by agentic resources how this variation may matter for lowachieving adolescents success in their transitions into vocational training and why their low qualification may constrain the success of such effort adolescents agency search and application activities depend on applicants initiative in terms of where to apply how many times to apply for what occupation to applyall are based on adolescents abilities to make such decisions thus application efforts of lowachieving adolescents may differ by their decisionmaking abilities and resourcessuch as cognitive and noncognitive skills aspirations and parental support a substantial number of these school leavers are underachieversthat is they underperform in terms of grades and schoolleaving certificates compared to their cognitive abilities this learning potential may become advantageous during the transition period research has demonstrated that higher levels of competence and noncognitive skills are predictors of lower risks of educational dropout and higher early occupational attainment thus underachievers among those with low school attainment may experience new opportunities for using their cognitive potential in the job search and in subsequent trainingwork moreover career aspirations and plans have been shown to promote more successful transitions probably because of more frequent application efforts and more effective application decisions furthermore network resources are known to influence individuals job search behavior supply networks provide information on vacant apprenticeship positions and give secondhand accounts of experiences with job requirements the group of lowachieving adolescents is not random but socially selective their family members and friends are more likely to be less educated nonemployed or only employed in lowskilled jobs compared to their highereducated peers as a result many lowachieving adolescents know less about where when and how to apply besides this informational dimension of networks poor parental resources may be associated with a lack of parental guidance engagement support and monitoring which may result in fewer application efforts at the same time however those lowachieving adolescents who do possess better network and parental resources may be more active and systematic in their job search network resources may not only support adolescents search for training positions but also the success of their efforts networks help improve their reputation if network members are employed in firms with vacant job or training positions such recruitment networks would be particularly important for lowachieving adolescents because network members could testify to these applicants actual cognitive abilities practical skills or motivational potential irrespective of missing credentials or poor school attainment correspondingly a study by seyfried revealed that recommendations by family members neighbors and friends play a major role for german firms when hiring lowskilled persons thus adolescents application effort and its success may vary by their network resources but agency may be less developed among lowachieving school leavers in general regardless of their decisionmaking abilities and resources stigmatization owing to their mostly negative school experiences and biographies may reduce lowachieving adolescents application effort they may have learned about their inferior status in societytheir stigma of having low education this may lead to disidentification with educational goals and a voluntary withdrawal from the apprenticeship market to avoid possible humiliation and negative reactions from others lowachieving adolescents may not permanently but only temporarily withdraw from training markets and choose to first attend prevocational programs as an educational investment to increase their future training opportunities no matter whether that withdrawal is permanent or temporary stigmatization would result in the phenomenon that a substantial part of lowachieving adolescents select themselves out of the applicant pooleven those who possess higher cognitive and noncognitive skills and parental resources constraints for adolescents agency the success of lowachieving adolescents application efforts may be constrained however by the selection practices of employers and vocational schools one important source of restriction is competition according to human capital theory signaling theory and job competition theories educational attainment is viewed as an observable proxy for adolescents trainability and therefore serves as an important selection criterion in recruitment processes school type certificates and grades can be observed from school reports given that applicants successfully pass the first selection stage and are invited for tests and interviews competences and noncognitive skills can be observed by employers and vocational schools based on these theories applicants with lower educational attainment and skills may be placed at lower ranks in the applicant queueleading to lower probabilities of being selected for a vacant regular training position moreover the study by seibert and colleagues has shown that lowachieving adolescents ranks in the applicant queue vary by regional differences in the supply of and demand for training placesbecause competition is stronger in more constrained training markets 2 however in a study conducted in the german state of lower saxony solga and kohlrausch found that the training opportunities of school leavers from lower secondary schools did not vary by regional economic conditions moreover the cohort studies by kleinert and jacob and solga demonstrated that regardless of the respective supplydemand relationship lowachieving adolescents in younger cohorts had lower chances to access regular training programs than their counterparts in older cohorts this suggests that lowachieving applicants may not only be ranked lower in applicant queues but that employers exclude them from the applicant pool altogether employers and vocational schools may view lowachieving adolescents as not capable of successfully completing training programs several studies demonstrated that employers increasingly complain about lowachieving school leavers low or even nonemployability in germany this view of lowachieving adolescents has been evident in the discussion on training maturity over the last two decades today employers and vocational schools are less willing to choose lowachieving adolescents for their training placeseven if there is a shortage of higherachieving applicants this phenomenon of sorting individuals with low formal qualifications out of the applicant pool because of their supposed incapability is called the discrediting mechanism it is an extreme form of statistical discrimination by schoolleaving certificate in sum students resources acquired in school and at home may enhance their application behaviour and success of their school to work transition at the same time the usefulness of these resources and the success of adolescents efforts may be constrained by gatekeepers recruitment decisions the current study the main goal of this study is to better understand the interplay between agency and constraints in the schooltowork transition period of lowachieving school leavers in germany entry into regular training programs is an important step in this transition not only in terms of continuing with upper secondary education but also in terms of entering the labor market most previous research compared educational groups by looking at entry to jobs or training as the dependent variable without differentiating between adolescents application efforts and employers recruitment preferences moreover existing research has paid only little attention to withingroup differences in agentic resources and adolescents activities hence the group of lowachieving adolescents has mostly been viewed as a homogenous group in contrast we focus on the variability in schooltowork transitions within the lowachieving group from a developmental perspective we explicitly investigate both the impact of agentic resources acquired during schooling and at home on their application efforts and the constraints that may limit the success of their agency in the transitions to work the sample size of the data we usethe german national education panel studyenables us to explore the impact of withingroup heterogeneity this data set also provides rich information on adolescents school attainment cognitive and noncognitive competencies educational aspirations and vocational orientation and family background moreover information on local differences in youth unemployment allows for exploring the influence of economic conditions on their success in entering regular training based on the theoretical considerations presented in the previous section we derive the following hypotheses about why lowachieving adolescents agency during the transition period may open up new opportunities despite their low qualification first we expect that lowachieving school leavers with advantageous decisionmaking abilities and resources are more likely to apply for regular training places than those with poor abilities and resources higher decisionmaking abilities and resources are defined as higher levels of cognitive and noncognitive skills higher career aspirations and better vocational orientation and better network resources second we expect that better network resources also directly improve adolescents chances to access regular training programs controlled for application behavior that is school leavers may enter regular firmbased training programs through informal contacts or prior internships in this case they may not report having formally applied because they were not selected through a formal recruitment procedure we also developed some theoretical explanations of the factors limiting the success of their application efforts and hence causing them to experience persistent disadvantages because of their low school attainment lowachieving school leavers may withdraw from the training market because they feel stigmatized owing to their prior school experience we therefore expect that lowachieving adolescents with especially inferior prior school experiences apply less often for training places than lowachieving school leavers with a lower or extended lower secondary school certificate moreover the success of their application efforts is highly dependent on gatekeepers selection whether or not lowachieving adolescents actually apply may not matter for their training opportunities because they may simply not be selected by firms and vocational schools one reason might be competition applicants are ranked in applicant queues during the screening process based on their educational attainment and cognitive and noncognitive skills the ranking place may also depend on regional training market conditions lowachieving applicants may be ranked lower in more competitive contexts than in less competitive contexts we therefore expect to find that the lower the school attainment and the lower the competences and noncognitive skills the lower their chances of entering regular training programs we also expect that lowachieving adolescents are less likely to enter regular training in regions with more competition in contrast to competition the discrediting mechanism states that lowachieving adolescents are not only ranked lower in applicant queues but also excluded from applicant queues because they are viewed as not being trainable this mechanism is supported if lowachieving adolescents training chances do not vary by their application efforts and regional training market conditions additional support is provided if their training chances do not vary by cognitive and noncognitive skillsindicating that lowachieving applicants are not invited to job interviews in which they could demonstrate their skills methods data and sample we use data from the socalled starting cohort 4 of the german national educational panel study in this cohort all respondents attended grade 9 at german secondary schools in fall 2010 the sample design followed a stratified twostage sampling strategy sampling first schools and then classes within schools the students were surveyed once or twice each year as long as they were still in the general school system they were interviewed in the classroom context via paperandpencil interviews afterwards they were surveyed individually with computerassistedtelephone interviews or computerassistedpersonal interviews we use the scientific use file suf sc4 700 which includes the first seven waves for this cohort 3 the total sample of students who agreed to participate in the study consists of 16425 students 16379 of these students participated in at least one wave 23 of the respondents attended lower secondary schools 20 intermediate secondary schools 18 comprehensive schools or schools with multiple tracks 32 universitypreparatory schools and about 7 specialneeds schools for learning disabilities this distribution is not the actual distribution of 9th graders in 2010 because students from three school types were oversampled students from lower secondary schools and from specialneeds schools and students from comprehensive schools in our descriptive analyses we account for this oversampling design by using corresponding design weights that adjust for both the sampling design and panel attrition the incorporation and oversampling of students from specialneeds schools makes the neps one of the very few data sets that includes a large group of students with learning disabilities 4 this is particularly important for our study as these students constitute a substantial part of school leavers without a school certificate among the respondents were 31 lowachieving school leavers 32 respondents who left school also after grade 9 or 10 but with a higher certificate and 37 respondents who stayed in the general school system after grade 10 for our study we only used the subsample of lowachieving school leavers that is those who left school with less than an intermediate school certificate after grade 9 and 10 we restricted this subsample to those for whom we have valid information on their status in october after they left school these restrictions left us with a sample size of 3417 lowachieving school leavers with a slightly lower share of females than in the total sample in line with the literature because boys are often found to be overrepresented among lowachievers our respondents were on average 167 years old at the time they left general school this corresponds to official statistics panel attrition was quite low in the first seven waves a total of 1289 students from the original sample dropped out of the panel permanently it is not possible to state how many of the dropouts belong to the group of lowachieving adolescents because being classified as lowachieving school leavers requires that we can observe respondents until they leave school in order to know about their schoolleaving certificate by definition this is not the case for those who dropped out of the neps earlier taking the school types they attended in grade 9 as a proxy attrition analyses found that students who attended lower secondary schools and specialneeds schools had a significantly higher propensity of panel attrition than students from higher school types this selective panel attrition is another reason why we use nonresponseadjusted design weights in our descriptive analyses dependent variables in our analyses we used two dependent variables whether lowachieving adolescents applied for regular training places and whether they were able to directly enter regular training programs controlled for their application effort application to regular training programs students were asked whether they applied for a training position in the first wave after they left school 59 of our sample applied we have no indication of potential underreporting by students who applied unsuccessfully because the percentage of respondents with applications is much higher than the percentage of those who entered regular training programs entry into a regular training position our second dependent variable is defined as entry into regular training programs or not in fall directly after leaving school we classified respondents in two groups as follows in each wave of the neps respondents were asked to report all episodes of school regular training and prevocational program attendance and other kinds of activities until the interview as many prevocational programs and some regular training programs are schoolbased respondents sometimes had difficulties differentiating between school prevocational and training episodes when reporting their activities we therefore inspected and edited the reported school episodes in the following way first we prioritized vocational and prevocational programs over school episodes if they were reported concurrently second we defined school episodes at vocational schools as regular training programs when students reported pursuing a vocational certificate and as a route to obtaining the abitur when students reported seeking a university entrance qualification 5 if students reported neither of these two options school episodes at vocational schools were classified as prevocational programs some students reported an internship or being on parental leave working or unemployed these activities are classified as others in our sample 39 of the respondents started a regular training program and 51 a prevocational program only 10 belonged to the other category the latter group is small because most of our students were under age 18 when leaving general school and thus had to remain in education for the sake of simplicity and because of the small numbers we grouped prevocational participation and the other category together for our multivariate analyses in many characteristics the subgroup others resembles those who started prevocational programs we also reestimated all models with entry into training instead of prevocational participation excluding the other group the results were very similar and substantially the same as reported in the article among those who started a regular training program 72 entered firmbased training programs and 28 schoolbased programs in our analyses we did not differentiate between the two types because of the rather small number of observations for the latter the robustness check in which we reestimated our models only including those with apprenticeships showed that the results were robust independent variables in the following we provide information on the independent variables of our analyses distributions and descriptive statistics of our independent and control variables are presented in table 1 schoolleaving certificates the schoolleaving certificate was reported by the respondents in the first wave after leaving school in vertical order we differentiated between extended lower secondary lower secondary certificate and no schoolleaving certificate school types we differentiated between lower secondary schools specialneeds schools and other types of schools at the time of leaving school this information is available from the sampling plan for respondents who did not change school after grade 9 otherwise it was reported by the respondents in the first wave after leaving school the share of those who attended lower secondary schools in our study is very similar to the 52 reported in official statistics however the share of those 6 these lower shares in our sample at least partly result from the fact that the neps only includes students at specialneeds schools for learning disabilities whereas official statistics include students at all types of specialneeds schools thus our shares may be representative of this subgroup grades the final grades and grade point average on students schoolleaving certificate were reported by respondents we used the gpa on a scale from 1 equal to failed to 6 if the final gpa is missing the average of the grades in mathematics and german on earlier report cards was used instead resulting in a very low itemnonresponse of less than 2 the mean gpa is 40 and understandably lower than the mean gpa of those who left school with an intermediate certificate the differences within the lowachieving group are also plausible it is lowest for those without a certificate and highest for those with an extended lower secondary certificate cognitive competences the neps administered competence tests in starting cohort 4 except for specialneeds school students the neps consortium has developed competence tests for different domains scaled by using models of item response theory the competence tests used four different response formats simple multiple choice complex multiple choice matching items and shortconstructed responses the neps provides the weighted maximum likelihood estimator which is a typical point estimate expressing the most likely competence score for each single person given the item responses of that person we used the tests administered in grade nine in our analyses we employed the average of the zstandardized mathematics and reading wle scores we zstandardized this average with a mean of zero and a standard deviation of one on average the competences of lowachieving adolescents were quite low as one would expect nearly one standard deviation lower than the competence mean of the entire sample of the neps starting cohort 4 school leavers with an intermediate certificate by comparison scored near the mean however variation within the lowachieving group is quite remarkable noncognitive characteristics we used a measurement of conscientiousness one dimension of the common five factor model of personality which also includes extraversion agreeableness neuroticism and openness the neps used a 10item short version of the wellknown big five inventory developed by rammstedt and john as we need many independent variables for testing our hypotheses we decided not to use all five dimensions but only conscientiousness our choice was driven by the idea that this dimension is closest to what is needed for successful job search and application behavior we also tested this empirically and found the correlation between conscientiousness and our dependent variables to be higher than for the other four dimensions conscientiousness was measured by two items in grade 9 on a scale of 1 to 5 students had to assess the extent to which the following statements apply to them i am easygoing and tend to be a bit lazy and i am thorough given the twoitem measurement the cronbachs α of 053 is low in conventional terms lacking an alternative better measure of personality traits we still used it although we may not best capture conscientiousness we also included students global selfesteem here the neps uses a revised version of the german adaptation of rosenbergs selfesteem scale consisting of 10 items and using a scale of 1 to 5 the cronbachs α is 085 for our sample for example students had to assess the extent to which the following statements apply to them i have found a positive attitude towards myself or i can do many things just as well as most other people for both measures we used zstandardized measures in our multivariate analyses a limitation is that neither conscientiousness nor selfesteem were assessed for specialneeds school students network resources we could not study the quality of network resources directly 7 we know that parents play an important role in their childrens search for training we therefore used parents employment status highest socioeconomic status and education as proxies for respondents potential network resources also in view of whom they know in their broader radius like relatives and friends to define parental employment we used students reports in grade 9 on whether their parents were working looking for a job or inactive at the time of survey we distinguished between no employed parent one employed parent or two employed parents by comparison about 77 of adolescents with an intermediate certificate had two employed parents as students had to apply to regular training programs one year in advance in order to enter training programs directly after leaving school the information in grade 9 is still reasonably valid for our analysis the occupational status of parents was measured by the international socioeconomic index of occupational status the isei is based on an optimal scaling procedure assigning scores to occupations in such a way as to maximize the role of occupation as an intervening variable between education and income the isei08 scale ranges from 11 to 89 the information on occupations collected in grade 9 is based on parents reports when available and on students reports otherwise if both parents were employed we used the higher isei of the two jobs the mean parental isei of lowachieving adolescents parents was 395almost 8 isei points lower than the mean for adolescents with intermediate certificates variation within the group of lowachieving adolescents is quite considerable as indicated by a standard deviation of about 18 isei points we used information on highest parental education based on parents reports if available and based on students reports otherwise we used the level of education of the higher educated parent and differentiated between no schoolleaving certificate lower secondary certificate intermediate certificate including completed regular vocational training universityentrance qualification and tertiary certificate in our sample the highest correlation between the three parental background variables is 45 for the detailed parental education and parental isei which is very reasonable for the german labor market the correlations between parental education and employment and between employment and isei are only 15 and 16 respectively for our multivariate analysis we therefore used a less detailed education scale only differentiating between the highest educated parent holding at least an intermediate certificate and less than an intermediate certificate with a correlation of only 34 with parental isei career plans as a first indicator of adolescents occupational orientation we looked at whether students were able to report a desired occupation in grades 9 and 10 students were asked considering everything you know right now what occupation will you most likely pursue in the future we coded 1 if students reported a desired occupation and 0 if students did not report one in the last wave before leaving school on average 74 of the lowachieving school leavers were able to report a desired occupationranging from only 68 of those who left school without a school certificate to 79 of those holding an extended lower secondary certificate the desired occupations seem to be quite realistic as the mean isei of the reported occupations is only 37 on averageranging from only 32 for those without a certificate to 40 for those with an extended lower secondary certificateand thus in the lower half of the isei scale as well as considerably lower than the mean isei for school leavers with an intermediate certificate our second indicator is adolescents training aspirations we used the information on whether respondents originally planned to do vocational training right after school collected in the first wave after leaving school one could argue that this retrospective response might be biased by the success of adolescents applications the high proportion of 75 who reported such a plan compared to only 39 who entered regular training programs suggests that if such a bias existed it should be very small neps also provides a prospective measure with a different wording and thereby associated with a slightly different meaning here students were asked what they expected to do after leaving school not what they wanted to do the retrospective question is more suitable for capturing students aspirations for doing a regular training program indicated by the fact that 70 of those who prospectively expected to enter prevocational education did not aspire to it as their response to the question was that they planned to pursue regular training after leaving school local training market situation the provision of firmbased training places correlates with the local economic situation we therefore used the local youth unemployment rate among young people under 20 years old as a proxy for the local apprenticeship market situation we linked the neps data to this unemployment rate at the municipality level based on respondents residential address the information was provided by the institute for employment research we used data for the year of leaving school that is for the 3rd quarter of 2011 and 2012 respectively the local unemployment rates ranged from zero to 218 for our multivariate analyses we used zstandardized rates reasons for participation in prevocational programs to better assess why lowachieving adolescents did not enter regular training programs we used the following information in our descriptive analyses respondents who entered prevocational programs were asked about their reasons and provided with the following response options i wanted a better qualification control variables we included gender migration background and german state as control variables gender was taken from school records in grade 9 based on students selfreports we defined students as having a migration background if they themselves or both parents were born outside germany in addition we included dummies for the 16 german states in which a student attended school this way we accounted for differences between states and took the sampling design into account we are not allowed to report the estimates of the states dummies owing to neps regulations in the analyses of adolescents application effort we used the local youth unemployment rate as a further control variable plan of analyses to test our hypotheses regarding the impact of agentic resources on lowachieving school leavers application efforts and their eventual success in entering regular training programs we estimated a series of logistic regressions first on their application efforts and second on the odds of entering regular training programs instead of prevocational programs or other activities controlling for whether they applied or not for methodological reasons and for easier interpretation we will report average marginal effects socalled ames the ames display the percentagepoint change in the probability of the dependent variable for a oneunit change in the respective independent variable in contrast to odds ratios ames are comparable across different model specifications continuous variables were zstandardized based on our subsample of lowachieving respondents to provide meaningful comparisons of the sizes of the ames because of the sampling design we estimated survey logit models and included dummies for the german states we used nonresponseadjusted design weights in our descriptive but not in our multivariate analyses as suggested by steinhauer and zinn we dealt with item nonresponse by imputing the data using the mice algorithm in stata 14 schoolleaving certificates school types gpa competences and noncognitive skills were expected to have an effect on both dependent variables the same applies to the parental background variables by including information on whether school leavers applied for training places into the regression on the odds of entering regular training we assume to control for the influence of adolescents application efforts and thus to observe the influence of these independent variables on the employervocational school selection side we faced some restrictions in our analyses first competences and noncognitive characteristics were not assessed for specialneedsschool respondents thus the test of our hypotheses is limited for these respondents we therefore estimated the final regression models twicewith the full set of independent variables for the sample without specialneedsschool students and with the limited set of variables including these respondents second we could not test directly the discrediting mechanism this would require an experimental design controlling for all other potential sources of disadvantage on the applicants side and at the local level we therefore argue that it is fair to assume their applications were not considered if we find that respondents training opportunities are not higher when they applied and if they do not vary by cognitive and noncognitive skills and the local market situation this interpretation presumes that all other mechanisms that might be at work here have been considered and measured in a way that accounts for the entire variance besides potential measurement errors although we certainly cannot rule out these potential error sources we would like to point out that we did much more than most other studies by allowing not only one but multiple individual characteristics to affect the training opportunities and by including competition at a finegraded local level we conducted several robustness checks with different specifications of variables models and subsamples overall the results proved to be robust results descriptive results only 39 of the lowachieving school leavers were able to enter regular training programs directly after school figure 1 shows that the training opportunities differ strongly by schoolleaving certificateranging from 55 of the school leavers holding an extended lower secondary certificate to only 10 of those without a schoolleaving certificate 8 correspondingly the proportion of those who enrolled in prevocational programs ranged from 30 to 77 and is much higher than the proportion among school leavers with an intermediate certificate who in turn more often continued with general education to pursue a university entrance qualification which lowachieving adolescents cannot do directly their application rates were much higher than their rates of successful entry on average and for all subgroups 59 of lowachieving school leavers applied ranging from 67 to 36 see table 1 above figure 2 displays the distributions of combined mathematics and reading competences although the distributions differ by schoolleaving certificate in the expected way we see a considerable variation within each subgroup as well as substantial overlaps in the competence distributions of lowachieving adolescents and school leavers with an intermediate certificate these overlaps indicate that quite a substantial share of school leavers with low formal qualifications are underachieversthat is they left school with lower qualifications compared to their relatively high levels of competences table 2 presents first descriptive findings on the importance of differences in agentic resources for lowachieving adolescents training opportunities we differentiated between lowachieving adolescents who entered regular training programs who started prevocational programs or who pursued other activities we focus on the comparison of the first two groups trainees had considerably higher educational attainment in terms of level of schoolleaving certificate and school type attended than prevocational participants they also more often had two employed parents in contrast the differences between the two groups in terms of grades mean levels of math and reading competences and of noncognitive skills and parental occupational status were very small the subgroups did not even differ in parental education we see that those who entered regular training applied much more often than prevocational participants yet we also observe that about 24 of trainees did not report that they applied for training most probably they got their training places by referrals or after internships the application difference between trainees and prevocational participants does not mirror differences in their aspirations the proportion of prevocational participants who planned to do a regular training program is high and not much lower than the proportion among the trainees the same is true for career orientation the proportion of prevocational participants who reported a desired training occupation is only slightly lower than the one of trainees compared to trainees prevocational participants reported occupations with lower occupational status expressed as the mean isei score indicating that their occupational aspirations were not unrealistically high the mean local youth unemployment rate was higher in the regions of those who started a prevocational program compared to those who entered regular training programs though the mean unemployment rate was quite low for both groups finally prevocational participants reported the following reasons for starting a prevocational program 52 wanted but did not get a regular training position the majority of prevocational participants hoped to improve their educational qualification and thereby their future training opportunities but 41 of prevocational participants lacked career guidance reporting they did not know which training program to choose application efforts table 3 reports the average marginal effects based on a logistic regression analysis on the odds of applying to regular training programs adolescents application efforts differed strongly by schoolleaving certificate those without a schoolleaving certificate were about 20 to 25 percentage points less likely to apply than those with lower secondary certificates while those with an extended lower secondary certificate were 4 to 5 percentage points more likely to apply these differences are independent of the gpa on the schoolleaving certificate the effect of gpa is close to zero and not significant in contrast the school type attended had an additional and substantial impact on adolescents application effort schoolleavers from specialneeds schools were 16 percentage points less likely to apply than those who attended a lower secondary school even when they had the same schoolleaving certificate gpa career orientation and parental resources given that the majority of them left school without a certificate the typical specialneedsschool student had a 36 percentagepoint lower application rate than the typical school leaver from a lower secondary school interestingly school leavers from other school types showed a 5 to 7 percentagepoint lower application rate than those from lower secondary schools this higher likelihood is partly explained by the fact that school leavers with higher math and reading competences were less likely to apply this result indicates that some of the better performing lowachieving students decided more often to attend a prevocational program most probably to improve their educational attainment before entering regular training concerning the noncognitive characteristics more conscientious school leavers applied significantly more often controlled for parental background the effect is not significant in general the effect size is rather small an increase of one standard deviation in conscientiousness increased the application rate by only 2 percentage points the effect for selfesteem was not significant career orientation had a strong influence on adolescents application activities those who planned to do regular training applied substantially more oftenindicated by an increase in the application rate of 31 to 32 percentage points net of other potential factors this is the largest effect on application behavior in addition those who reported a desired occupation were 5 to 6 percentage points more likely to apply finally parental resources played a minor role for adolescents application efforts parental education and employment were not significant for the isei of the highest parental occupation we observe a significant and very small effect similar to higher competence levels the effect is negative an increase of one standard deviation in parental isei decreased the likelihood to apply by 2 percentage points entry into regular training positions table 4 reports the results of a logistic regression on the odds of entering regular training positions school leavers who applied were 16 to 20 percentage points more likely to enter regular training programs than those who did not apply net of application the ability to report a desired occupation increased the training chances additionally by 7 to 11 percentage points net of application effort adolescents schoolleaving certificate strongly affected the likelihood of entering regular training programs school leavers with an extended lower secondary certificate were 7 to 8 percentage points more likely to enter regular training than those with a lower secondary certificate in contrast adolescents with no certificate were about 21 to 22 percentage points less likely than those with a lower secondary certificate the inclusion of respondents from specialneeds schools reduced this effect size only a little bit figure 3 reports the interaction between application effort and schoolleaving certificate applying is associated with higher training chances for all three groups but the effect sizes differ remarkably between the groups that is applying paid off more for school leavers with a lower secondary certificate than for adolescents without a certificate for the former their application effort increased their training chances by about 30 percentage points for the latter that increase was only about 14 percentage points training chances did not differ by regular school type however lowachieving adolescents from gpa significantly affected training chances even when controlled for schoolleaving certificate and other variables an increase of one grade was related to a 9 to 10 percentagepoint higher probability of entering regular training in contrast models 24 show that the effect size of competences conscientiousness and selfesteem were small and not significantthough lowachieving school leavers differed quite remarkably in these characteristics we tested whether the effects of competences were already taken up by schoolleaving certificate school type or gpa by reestimating model 2 adding only math and reading competences again the effect size was zero 9 labor market conditions positively influenced training opportunities one standard deviation of increase in the local youth unemployment rate reduced the odds to enter regular training by 4 to 5 percentage points net of other characteristics parental education and occupational status did not affect lowachieving adolescents training chances whereas parental employment did those with no employed parent were 13 percentage points less likely to enter regular training when including school leavers from specialneeds schools the effect size decreased to 7 percentage points and lost its significance we reestimated model 5 separately for school leavers from specialneeds schools and for those from regular schools for the latter we found a negative effect of no parent employed as in model 4 while the effect for those from specialneeds schools was 001 in other words parental employment only mattered for lowachieving adolescents from regular schools in sum career plans and vocational orientation as decisionmaking resources influenced adolescents application efforts however skills and parental resources did not a positive association between parental resources and entry into training was only found for lowachieving adolescents from regular schools but not for those from specialneeds schools moreover the results provide strong empirical support for withdrawal because of stigmatization on the one hand and for job competition restricting the success of application efforts owing to gatekeepers selection on the other we observed however considerable differences in the impact of application on training chances by schoolleaving certificateranging from only 14 percentage points for those without a certificate to 30 to 31 percentage points for those with a lower secondary certificate robustness checks besides the robustness checks reported above we reestimated several other model specifications variable definitions and subsamples the results for application efforts and odds to enter training were robust for all robustness checks conducted we only compared respondents who entered apprenticeships to those who started prevocational education or other activities the results were also robust when excluding respondents with other activities after leaving school we included parental education in a more differentiated way we also tested a nonlinear relationship between application effort and conscientiousness and selfesteem respectively by including also quadratic terms for the two latter variablesbecause moderate levels of these two personality characteristics may be better than the two extreme points the quadratic terms were not significant and the main effects did not change we did the same for the odds of entry into regular vocational training the results were the same we tested alternative indicators for the local labor market situation we also included schoolleaving age in all these specifications the results reported in 3 and4 proved to be robust we additionally reestimated model 3 of table 4 by including an interaction term of the local unemployment rate with respondents schoolleaving certificate in doing so we explored whether the influence of the local unemployment rate on the odds of entry into regular training programs differed by schoolleaving certificate the coefficients of the interaction term were not significant discussion in this article we investigated whether the schooltowork transition period provided lowachieving school leavers with new opportunities or whether they still faced persistent disadvantage owing to their low qualification regardless of their agentic resources and efforts existing research has demonstrated that cognitive and noncognitive skills aspirations and parental resources shape individuals continuing enrollment in education as well as their early occupational career and later work life in our study we investigated whether adolescents efforts and initiatives to search and to apply for a regular training position were influenced by these decisionmaking abilities and resources we also looked at the success of their application efforts given that employers use educational certificates in their first screening of applicants we studied the entry of lowachieving adolescents into regular vocational training in germany which can be regarded as the equivalent to entering the labor market the results of our analyses show that lowachieving adolescents with better decisionmaking abilities made stronger application efforts however only higher aspirations career plans and vocational orientation predicted a higher likelihood to apply for training places in contrast to existing population studies we found that neither cognitive and noncognitive skills nor parental resources had an effect on adolescents application efforts and the success of these applications the reason for these findings is not that lowachieving adolescents competence levels and noncognitive skills are too lowafter all there is considerable overlap in their competence distributions with those of school leavers with intermediate certificates and quite similar mean levels of noncognitive characteristics the findings rather indicate that the existing underachievers had little opportunity that employers discovered their learning potentialbecause of employers screening of applications based on school attainment schoolleaving certificate and school type had the strongest impact on lowachieving adolescents application effort and the success of this effort the most vulnerable lowachieving school leavers among themthose who left school without a certificate andor attended a specialneeds schoolapplied much less frequently compared to their better performing peers and submitting applications improved their chances to enter regular training programs only to a small extent in contrast applications of those with a lower secondary school certificate strongly increased their training chances thus the success of lowachieving school leavers application efforts seems to be strongly restricted by competition and those with the lowest attainment even seem to suffer from discrediting processes in terms of parental resources only parental employment statusbut not parental education and occupational status proved to be a somewhat valuable resource for access to regular training albeit only for school leavers from regular schools thus it is not just that lowachieving adolescents usually lack better parental resourceseven when they do have access to better resources these resources do not seem to have the power to compensate for disadvantages resulting from the negative signal of low school achievement taken together our results indicate that the transition period gives adolescents with better career orientation and relatively higher educational attainment new opportunities to enter regular training they have better capacities and resources to actively search for jobs or training positions and if there is less job competition the opportunity to achieve successful schooltowork transitions but even for that group not all agentic resources are related to more agency and success in contrast lowachieving adolescents with the lowest educational attainment andor those labeled as learning disabledbecause they come from specialneeds schools experience persistent disadvantage to account for the persistent disadvantage in the transition period for this most vulnerable subgroup we found some indication of both lack of agency owing to stigmatization and a high extent of unsuccessful applications owing to discrediting processes by gatekeepers these differences in the timing and chances to enter the labor market have been shown to have longlasting effects on later labor market attainments and this might be even more the case in germany where the normal life course requires completion of vocational education and training or higher education before starting to work moreover although our study showed that career guidance at german lowertrack schools seems to be quite effective in terms of helping lowachieving adolescents develop career aspirations and plans those who are forced to continue with prevocational programs may see these unfulfilled expectations translate into frustration possibly leading to higher risks of educational coolingout processes and less agency later on our study contributes to the existing literature in several ways ours is one of the few studies capable of differentiating the respective impact of adolescents agency and structural constraints on the successfailure in transitions into workstill a largely underresearched area we extended existing research by not only relying on schoolleaving certificates as a proxy for adolescents skills but also considering grades cognitive competences and noncognitive characteristics moreover family background was measured in a comprehensive manner by including three dimensions we addressed structural constraints of lowachieving adolescents training chances by including finegraded regional differences in youth unemployment we thereby added new insights into whether the low qualification label per se results in lower training chances irrespective of differences in individual resources finally this is one of the very few german studies to include school leavers from specialneeds schools this is important because most students classified as disabled are still not integrated into mainstream schools and the vast majority of them leave school without a certificate or a lower secondary certificate including these students makes our study useful at the international level as well because studies for countries with inclusive school settings for specialneeds students may not adequately cover the population of disabled adolescents when relying on voluntary survey participation our study has some limitations the discrediting mechanism could only be studied indirectly experimental designs would be required to validate and strengthen our findings in this respect moreover stigmatization was examined via observed application behavior but not directly as an identity construct further studies should try to measure stigmatization more directly the neps data do not provide measures of competences and noncognitive characteristics for respondents from specialneeds schools meaning we do not know whether their lower application rates and training chances are owing to very low skills this may not be the case however because competences and noncognitive characteristics were not related to the differences in training chances of lowachieving adolescents from mainstream schools moreover the neps data do not allow for reliably detecting integrated students with learning disabilities we were therefore not able to study the extent to which the very low training chances of respondents from schools for learning disabilities are caused by their classification as being learning disabled and the fact that they attended special schools once data are available future research should intend to disentangle the impact of these different dimensions of labeling moreover to fully cover the group of lowachieving adolescents including students with other types of disability would be preferable as well finally our study addressed the difficulties of lowachieving adolescents in a country with a strong vocational education and training system and a highly stratified education systemassociated with the fact that educational credentials are very important in both training and labor markets given that low educational attainment is associated with very different levels of competences across countries as well as different meanings research for countries with different institutional configurations should replicate our study to broaden further our understanding of the impact of educational credentials and agentic resources on new opportunities or persistent disadvantages of lowachieving adolescents in the schooltowork transition period conclusion educational attainment and skills are known to be important for successful schooltowork transitions in particular and transitions to adulthood in general hence preventing students from dropping out of education before achieving the recognized level of educational attainment is an important societal task in this respect vocational education and training are perceived as a means to reduce educational dropout research has shown however that lowachieving school leavers have a high risk of not entering or dropping out of vocational training as well many reasons have been proposed for thisranging from employer discrimination lack of competences and skills to withdrawal because of stigmatization in our study we investigated to which extent transitions to work are influenced by both lowachieving adolescents application efforts and the success of their efforts agentic resourceslike competences noncognitive characteristics and parental resourcesdid not or only to a very limited extent influence adolescents application efforts and the recruitment decisions of firms and vocational schools despite the fact that lowachieving school leavers vary considerably in these resources we demonstrated that the main disadvantage of lowachieving adolescents in germanys training marketswhich serve as entry labor marketsis their low school attainment career aspirations and a good occupational orientation developed during school however opened up new opportunities in the transition period they increased adolescents application efforts which in turn promoted entry into regular training however for those who left school without a certificate and those from special schools for learning disabilities the label of having low qualifications is the major obstacle to leveraging agency in this transition period they are exposed to persistent disadvantages in the transition period and most likely throughout their work life the findings of our study also have important policy implications for promoting apprenticeships as a means to prevent early educational dropout among lowachieving adolescents steedman stated that apprenticeships are not a sufficient solution to improving the labour market situation of young people with poor school achievements or other disadvantages she argues that many of these young people have failed to find places employers now discriminate much more than in the past in favor of apprentices with good or very good school achievements lowachieving school leavers are therefore forced to enroll in remedial or prevocational education programs after compulsory general education our results support her considerations we found that a major source of lowachieving adolescents disadvantage in access to regular training is competition policies should therefore aim at providing a sufficient number of training places corresponding to the size of the applicant pool second policies should also aim to improve employers opportunities for detecting the competences and skills these young people possess despite their low schoolleaving certificate doing internships prior to application for example might be beneficial for enhancing their training opportunities finally prevocational programs should be evaluated in terms of how effectively they improve lowachieving adolescents training and labor market entry chancesan area where we still lack research author contributions ach performed the data editing and statistical analyses participated in the design of the study and the interpretation of the data lm participated in the data editing and statistical analyses hs conceived the study drafted the manuscript and participated in statistical guidance all authors participated in improving the manuscript revisions and approved the final version compliance with ethical standards this study uses data conducted by the neps consortium the data collected followed the ethical regulations of the german states and was approved by their data protection officers conflict of interest the authors declare that they have no competing interests informed consent informed consent was obtained from all individual students and parents included in this study

school leavers with low educational attainment face great difficulties in their schooltowork transitions they are however quite heterogeneous in terms of their personal and social resources these withingroup differences may influence who shows initiative during the schooltowork transition period and thereby helps employers recognize their learning potential at labor market entry yet this recognition also depends on the ways employers select applicants which may prevent them from discovering such withingroup differences we therefore investigate the interplay between agency and its constraints that is whether higher cognitive and noncognitive skills and more parental resources provide lowachieving school leavers with new opportunities in the schooltowork transition period or whether their low school attainment causes the persistency of their disadvantages we use panel data from the german national educational panel study neps which started in grade 9 the neps also includes school leavers from specialneeds schools our sample consists of 3417 lowachieving adolescents 42 female defined as adolescents who leave school with no or only a lower secondary schoolleaving certificate their average schoolleaving age is 16 to 17 years our key findings are that the transition period opens up new opportunities only for those lowachieving adolescents with better vocational orientation and higher career aspirations leading them to make stronger application efforts the success of youths initiative varies considerably by schoolleaving certificate and school type but not by competences noncognitive characteristics and parental background thus the label of having low qualifications is a major obstacle in this transition period especially for the least educated subgroup their poor school attainment strongly disadvantages them when accessing the required training to become economically independent and hence in their general transition to adulthood our results are also of interest internationally because participation in firmbased training programs functions as the entry labor market in germany thus similar explanations may apply to lowachieving adolescents difficulties in finding a job

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introduction operational deployments are a routine part of military life which most personnel cope well with however for those who experience numerous stressors associated with both home and military life there is a risk of developing adverse mental health outcomes 1 the mental health impact of deploymentrelated trauma has been widely researched 23 however service personnels anxieties about home life such as the potential impact of separation on relationships and the impact of absence from the family may also have deleterious psychological effects military personnel can be concerned that aspects of their service might have a negative impact on their families and among the various apprehensions arising during deployment worries related to the family at home are a key concern 4 over half of a representative sample of 3198 uk military personnel with children believed that their military career had negatively impacted their children 4 a study of us navy personnel showed that concerns about children and spouses were substantially greater during deployment and following return than before deployment 5 military deployments and operational trauma can adversely affect the quality of relationships between military personnel and their spouses or partners and their children uk military reservists that deployed to iraq were more likely than their regular counterparts to report actual or serious consideration of permanent separation from their partners 6 most military studies tend to focus on combat and operational events while research examining the effects of deployments on families is less frequent and is usually conducted retrospectively with the exception of one study reporting on the impact of home front stressors 1 no studies relating to the impact of deployment on intimate relationships and children have been conducted among military personnel while they are deployed in 2009 the uk armed forces first deployed a mental health research team to evaluate the mental health of deployed personnel the project known as the operational mental health needs evaluation was subsequently repeated on three further occasions the data collected included measurements of mental health symptoms helpseeking and combat events participants perceptions of how their current deployment impacted their intimate relationships and the potential effect on their children methods data were collected during operations in iraq in 2009 7 and afghanistan in 2010 2011 and 2014 we sought to survey the bulk of personnel from the middle to the end of their deployment with the exception of special forces personnel participants were eligible to take part in the studies if they were members of any of the three uk armed services and were deployed during the study period purposive sampling was conducted to ensure that the study sample was representative of the deployed force at the time of the survey the omhne surveys were as follows iraq 2009 afghanistan 2010 afghanistan 2011 and afghanistan 2014 for omhne i the survey team collected data primarily in the main operating base and satellite locations 7 omhne a1 took place during intense combat operations a2 during a steady state period where it was possible to focus the survey effort on more austere and dangerous locations while a3 took place during the drawdown phase in afghanistan while preparations to end the mission were underway all surveys used a similar procedure where the visiting team undertook data collection in the participants deployed location however omhne a3 data collection was carried out by a mental health practitioner following the delivery of a psychoeducational stress briefing which may or may not have influenced participant responses secondary data analysis was undertaken following the teams return to the uk ethical approval was granted by the ministry of defence research ethics committee data were collected using a selfreport questionnaire which included questions about sociodemographic and military characteristics deployment experiences psychological distress symptoms of posttraumatic stress disorder and selfrated health psychological distress was assessed using the 12item general health questionnaire 8 for the current study those endorsing four or more symptoms on the ghq12 were classified as cases symptoms of ptsd were measured with the 17item national centre for ptsd checklist 9 for the current study a screening score of 30 or more was used to indicate the presence of traumatic stress symptoms combat exposure was assessed with a 17item measure that asked about the frequency of exposure to combat events scores were summed and tertiles were generated to facilitate a comparison of low medium and high levels of exposure homefront stressors were measured by seven questions asking about injury or death of a loved one spouse separating from the deployed person financial problems the birth of a child problems with children at home facing other major problems at home while deployed and having been concerned i might lose my civilian job the latter was answered by reservists only perceived support for the family during deployment was measured by a question asking has the military provided any reassurance or support to your spousepartnerfamily while you have been on this deployment participants selected one of the following responses to this questions yes it is sufficient yes but it is not sufficient no or not applicable the primary outcomes in this study were the perceived impact of deployment on intimate relationships which was measured by a question asking so far what impact do you think this deployment has had on your marriage or relationship and the perceived impact of the current deployment on children which was measured by a single question asking so far what impact do you think this deployment has had on your children participants selected one of the following responses no impact positive impact negative impact or not applicable participants were further asked if they were currently planning divorce or separation or if their spouse or long term partner was planning divorce or separation multinomial odds ratios and 95 confidence intervals were calculated using univariate and multivariate multinomial logistic regression the associations between covariates and the primary outcomes were explored in unadjusted multinomial logistic regression models covariates showing significant associations with primary outcomes were included in adjusted multinomial logistic regression models the analyses for perceived effect of deployment on intimate relationship were restricted to those who reported that they were in a longterm relationship and the analyses for perceived impact of deployment on children were limited to those who reported having dependent children all analyses were performed using the statistical software package stata results the ninetyone per cent of the overall sample was male 39 were under the age of 25 72 were junior personnel 84 of the sample was in the armyroyal marines 56 served in a support rather than a combat role and 94 were regulars 2788 participants reported they were in a longterm relationship and 1464 reported having dependent children around a third to a half of those surveyed perceived deployment to have a negative effect on their intimate relationships and around a half to two thirds perceived that deployment had a negative effect upon their children univariate analyses of the sociodemographic variables showing significant associations with the outcome variables were then included as potential confounding variables in adjusted multinomial logistic regression models planned separation either by deployed military personnel or by their partner at home was significantly associated with the deployed person reporting four or more symptoms of psychological distress similarly planned separation was significantly associated with the deployed person reporting one or more home front stressors military personnel on deployment were also more likely to report considering separation from the partner at home when they perceived support for their family at home to be insufficient compared with regular personnel reservists were significantly more likely to report a positive impact of deployment upon their intimate relationships personnel reporting four or more symptoms of psychological distress perceived deployment to have a negative impact on their intimate relationships as did those reporting traumatic stress symptoms participants who reported being in danger of being injured or killed on one or more occasions were more likely to report that deployment has negatively affected their relationships reservists were less likely to report a negative impact of deployment on their children compared with regular personnel junior ranking personnel were also less likely to report that they perceived deployment to affect their relationships negatively personnel reporting symptoms of traumatic stress perceived that deployment had a negative impact on their children personnel reporting symptoms of psychological distress ptsd and those holding junior ranks were more likely to perceive that the support available to their families was insufficient those deployed in a combat role were less likely to perceive family support provided by the ministry of defence to be insufficient discussion combined estimates from four mental health surveys conducted in iraq and afghanistan over a 5year period suggested that overall 41 of those surveyed thought that the deployment had had a negative effect on their intimate relationships while 55 perceived that their children had been negatively affected these percentages were almost identical over the course of individual deployments the highest rates of perceived negative impact on both intimate relationships and on children were reported during the iraq deployment in 2009 and the afghanistan deployment in 2010 while the lowest rates of negative impact were reported during the 2014 afghanistan deployment the earlier deployments to afghanistan were characterized by more intense periods of fighting sustaining casualties combat deaths and engaging the enemy it is highly likely that personnel felt that they were at heightened risk of experiencing injury or death during earlier deployments the iraq survey took place when uk forces were confined to the main operating base and feelings of boredom and nervousness were high as many personnel had deployed to previous iraq operation in which they had experienced indirect and direct rocket fire in their base locations and may well have perceived a heightened threat to life 10 in comparison the 2014 deployment to afghanistan coincided with the drawdown phase of current operations with an accompanying lower risk of exposure to dangerous or life threatening events the perceived negative effect of deployment was related to a number of factors among deployed personnel including symptoms of psychological distress and traumatic stress symptoms and stressful events occurring at home during the deployment our findings are in keeping with research which shows that negative outcomes for families increase with the amount of exposure 8 55 111 74 106 rank officer 525 74 168 145 138 senior 655 104 212 180 159 junior n number percentage service personnel have to traumatic or lifechanging experiences and to deployment stress us military studies conducted during the iraq and afghanistan conflicts have shown that separation from the family is one of the primary deployment worries service personnel reported and for those with mental health problems concerns for their family was the most influential risk factor of all those measured 11 as such military service in general and deployments where combat and operational tempo is low do not appear to significantly increase the probability of negative outcomes for military families 12 however reporting symptoms of poor mental health can be associated with negative outcomes 13 and separation from ones family can in itself be a cause of loneliness and strain in the us military deployment in the past year was related to higher levels of ptsd symptoms for military husbands and the husbands current ptsd symptoms were associated with lower marital satisfaction confidence in the relationship positive bonding between the partners parenting alliance and dedication to the relationship for both military husbands and their wives 14 our results showed that home front stress was associated with planned separation by both military personnel and their partners interviews conducted with mental healthcare providers reveal that home front stress such as relationship difficulties or financial problems is the major reason for which us service personnel sought help while they were deployed 15 inevitably knowing that ones family is experiencing difficulty at home and not being there to support them could give rise to negative perceptions about the effect of deployment on families 16 research has shown that support from a supervisor can reduce role stress which in turn was associated with reduced family conflict and improved family cohesion in a population of policewomen 17 our study extends these findings by demonstrating that support for families is also an essential factor associated with the health of deployed military personnel contrary to previous findings from the uk 6 our findings show that while deployed reservists were less likely to report a negative effect of deployment on their children and more likely to report a positive effect of deployment on their intimate relationship in a study of families of us military reservists most family members reported deployment had increased family closeness along with a combination of patriotism pride and civic responsibility 18 furthermore reservists and their spouses also saw the financial benefits of deployment as a positive outcome 18 which may have some relevance to uk reservists findings from a recent study of regular us service personnel show that they reported better family life while they were on deployment 19 the authors postulate that this may be because personnel were removed from the daily stresses associated with family life or possibly because they appreciated their family more while they were separated from them 19 it is possible that openly discussing the benefits and potential detriments of deployment to the family system while deployed allows reservists to view their deployment in a more positive light compared with regulars in this study the data are crosssectional and therefore it is not possible to comment on causality these data were gathered by survey which limits the richness of the data and only allows for forced choice responses however this study is unique in offering a during deployment perspective of how military personnel think about the ways in which their deployment might affect their families and the key variables associated with negative outcomes in conclusion a significant number of deployed uk military personnel perceived their deployments to have a negative effect on their intimate relationships and on their children these findings are consistent with existing research showing links between deployment experiences and poor family outcomes research from the uk has already shown a lack of support for military families to be associated with relationship difficulties there is scope for improving the reach of predeployment preparedness briefings for military families and for workshops that involve military personnel their spouses and children future research should focus on gathering data from all family members during the deployment cycle ultimately military families do well when they have adequate support as such welfare support programmes should actively target families that experience problems on the home front key points • during deployment perceiving that deployment had a negative impact on families was associated with psychological distress traumatic stress symptoms and being in danger of being injured or killed • reservists were less likely to report negative effects of deployment on their children compared with regulars • perceived insufficient support from the ministry of defence was associated with poor mental health during deployment and holding a junior rank conflicts of interest none declared

in the uk little is known about the perceived effects of deployment on military families from military personnel in theatreto investigate military personnels perceptions of the impact of deployment on intimate relationships and childrendeployed service personnel who were in a relationship and who had children completed a survey while deployed on combat operations data were taken from four mental health surveys carried out in iraq in 2009 and afghanistan in 2010 2011 and 2014among 4265 participants after adjusting for military and socialdemographic covariates perceiving that deployment had a negative impact on intimate relationships and children was associated with psychological distress and traumatic stress symptoms military personnel who reported being in danger of being injured or killed during deployment were more likely to report a perceived negative effect of deployment on their intimate relationships reservists were less likely to report a perceived negative impact of deployment on their children compared with regulars military personnel who themselves planned to separate from their partner were more likely to report psychological distress and stressors at home perceived insufficient support from the ministry of defence was associated with poor mental health and holding a junior rank conclusions deployed uk military personnel with symptoms of psychological distress who experienced stressors at home were especially likely to perceive that their family were inadequately supported by the military those planning to separate from their partner were at increased risk of suffering with mental health problems while deployed

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problemas de saúde mental são comuns na atenção primária e são geralmente relacionados à ansiedade e à depressão este estudo tem o objetivo de avaliar a taxa de transtornos mentais comuns e suas associações com características sociodemográficas em unidades de saúde da família é um estudo multicêntrico transversal com os usuários da atenção primária do rio de janeiro são paulo fortaleza e porto alegre brasil utilizouse o general health questionnaire e o hospital anxiety and depression scale a taxa de transtornos mentais nos usuários do rio de janeiro são paulo fortaleza e porto alegre foram respectivamente 519 533 643 e 577 com diferenças significativas entre porto alegre e fortaleza comparandose ao rio de janeiro problemas de saúde mental foram especialmente altos em mulheres desempregados em pessoas com baixa escolaridade e com baixa renda dadas as iniciativas do governo brasileiro para o desenvolvimento os cuidados primários e para reorganização da política pública de saúde mental é importante considerar os transtornos mentais comuns como uma prioridade tal como outras morbidades crônicas cad saúde pública rio de janeiro 30623632 mar 2014 introduction common mental disorders are associated with disability 123 poor prognosis of comorbid diseases 45 and impacts on health care costs and economic productivity 678 a significant proportion of the global health burden is attributable to mental health 9 severe mental health problems account for 215 of all disabilityadjusted life years in brazil 1011 recent epidemiological research among adults in the megacity of são paulo showed a oneyear prevalence of 199 for anxiety disorders 11 for mood disorders 43 for impulsecontrol disorders and 36 for substance abuse these represented some of the highest prevalence estimates among cities around the world 12 in order to improve health conditions the brazilian government has been promoting significant changes in the health system investing and remodelling primary care and mental health services 13 it is proposed that the substantial burden of mental disorders can be reduced by integrating mental health into primary care particularly in places with high levels of inequality and socioeconomic deprivation 14 the family health strategy is the cornerstone of this integration involving the introduction of 30000 family health teams covering 95 of brazils municipalities and more than 50 of the population each team comprises one doctor and one nurse two nurse assistants and six community health workers there are few studies of prevalence estimates of mental disorders in family health units in brazil and most of these were done in cities with no more than 650000 people 151617 some studies have taken place in large cities but in traditional primary health centers 1518192021 in petrópolis 22 and santa cruz do sul 16 a range of between 51 and 56 common mental disorders were found among people in family health units azevedomarques zuardi 17 found 367 of any dsmiv disorders in family health units in ribeirão preto considering são paulo or other big cities the prevalence of psychiatric morbidity among patients in traditional primary health centers varies from 46 and 47 in são paulo and rio de janeiro 1519 to 56 in porto alegre 18 considering the breadth of responsibilities of the fhs which include a major role in mental health it is important to investigate further the epidemiology of common mental disorders in the context of the fhs in brazil the aims of the current paper are to estimate the prevalence proportions of common mental disorders among patients in the fhs in four cities são paulo rio de janeiro porto alegre and fortaleza to study the association between sociodemographic factors and common mental disorders methods research design and population the study was based on surveys conducted during 2009 and 2010 in four state capitals which represent different regions of brazil with considerable geographic and cultural differences porto alegre is located in the southern region of brazil and has a population composed mainly of descendants of european immigrants with an economy based on agroindustrial activities and one of the best human development indices in the country fortaleza is the 5th most populous city in brazil located in the northeast region with a high prevalence of illiteracy and a lower hdi its economy is based on business commerce and tourism and its population is composed mainly of portuguese and native american descendants são paulo and rio de janeiro are located in the southeast the most industrialized urbanized and wealthiest region of the country são paulo is the biggest city in south america and has a population based mainly on immigrants from europe and asia and migrants from the northeast region of brazil rio de janeiro is the second largest city in the country its population is originally european and afrobrazilian with a strong presence of northeastern migrants the study was originally designed to evaluate an intervention for training primary care and mental health workers in shared care which is published elsewhere 23 the population of interest was composed of patients from 20 urban health family primary care centers with 27 family health teams from these four cities these units were those chosen by the health secretaries from the four cities where training in mental health in primary care was considered a priority the number of teams evaluated in each city was proportional to the number of professionals trained in each one there were 3 teams in porto alegre 3 in fortaleza 6 in são paulo and 12 in rio all patients aged 18 to 65 and attending nurses and doctors were invited to take part in the study pregnant women and patients with impaired cognitive functioning were not incad saúde pública rio de janeiro 30623632 mar 2014 cluded the original study was conceived as two crosssectional surveys in a quasiexperimental prepost design the first crosssectional survey was carried out from september to november 2009 and the second survey from june to august 2010 no patient who participated in the first survey was allowed to participate in the second for this study the entire sample was gathered and analysed together for local logistical reasons there was no sample from fortaleza in the second phase the research protocol was approved by the ethics research committee of the são paulo federal university rio de janeiro state university and all four municipalities allowed the research to take place in their primary care health centers measures a researcher who was based in the waiting room obtained written consent from patients and applied the portuguese version of the general health questionnaire hospital anxiety and depression scale and a sociodemographic questionnaire these instruments were applied as interviews due to the high illiteracy prevalence proportions within this population 151920 the ghq12 was used to identify probable common mental disorders among patients this instrument has been validated against a semi structured psychiatric interview 2425 and the brazilian version at the cutoff point of 23 has demonstrated a sensitivity of 91 and specificity of 71 for the presence of common mental disorders in a population with no more than four years of schooling 2226 to evaluate probable depression and probable anxiety the had scale was used with a cutoff of 89 as previously validated in brazil 27 these scores are associated with mood and anxiety distress which is related with functional impairment and higher risk of developing mental disorders 28 common mental disorders were used to highlight the psychiatric morbidity on emotional distress as described by goldberg huxley 29 it is different than probable depression andor anxiety disorders analyzed by specific scales that were used to point out more severe cases and also to allow comparison between wider data among other studies sociodemographic data included gender age selfreported ethnicity marital status education employment status income and ethnicity continuous variables were coded into dichotomous values we divided ethnicity income and education variables as white or nonwhite income higher or lower than half the minimum monthly wage per person per family and more or less than four years education data analyses the scores from ghq12 and had were dichotomized and taken as the dependent variables patients scoring at least 3 points on the ghq were considered cases of probable common mental disorders and with 9 or more points in had for both subscales were cases of probable depression and probable anxiety we present descriptive statistics on the prevalence proportions of probable common mental disorders probable depression and probable anxiety the chi square test was used to determine differences in prevalence proportions between sites we used logistic regression to examine variation between cities in prevalence proportions of common mental disorders while adjusting for gender age education level ethnicity employment and marital status odds ratios with 95 confidence intervals were calculated to estimate the association between sociodemographic variables and the presence of common mental disorders depression and anxiety statistical analyses were performed using the ibm spss version 190 results a total of 1857 patients completed the screening questionnaires during the period of the surveys 1260 in the first phase and 597 in the second 909 were from rio de janeiro 557 from são paulo 171 from fortaleza and 220 from porto alegre only income and employment status were significantly different between the samples from the two phases patients were mainly women over 35 years in age with more than four years of education the majority were married or living with a partner and self reported their ethnicity as nonwhite about onethird of patients come from a deprived background with family income lower than half the minimum wage at the time table 2 depicts sociodemographic characteristics between health centre patients among cities the prevalence proportion of common mental disorders anxiety and depression are presented in table 3 there were no significant differences between patients in these cities for common mental disorders depression and anxiety with two exceptions among fortalezas patients the prevalence proportion of common mental disorders was significantly higher than in rio de janeiros even when adjusting for gender income employment status race marital condition and education level patients in porto alegre also presented significantly more common mental disorders than those in rio de janeiro after controlling for these sociodemographic factors table 4 shows the associations between common mental disorders depression and anxiety cases and sociodemographic factors the bivariate analysis revealed that common mental disorders and depression were statistically and positively associated with gender educational level and income there were minor changes after controlling for all sociodemographic factors employment status was no longer related to common mental disorders and depression and educational level no longer showed significant associations with depression after adjusting for confounders discussion this paper reports the first multicentre study in brazil examining the prevalence proportion of common mental disorders in primary care attendees and its association with patient sociodemographic factors we found high prevalence proportions of common mental disorders anxiety and depression in all cities patients attending primary care in fortaleza and porto alegre presented significantly more common mental disorders than in rio de janeiro even after adjustment for confounding variables there were no significant differences between patients from the health centers of these cities when we analysed depression and anxiety disorders separately psychiatric morbidity among primary care patients was higher for females those unemployed those with less education and those with lower income after adjusting for the joint effects of sociodemographic factors on common mental disorders and anxiety only employment status failed to show a significant association with disorder prevalence proportions there was no association of depression with education level after adjustment for other variables the prevalence of mental health problems in primary health care is high especially common mental disorders in all low and middle income countries with particularly high prevalence proportions in brazil in chile 30 and nicaragua 31 it is 53 and 47 respectively similar to india 323334 that is 50 even in european countries there is a high prevalence of psychiatric morbidity depression is present in 37 of patients in the uk 35 327 in portugal 35 35 in the netherlands 35 and 344 in spain and bosnia 3637 there are icd10pc diagnoses in 497 of primary health care patients in denmark 38 it is clear that there is a high prevalence of common mental disorders in primary care regardless of the average levels of income the present study found the highest prevalence proportions of probable anxiety which is consistent with a recent epidemiological study that found a community prevalence of 199 in são paulo the highest compared with 23 other countries studied in the same survey 12 there are many reasons which might explain the high prevalence proportions of anxiety disorders in brazil such as widespread urban violence and adverse socioeconomic conditions it is known that one of the main sources of mortality and morbidity in brazil is violence 39 furthermore pollution high noise levels and lack of recreational areas in brazilian cities might be related with anxiety levels cad saúde pública rio de janeiro 30623632 mar 2014 in accordance with other studies 19333438 we found associations between prevalence proportions of disorders indicators of poverty and female gender however this profile of association changes among countries in india 323334 a low income is most strongly associated with common mental disorders which was not observed in chile 30 in the present study this was the second most relevant variable while gender was the most important factor in contrast being female in chile is strongly associated with common mental disorders while in india there is no association patel kleinman 40 pointed out in a review of 11 community studies in six low and middle income countries that the most consistent factor is low levels of education we also found low education to be an important factor after adjustment education was not associated with depression this could reflect an inverse correlation with social disadvantage education level and prevalence of common mental disorders in chile 41 social class and education nonwhite 715 10 711 10 752 10 or odds ratio 95 ci 95 confidence interval demonstrated a reduced strength of association after adjustment in a community survey similar results were found in brazil 42 where the relationship between education and common mental disorders was significant only when the income was not extremely low extreme poverty reduced the strength of this association probably because both factors are related and used to happen together in low and middle income countries the sample size for the surveys was calculated in order to assess changes in recognition of common mental disorders over time and not for a prevalence study the number of patients who refused to participate was not assessed and therefore could not be included in the analysis consequently it was not possible to estimate the true prevalence among all patients and the results cannot be rigorously extrapolated for the population of each city however this sample should be comparable to the primary practice routine of other urban areas in brazil it is not possible to generalise to smaller urban areas and rural populations although 85 of the brazilian population is estimated to live in urban areas the samples were from two crosssectional surveys conducted at different times but were considered homogeneous enough for pooled analysis the screening questionnaires measure psychiatric symptoms and do not provide a formal diagnosis however in practice emotional distress is related with disability and poor social functioning 28 individuals with subthreshold depression and anxiety are frequently seen in primary care 43 and some researchers suggest that these conditions are important contributors to overall impairment and high service utilization 44 it is very important to measure and identify probable cases at risk of developing formal psychiatric disorders it is justifiable to use the concept of common mental disorders which encompasses emotional distress with vulnerability and recovery 29 and does not exclusively focus on categorical classification such as depression and anxiety discussing the possible implications of the results of this study to the delivery of care to the brazilian population is one of the most important consequences of the results we have found with over half of all adults attending primary care being classified as having probable common mental disorders health policies must be developed to address this public health problem which differ substantially to the patients usually attending specialized units that have been the emphasis of mental health planning in recent years in brazil first of all it is important not to see common mental disorders as only categorical diagnoses but as possible risk factors for the development of more severe disorders 46 despite some possible biases about high common mental disorders prevalence proportions as over reporting or diagnosing self limited cases family health teams must be aware of the extent of psychosocial problems in order to take an integrated care approach studies have demonstrated evidences of costeffectiveness and efficacy of psychosocial interventions for common mental disorders in low and middle income countries 45 but implementing these interventions and developing confidence and skills in primary care professionals is challenging training and education programs for primary care professions need to be introduced together with structured pathways and network support services 42 education strategies must involve additional competencies other than simply diagnosing and managing medication in common mental health disorders 46 the strong association of emotional distress with psychosocial variables suggest that psychosocial interventions may help in supporting these patients involving other primary care professionals may help teams identify cases 17 supporting professionals should be available in order to help primary care professionals manage common mental disorders and more severe problems recent evidence demonstrated the effectiveness of primary carespecialist collaboration 47 in brazil matrix support introduced this collaborative model but the support of specialists must be made accessible to all primary care teams and shared care coordinated by appropriate management 48 finally policymakers must make efforts to reduce economic inequities and implement educational and public safety policies to overcome the vicious circle of poverty urban violence and mental disorders acting directly for promoting human wellbeing conclusion this study reports high levels of probable mental health problems among four state capitals and identifies associations between sociodemographic characteristics and mental health problems in primary health care considering the moves the brazilian government is making towards the development of primary care and the reform of its mental health policies it is very relevant to consider common mental disorders as a priority alongside other chronic health conditions establishing comprehensive care at primary care level and integrating health services are relevant steps to achieving equity in the brazilian national health system cad saúde pública rio de janeiro 30623632 mar 2014 resumen los problemas de salud mental son comunes en la atención primaria y están relacionados con la ansiedad y la depresión este estudio tiene como objetivo evaluar las tasas de trastornos mentales comunes y sus asociaciones con las características sociodemográficas de los usuarios de la atención primaria se trata de un estudio multicéntrico transversal con usuarios de río de janeiro são paulo fortaleza y porto alegre brasil se utilizó el general health questionnaire y el hospital anxiety and depression scale la tasa de trastornos mentales en pacientes de río de janeiro são paulo fortaleza y porto alegre fueron respectivamente 519 533 643 y 577 con diferencias significativas entre porto alegre y fortaleza los problemas de salud mental fueron especialmente altos en las mujeres desempleados personas con bajo nivel educativo y quienes tienen bajos ingresos teniendo en cuenta los esfuerzos del gobierno brasileño para el desarrollo de la atención primaria y las políticas para la reorganización de la salud mental es importante considerar los trastornos mentales como una prioridad junto a otras afecciones crónicas trastornos mentales salud mental atención primaria de salud contributors d a gonçalves contributed to the methodological design statistical analysis and writing of the paper j j mari contributed to the methodological design and writing and revision of the paper p bower l gask and c dowrick contributed to the methodological design and writing of the paper l f tófoli contributed to the methodological design data collection and writing of the paper f b portugal contributed to the data analysis and writing of the paper d ballester contributed to the study design data collection and revision of the paper m campos contributed to the methodological and study design data interpretation statistical analysis and revision of the paper s fortes contributed to the study design data collection and revision of the paper

mental health problems are common in primary health care particularly anxiety and depression this study aims to estimate the prevalence of common mental disorders and their associations with sociodemographic characteristics in primary care in brazil family health strategy it involved a multicenter crosssectional study with patients from rio de janeiro são paulo fortaleza ceará state and porto alegre rio grande do sul state assessed using the general health questionnaire ghq12 and the hospital anxiety and depression scale had the rate of mental disorders in patients from rio de janeiro são paulo fortaleza and porto alegre were found to be respectively 519 533 643 and 577 with significant differences between porto alegre and fortaleza compared to rio de janeiro after adjusting for confounders prevalence proportions of mental problems were especially common for females the unemployed those with less education and those with lower incomes in the context of the brazilian governments moves towards developing primary health care and reorganizing mental health policies it is relevant to consider common mental disorders as a priority alongside other chronic health conditions

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introduction occupations are defined as valued daily activities performed with a specific purpose and meaning that are impacted by ones culture and factors internal and external to the person 1 it is common for individuals to overlook the significance of participation in everyday occupations until the ability to do these activities is lost or altered individuals who have faced any type of challenge in their lives including physical may not be able to independently engage in desired occupations 2 when individuals have deficits in completing daytoday occupations assistive technology is a tool that may be utilized to aid individuals in engagement 3 according to the technologyrelated assistance for individuals with disabilities act of 1988 4 at is any item piece of equipment or product system whether acquired commercially off the shelf modified or customized that is used to increase maintain or improve functional capabilities of individuals with disabilities at service is directly assisting an individual with a disability in the selection acquisition or use of an assistive technology device the use of at devices and services can help individuals to regain independence and function in various aspects of life 356 service dogs perform a variety of tasks that can maintain or improve functional capabilities of the individuals with whom they work service dogs can be trained to help individuals with mobility impairments engage in occupations such as assisting to propel wheelchairs opening doors retrieving dropped items providing balance and conserving energy camp 7 reports that service dogs are used to enhance independence in occupational performance areas and to contribute to improvements in psychosocial functioning given these benefits service dogs could be used as a form of assistive technology under the technology act in that they also are used to increase maintain or improve functional capabilities of individuals with disabilities similarly shintani et al 8 found positive effects of service dogs on various aspects of healthrelated quality of life as measured by the medical outcomes study 36 item shortform health survey version 20 the researchers concluded that they hope that this research will encourage more therapists to acknowledge service dogs as a new assistive technology and to consider the recommendation of service dogs under the right circumstances for the people with physical disabilities they work with it is clear that service dogs can assist persons with mobility impairments to engage more fully in valued daily occupations 8 9 10 11 12 13 prior research has verified the positive impact of service dog ownership on various aspects of health quality of life and social participation for example a study by hall macmichael turner and mills 14 found that when compared to persons on a waitlist for a service dog persons partnered with a service dog had significantly higher scores on an assessment of quality of life in particular the researchers reported that those with service dogs had higher scores on areas related to socialization and engagement in educational volunteer and work activities similarly the results of a randomized controlled trial by allen and blascovich 15 concluded that among persons with severe disabilities affecting ambulation service dog partnership resulted in improved psychological social and educationalvocational functioning as well as a decrease in the number of hours of paidunpaid assistance required furthermore the results of research by lane mcnicholas and collis 16 suggested that service dog partnership is associated with increased social interaction and improved selfperceptions of health a longitudinal study by guestcollisand mcnicholas 17 focused specifically on persons who were deaf or hardofhearing found that partnership with a hearing dog had positive impacts on psychological wellbeing as well as social interaction while prior research has demonstrated the positive impacts of service dogs on social interaction psychological wellbeing and selfperceived health there is a limited body of qualitative research specifically examining how service dogs impact engagement in occupation among individuals with mobility impairments studies conducted by camp 7 and fairman and huebner 13 provided preliminary research supporting the idea that service dogs can assist with performance of occupations however camp indicated that there was a need for further research regarding how assistance dogs compare to an individuals prior form or forms of at in a literature review conducted by winkle crowe and hendrix 11 it was concluded that additional qualitative studies should be conducted to examine the meaningfulness of service dog use and provide comparison of previous at with current service dog use furthermore as stated by shintani et al 8 additional research is needed to assist rehabilitation professionals in understanding the impacts of service dogs on the daily performance of those with disabilities and grasping the potential role of rehabilitation professionals in working with persons who may benefit from service dog partnership the purpose of this qualitative descriptive study was to learn how service dogs impact engagement in occupation among persons with mobility impairments that affect gait or balance as well as their experiences utilizing a service dog as a form of at this study built upon previous research by exploring from the owners perspectives how their service dogs influenced their engagement in occupations inside the home and throughout the community and how their service dog compared to at used in the past materials and methods this study utilized a qualitative descriptive research design involving interviews with four participants this approach allowed the researchers to learn about each participants engagement in occupation while partnered with a service dog and how their experiences with their service dog differed from their experiences with various types of at all subjects gave their informed consent for inclusion prior to participation in the study the study was conducted in accordance with the declaration of helsinki and the protocol was approved by the saginaw valley state university institutional review board participants were obtained through convenience sampling and snowball sampling recruitment flyers containing information about the research study were distributed to clients of one organization that trains service dogs a total of four persons who met the inclusion criteria volunteered to participate in the study the population for this study consisted of englishspeaking adults over 18 years of age with a mobility impairment participants were required to have been partnered for at least one year with a service dog trained by the organization the service dog had to assist them with completion of activities of daily living and instrumental activities of daily living data was collected through indepth semistructured phone interviews which lasted for approximately one hour a structured interview schedule consisting of three core questions was used to guide each interview questions were developed based upon the main areas of focus of the research study which included the impact of service dog partnership on individuals engagement in occupation comfort level going into the community with their service dog and their feelings regarding working with a service dog as a form of at all participants were allowed to speak for as long as they felt necessary to fully respond to the presented questions all interviews were transcribed for data analysis which was completed through a process of open axial and selective coding as described by patten 18 open coding was used to identify common ideas expressed by all participants in interviews these shared ideas were given a descriptive label axial coding was used to condense the number of categories identified during the open coding process by combining categories sharing similar ideas finally selective coding was used to further condense the number of categories identified during the axial coding process and identify core overarching ideas identified by participants triangulation of researchers member checking and peer examination as described by krefting 19 were utilized during the research process to enhance trustworthiness of reported results results a total of four females volunteered to be interviewed for this qualitative descriptive study following analysis and coding of the data four broad themes appeared all participants expressed that their service dogs had made significant impacts on their daily lives and their abilities to independently perform everyday occupations and had characteristics that made them unique from prior forms of at used in the past value of service dogs as a form of at the first broad theme expressed by the participants was that service dogs provide valuable assistance in the completion of everyday activities within the home and community the support that service dogs provide as a form of at allows handlers to engage in everyday occupations more independently the participants explained that because of the assistance they receive from their service dog they can perform tasks more safely conserve energy and require less help from other people while performing daily occupations including bathing and showering dressing functional mobility personal hygiene and grooming and toilet hygiene p2 described how her service dog is extremely helpful in assisting with her daily task of dressing when i get ready for bed at night all i have to do is kick off my sneakers and my dog picks them up and puts them away she knows where they go and if like the next morning im someplace else in the house and ask her for my sneakers she will go get them and bring them to me all participants stated that one of the biggest assets of owning a service dog is the dogs ability to assist with functional mobility including transferring reaching to the floor ascending and descending stairs and carrying items additionally the participants described how their service dogs help them in more complex daily activities such as doing the laundry shopping meal preparation traveling and performing workrelated tasks for all participants the assistance provided by their service dogs allowed them to continue to engage in valued habits and routines all participants stated that their service dogs impact their safety both at home and in the community which in turn impacts the abilities of themselves andor loved ones to engage in various activities in the community for example when talking about her service dog p1 stated that i couldnt tell you how many times my dog has kept me from falling if i lose my balance she plants her feet like a rock and doesnt move so i feel very safe my husband that was one of the things he remarked from the getgo was that it made him feel so much better with me being home alone because she was there and because she takes care of me p4 commented how having the constant support of her dog has enabled her to go outside alone before i got my dog i never went outside by myself unless someone was coming to pick me up once i got her i had to go out alone because she needed to play i realized how good it felt to go outside on my own i actually started going outside on nice days to just sit and read for my classes i also got out of my wheelchair and sat in the grass because i knew she could help me back into my wheelchair when i was ready to go because of the assistance and support provided by their service dogs during completion of daily occupations the participants reported an increase in their energy level and safety and they ultimately came to rely less on others for everyday needs impact of service dog partnership on community integration the second theme that emerged focused on how participants service dogs impacted their experiences in the community responses were broken down into two subthemes positive situations in public and challenges which led to the education of others positive situations in public all participants noted that their service dog made them feel like they could go out into public more while visiting public places they felt a sense of security because the service dog was solely focused on the handlers wellbeing participants discussed that with their service dog by their side they felt that they could participate in more social situations as well many common anxieties about going into public that were experienced by the participants diminished when they had their service dog by their side p3 described how her partnership with her dog gave her the confidence to go into the community without relying on other peoples assistance my dog helps me get things done without having to ask people all the time i dont have to hold my husbands hand all the time when i cant walk i can do things by myself for the first time ever last year i was able to go swimsuit shopping by myself in the mall because i had my dog as a counter balance and as an alert dog so i knew i was completely safe i knew i could do it all by myself all participants reported feeling more confident and competent going into community settings with their service dogs by their side to retrieve items assist with transferring opening and closing doors and help with any other necessary tasks challenging situations and education of others in public while going out in public with a service dog it is common for others to want to pet stare at and ask questions about it all participants reported that they often must educate others that the service dog is working and should not be distracted from his or her work participants alluded that it is common for them to be stopped while they are out as p1 describes for the most part its usually positive it can be a little tiresome repeating a million questions whats that thing on her back and what does she do for you and why do you have that thing on her back that looks heavy unfortunately not all community business employees are as receptive of service dogs as others or understand what it is doing for its handler as described by p1 service dog teams may face challenges even in businesses they frequently visit well one morning i went in and my dog went to go do the go pay and it was a young kid all of a sudden it was ah im not touching that money that dog doesnt even belong in this place this situation led to the education of the employee the business as well as other residents and other businesses in the community the participants expressed that some social settings present challenges often when people do not know how to respond appropriately to an individual with a service dog misinterpretations can occur however the participants discussed how they have learned to provide education to people who may not understand the role of a service dog comparison of service dogs versus other forms of at adaptability of service dogs the third theme focused on benefits and drawbacks associated with obtaining and maintaining service dogs versus other forms of at participants reported that each of their service dogs had learned to adapt to fit specific needs in different contexts to help maximize their handlers independence which was a significant benefit associated with service dog partnership as p1 described if its late at night and i need medication or just a snack or something i will text down stairs and say hey if i send my dog down will you get me a baggy of crackers or can you put two tylenol in a ziploc baggy or whatever and send it up for me i send her i say go take it and then she brings whatever i asked for up in a baggy all participants expressed how they have developed ways of tailoring their service dogs skills to fit their individual needs they valued the ability of their service dogs to adapt and change over time and felt that this was a valuable characteristic of their service dogs that they hadnt encountered with other forms of at used in the past extra effort and expenses there are also potential drawbacks associated with the use of a service dog as a form of at for example there are expenses associated with ownership and the upkeep of a service dog which are not present with other forms of at the organization from which the participants in this study obtained their service dogs utilizes a sliding fee scale clients are asked to pay anywhere from 1000 to 5000 towards the initial cost of their dog participants noted that there are also costs and effort associated with initial training including travel to the training siteorganization and community training outings participants also highlighted the multiple expenses associated with longterm service dog ownership including vet care food grooming supplies and toys while the participants noted that their service dogs require extra work and expenses they claimed that the benefits and support that they provide outweigh the additional work fluctuations in performance of service dogs service dogs are living creatures and demonstrate fluctuations in daily performance that are not encountered with other forms of at all participants commented that they have learned to be prepared for these instances p4 described how she handles these situations if i tell my dog to take something and she decides for some reason that she doesnt want to take it i cant take no for an answer so i have to persist until she cooperates so you know in that way sometimes what i think is a two second project turns into a five minute ordeal laughing and its like oh my goodness i dont know if i had time for that since the handlers can never guarantee how a dog will react to all situations they must learn to plan for them p1 is familiar with these fluctuations in her dogs performance and has modified some situations in which she asks her dog to complete task work once in a blue moon yea they get their attitude i dont give her anything glass because occasionally she gets an attitude where shell just look at me and drop the bags and i dont give her eggs laughing at the grocery store for that same reason the participants all stated that they had to learn to understand that their service dog is just thata dogand that they must be flexible and prepared for variations in the dogs performance depending upon the day and situation value of relationship with service dog the final theme that emerged focused on the value of the relationship formed with their service dogs and how the presence of this relationship made service dog partnership preferable to the use of other forms of at in many situations due to the constant companionship and interaction strong bonds form between the handlers and their service dogs p3s description of a situation in which she had to utilize a scooter highlighted the importance of the relationship between her and her service dog my dog is just great at helping in general i did use a scooter once right after a seizure when i was in a grocery store i tell you if i ever had to use something again i still think id just use the dog because they have an emotional substance to them that you just cant get from a walker or a scooter or a wheelchair they just do so much more for you and they give much more to you when youre in pain they feel it and they try to help you so much and give you so much back that it is just so worth it all participants reported that they have developed a strong relationship with their service dog because of their constant interaction they noted that their dogs seem to understand them and their capabilities and can respond as needed to provide appropriate assistance and support for example p2 expressed how well her service dog understands her physical tolerance level and knows when she needs to refrain from an activity she knows me better then i know myself shell tell me when im done fatigued if i try and get up and take a couple steps or something shell stand in front of me not beside me the participants disclosed how their service dogs have impacted their lives by providing a constant sense of security and support they placed a high value on the relationship that they developed with their service dogs and felt that the service dogs modified task performance based upon their current condition overall participants felt that the handlerdog relationship was the key factor that made their service dog superior to other forms of at used in the past discussion the results of participant interviews suggested that service dogs have had a positive impact on their handlers lives and have allowed them to be more independent in daily occupations not only do the participants service dogs aid in the performance and completion of adls and iadls but they have also been a constant source of support and increased their handlers participation in a variety of social contexts previous research has indicated that because assistance and service dogs possess the ability to assist persons with disabilities by improving their independence and participation in occupations they can be considered an alternative form of at 781220 the participants in the present study reported that they continued to use some forms of at they had utilized before obtaining their service dog despite this the participants identified that the service dogs functioning as a form of at increased independence and participation in occupations for individuals with mobility impairments more than many other forms of at available to them additionally they recognized the value and importance of the relationship they formed with their service dogs in terms of helping them to feel secure in completing daily activities at home and in the community for all participants this relationship is what ultimately differentiated their service dog from other forms of at utilized in the past and what made service dog partnership superior to the use of other forms of at in many situations interestingly the participants in the present study identified the importance of personalization of service dogs to fit each handlers specific needs this concept was not originally addressed in the research questions but emerged during the participant interviews all participants reported using their service dog in conjunction with at devices that they were already using however they also expressed how they established specific unique cues or gestures with their service dog to help their dog to best meet their own needs therefore service dogs have the potential to offer evolving customized assistance that individuals may not be able to obtain from other forms of at the results of this study indicated that there are significant benefits associated with the use of service dogs however there are factors unique to service dogs that must be addressed with persons considering this form of at in the present study participants discussed the extra time cost and energy involved in grooming feeding exercise and caring for their service dogs they also noted that service dogs as living creatures demonstrate some fluctuations in performance that may not be seen in other forms of at they had to be prepared to work through these situations nonetheless all the participants expressed how the benefits of owning a service dog surpassed the extra costs time and energy required these are all factors that likely need to be considered when exploring the use of a service dog as a form of at the present study found that service dogs impact every aspect of their handlers lives including participation in daily routines and occupations within the home and community occupational therapy practitioners concentrate on client performance in areas of occupation including daily routines and occupations it might be beneficial for occupational therapy practitioners to work more closely with service dog training organizations occupational therapists are trained to provide clientcentered assessments and interventions to best meet each clients individual needs similar to findings reported by shintani et al 8 and fairman and huebner 13 the results of the present study suggest that therapists could work in collaboration with service dog training organizations to assist with the client assessment and educationtraining process several limitations were present within this study a main limitation was the small sample size of only four caucasian female participants additional information about participants was not gathered as part of the interviews which may impact the generalizability of findings all the dogs were trained through the same service dog training organization leading to a lack of diversity of training and placement experiences additionally the individuals who participated in this study described positive experiences with their service dogs however participants who may have had negative experiences might not have been motivated to participate in the study consequently the results of the study are not necessarily generalizable to the greater population conclusions the purpose of this qualitative descriptive study was to learn how service dogs impact engagement in occupation among individuals with mobility impairments and learn about experiences utilizing a service dog as a form of at after completing interviews with four female participants and analyzing the data it was found that the participants service dogs substantially impact their everyday lives service dog partnerships influence the participants abilities to independently perform everyday occupations additionally the relationship the participants formed with their service dogs provided them with a sense of increased security and support thus encouraging them to be more active at home and in the community the positive outcomes reported by participants indicated that service dogs could be recommended more as a form of at for persons with mobility impairments the use of service dogs as a form of at by people with disabilities is an emerging area 11 additional research is suggested to examine best practice recommendations regarding the process of obtaining and utilizing a service dog this suggests the need for more rigorous studies with a larger sample size variance in gender and a wider geographical range author contributions this manuscript was based on a research project completed by rachel csatari alyssa kolanowski amy londry and rachel dawson as part of requirements for the master of science in occupational therapy program at saginaw valley state university ellen herlachepretzer served as the faculty advisor and assisted with research study design and implementation and contributed to data analysis interpretation of results and final manuscript construction melissa y winkle served as an advisor and conceived the initial focus and design of the research study and contributed to data analysis interpretation of results and final manuscript construction rachel csatari alyssa kolanowski amy londry and rachel dawson completed research study design and data collection they were active in data analysis interpretation of results and final manuscript construction

it is becoming more common for people with disabilities to procure service dogs as a form of assistive technology at however there is little qualitative research examining the impact of service dogs on engagement in valued daily activities occupations among persons with mobility impairments this study used a qualitative descriptive methodology to learn about the experiences of four female service dog owners with mobility impairments with a focus on the impact of service dog use on the performance of daily occupations and participation in social activities and their experiences utilizing a service dog as a form of at data analysis indicated that each participants service dog made a significant impact on their everyday lives and their ability to independently perform everyday activities however there are also unique challenges associated with service dog ownership that must be considered when evaluating benefits of service dog partnership overall the positive outcomes reported by participants indicate that service dogs can be considered a beneficial adaptable form of at for some persons with mobility impairments

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to the editor the prodigious greek philosopher aristotle with other renowned classical and contemporary thinkers plausibly observed that the human person is by nature a social being 1 or in the aristotelian term a political animal as a social being or a political animal mans sense of purpose is always intrinsically connected with the nature of socialization in other words the way a person deals with other human beings in the process of socialization defines how an individual creates meaning in relation to his own existence hence socialization is important not only in the search of the human person for existential meaning but also for keeping himself psychologically lucid departure from this natural tendency of the human person to socialize and to participate in the existential discourse of society would tragically result into a certain feeling of dejection and anxiety 2 in the case of the present situation that the society in general is currently facing in the midst of the covid19 pandemic this tendency to express oneself in the process of socialization has been pacified different governments across nations had implemented various forms of community quarantine just to prevent the widespread of the disease and the deleterious effect of the virus to different sectors of society 3 the preventive measures of the government in controlling the spread of the virus while good in itself pose a danger not only on the mental health of individuals but also their socioeconomic condition these aspectsthe mental health of individuals relational aspect of the human person and the socioeconomic condition of individuals are interrelated with each other simply because one aspect respectively affects the condition of the other two aspects in the case of the social condition brought by the pandemic many people across countries have lost their jobs when various businesses needed to be shut down because of the mandated quarantine or because of the lack of resources in funding their operation if these businesses would not shut their operation they would consequently end up minimizing their overall operation cost by reducing employed personnel and shortened their production hour just to cope up with their monetary lost which resulting to a sense of depression and anxiety on the part of those who are heavily affected the ones who lost their jobs this condition has left those people who have lost their jobs to spend their hardearned savings to provide the basic needs of their families and think of practical ways to survive given the absence of a suitable job the withdrawal from communal life and participation in social affairs certainly poses a threat to the socioeconomic condition of an individual which in return would affect his own mental health this proposition is true especially in the case of the most deprived ones in the social stratum 4 leaving them more deprived and utterly vulnerable however in the midst of the catastrophic phenomenon that the general populace is currently experiencing the natural tendency of the human person to socialize is still apparent the pandemic or any forms of restrictions could not stop the human persons participation in the process of socialization but instead makes his yearning for the other person even stronger the human nature to socialize could not be stopped by the pandemic simply because it is imbedded in his nature and it is this same social setting that the pandemic brings gives sufficient reason for the human person to be connected to others especially the suffering ones many people were moved into action in helping those who are deeply affected by the pandemic the silent yet obvious cry of those afflicted by the pandemic serves as a force that enable many people to socializes in the spirit of fraternal charity with a profound hope to alleviate the suffering and replace it with a deep sense of hope for a better tomorrow a hope that shines through the feeling of hopelessness that the pandemic brings fraternal charity seen in the process of socialization is a proactive advocacy and response to the anguish of the vulnerable 5 while people suffer in this time of global crisis the ray of hope coming from the natural tendency of the human person to socialize done in the spirit of fraternal charity is an assurance that humanity could withstand the disaster that threatens its very own existence who would have thought that the covid19 pandemic could bring out the best in many people to be a neighbor toward the other even if the situation requires corporal isolation who would have thought that the pandemic could result in a social paradox

government across all nations had promulgated precautionary measures in controlling the wide spread of the disease one that takes precedence is the practice of community quarantine where people are mandated to stay at home and avoid going outside if is not utterly necessary this mandate caused a lot of catastrophic outcomes in the socioeconomic condition and mental health of many many people are in psychological and existential despair for the loss of their jobs and the isolation that they are experiencing however in the midst of this undesirable condition the natural tendency of the human person to socialize is still present done in the spirit of fraternal charity an individuals way of socialization gives hope to those who are in despair the covid19 pandemic does not deter the human person to exercise his fraternal instinct but gives him sufficient reason to employ it all the more creating the social paradox of human presence

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introduction as income inequalities persist and are even increasing in many countries 1 relative poverty affects many families however apart from small pockets of dire poverty relative poverty in affluent countries does not mean absolute deprivation but merely that the level of economic resources is distinctly lower than the average in comparison with most other families relatively poor families will command fewer economic resources and consume fewer goods and services relative poverty may nevertheless go handinhand with an access to a material standard of living which from a historical perspective is fairly high this is for instance the case in norway the setting of the present study using the european unions definition of relative poverty ie householdequivalized disposable family income below 60 per cent of the median 2 a 2003 norwegian survey found that among families who qualified as poor according to this criterion about 95 per cent had a washing machine 95 per cent had a deep freezer and around 80 per cent had a car a personal computer and a dishwashing machine lack of food and clothes were practically nonexistent and almost all had a fairly suitable dwelling 3 should this type of poverty be a health policy concern in the sense that policy makers should seek a substantial reduction of relative poverty in order to improve population health an affirmative answer to this question presupposes that relative poverty has a causal impact on health here this question is examined with respect to adolescents health as serious somatic disease rarely occurs in these age groups other healthrelated indicators such as risk behaviours overweight and selfrated overall health may be more suitable for examining health inequalities among young people in this paper the focus is on subjective health ie on selfreported somatic and mental symptoms we ask is living in relative poverty a cause of such subjective health complaints among adolescents diverging answers to this question are found in the literature the family economic stress model 4 5 6 argues that economic hardship will result in family stress due to the mismatch between needs and resources family stress will trigger parental conflict frustration and hopelessness which affect the lives of the offspring and become manifested in higher levels of subjective health complaints the investment model 7 suggests that lack of economic means could lead to a neglect of childrens need for attention and support because parents have to prioritize immediate material concerns these two models differ in emphasis but both assume a causal effect from economic resources to offsprings subjective health this contrasts with accounts which regard associations between family economy and offsprings developmental outcomes as mostly spurious a viewpoint forcefully put forward by mayers what money cant buy 8 in this book the main narrative is that parents personal characteristics which facilitate higher earnings are basically the same traits which create the secure and supporting family environment that promotes good subjective health among children thus there is no important direct causal influence from relative poverty to offsprings subjective health if these two are statistically associated the reason is their joint origin in parental ability and dispositions certainly both accounts are plausible restricted money resources may trigger quarrels between parents and harm family life with detrimental consequences for the offsprings subjective wellbeing moreover it is likely that there will always be some parents who both have problematic economic careers and lack the personal qualities which promote subjective health among their children individual families exemplifying both patterns will probably be found in any empirical material and a study of causality will help to establish which pattern predominates in a given population many empirical studies have demonstrated that families relative poverty as well as parental characteristics such as low education unskilled occupations and unemployment tend to be associated with less good health in the offspring examples can be found in the united states 9 and australia 10 as well as in the nordic countries 6 11 12 13 14 15 16 17 18 britain 19 20 21 22 and germany 23 24 25 exceptions from the predominant pattern can also be found 2627 and studies differ considerably with regard to design and variables but overall the results indicate higher levels of ill health among adolescents from low income families to assess causality from these studies is rather difficult however as data well suited for causal analysis are often lacking 28 with few exceptions 22 only crosssectional data have been available making the timeordering of variables uncertain moreover information about health and socioeconomic status has often been collected by survey answers from only one sourceeither from parents only or from childrenadolescents only therefore statistical associations may sometimes be artificially produced because of variations in respondents response styles for instance respondents who give negative verdicts of all types of circumstances in addition to these difficulties it is evident that adolescents subjective health is influenced by a number of other circumstances apart from the familys economic situation a regular finding is for instance that subjective health complaints are more often reported by girls than boys 29 individual susceptibility will have a role as will neighbourhood characteristics and school experiences 30 also the choice of age groups could be consequential the equalisation of health in youth thesis 3132 suggests that socioeconomic variations in subjective health are practically absent in late childhood and early adolescence before reemerging when adolescents approach early adulthood if so data covering late adolescence are needed in order to detect a causal effect of relative poverty this paper is an attempt to shed further light on these topics using longitudinal data material with information collected both from parents from the adolescents themselves and from public administrative registers we make a causal analysis of the association between relative poverty and adolescents subjective health ie their reporting of various somatic and mental symptoms we understand causality in terms of the counterfactual model 33 34 35 this implies that we seek answers to what ifquestions if the relatively poor adolescents had not been poor would their health have been better conversely as regards the nonpoor adolescents would their health have been worse in the hypothetical case that they lived in relative poverty propensity score matching is employed in the analyses as this method although more and more used in causal analyses 36 37 38 is still not widely known we first describe shortly some main aspects of this method 343940 before we proceed to data description analysis and discussion causal analysis by means of propensity score matching if we have reasonably valid data about families economic situation and the offsprings subjective health we can estimate how subjective health differs between adolescents in relatively poor and adolescents in nonpoor families however this observed difference is likely to be different from a true estimate of the causal effect of relative poverty because the samples of poor and nonpoor families will probably differ not only with respect to economic resources but also with respect to other circumstances which could be involved in the production of subjective health thus the two samples are imbalanced they are differently composed with regard both to their economic situation and to a number of other relevant characteristics a solution to this problem is to try to eliminate the imbalance by constructing a matched control sample ie to select in the sample of nonpoor adolescents a subsample which corresponds as closely as possible to the sample of relatively poor adolescents with respect to all relevant circumstances if this could be done perfectly we would have two samples which differ only along the poornonpoor dimension in other words we would have approached the balanced composition of the treatment group and the control group which is the aim of randomization if so the difference between the relatively poor and the matched nonpoor adolescents would approximate the true causal effect however all data sets have limitations and many circumstances some of them unobserved are likely to vary between the relatively poor and the nonpoor adolescents therefore it is practically impossible to construct a matched sample so that each relatively poor adolescent has a duplicate in the nonpoor sample with exactly the same values on all relevant background variables a way out of this difficulty is to construct a matched sample which is similar to the sample of relatively poornot with respect to the specific values on a large set of variables but with respect to the values on a single dimension the probability of becoming relatively poor this probability can be calculated for each individual in the entire sample both among those who actually became poor and those who avoided poverty this calculation is usually made by fitting a logit or probit regression model which includes all variables available in the data which could reasonably be considered as being part of or related to the trajectories and social processes which lead into relative poverty the probability of entering relative poverty calculated in this way is termed the estimated propensity score causal analysis by means of propensity score matching implies that we try to remove the imbalance between the samples by selecting a control sample which has the same distribution of estimated propensity scores as the sample who actually was exposed to relative poverty the method rests on the assumption that a comparison of units with equal propensity scores can effectively substitute for a perfect multidimensional matching on the observed variables 41 with two samples which have identical distributions of propensity scores the desired balance with respect to confounding variables can be achieved and the difference in outcome will therefore approximate the true causal effect of being exposed to relative poverty thus matching by estimated propensity scores may remove the imbalance between the two samples with respect to the observed variables however the technique does not provide a guarantee against bias arising from unobserved variables 42 matching by propensity scores does not avoid the problem posed by unobserved heterogeneity but the method is a useful tool when we try to estimate causal effects in observational data in comparison to regression techniques matching by estimated propensity scores can have some advantages 3435 for instance the adjustment for confounding factors achieved through conventional multivariate regression will usually rest on assumptions about linearity and additivity in contrast matching in general and propensity score matching in particular is a nonparametric strategy which can be used without making assumptions about the functional form of the associations or about the presence of interaction effects between the control variables multivariate regression analyses will often lead to inferences based on extrapolation outside the range of the observed data points while matching by propensity scores can avoid this difficulty while regression analyses often imply that an explanatory variable has an invariant structural causal effect that applies to all members of the population 34 propensity score matching is a convenient tool for examining how effects differ between various subcategories in the sample data variables and statistical analysis data and analyzed sample data come from the project childrens level of livingthe impact of family income conducted at norwegian social research and cofinanced by norwegian womens public health association 4344 statistics norway was commissioned to obtain personal interviews with a sample of families with children in three interview waves 20032009 information from statistics norways educational register and taxation register has been linked to the sample by means of the personal identification number data were made available for research after being anonymized according to the regulations of the norwegian data inspectorate in this study adolescents born 19911993 are analyzed because this birth cohort was asked about subjective health both in the 2009 interviews when aged 1618 and in the 2003 interviews when aged 1012 this enables analyses both of the level of subjective health in late adolescence and of changes in subjective health during adolescence as late adolescence often will be a critical period with farreaching consequences for adult life a focus on this life phase is particularly interesting a supplementary reason for examining this age category was that socioeconomic variations in subjective health may be easier to detect among 1618 years old than among younger adolescents 31 altogether 557 adolescents born in 19911993 participated both in the 2003 and 2009 data collection waves among them 510 gave complete answers to the subjective health questions in both years and these 510 adolescents are analyzed in the present study although random sampling from population registers was utilized in the upstart of the project the sample analyzed in this paper cannot be considered a representative sample of norwegian adolescents born in 19911993 mainly because of sample attrition of those who originally were included in the gross sample only 38 per cent were interviewed in 2009 moreover the sample was first divided into one subsample drawn randomly from the 2000 population register among all families with children and another larger subsample drawn randomly among families with children who had low incomes in 2000a particular purpose of the project was to study living conditions among lowincome families with children in the present study these two subsamples have been pooled which can be justified as the data collection procedure was identical in the two subsamples moreover upward income mobility has been substantial in the lowincome sample resulting in quite diluted economic differences between the two subsamples in 2009 the topic of the present study is not to make precise estimations of the overall life situation among norwegian adolescents aged 1618 but to analyze possible causal effects of relative poverty this purpose may be obtained fairly well even though the analyzed sample deviates somewhat from a fully representative sample a population register analysis of all families with children in norway in 2007 45 suggests that the sample analyzed in the present study has some low income bias but higher income strata are well represented as nearly 40 per cent of the sample had equivalized incomes above the national median in 2008 measurements of subjective health and relative poverty the measurement of subjective health in this study corresponds to the measurement used by the large crossnational project health behaviour in school children 1729 answers to eight questions given in personal interviews about frequency of headache stomach pain back pain feeling low bad temper nervousness dizziness and sleeplessness were coded from never 0 to several times a week 4 and added into an index the index theoretical range is from zero to 32 two outcomes are analyzed in this study the level of symptom burden in 2009 and the change in this burden from 2003 to 2009 while the health outcome was gauged by survey answers given by the adolescents themselves the classification of the sample into relatively poor and nonpoor was based on tax register data obtained from statistics norway this ensures a more objective assessment of the familys economic resources than assessments based on subjective survey statements the tax registers provided information for each year 20002008 about the sum of all family members posttax income and the sum of financial assets ie the value of bank accounts shares and similar assets which swiftly can be converted into cash statistics norways registers were utilized in order to obtain information about each adolescents family situation and how it changed because of new siblings divorce etc in this way a fairly precise measurement of each familys economic situation has been obtained for each year in the period under study for all the 510 adolescents who had answered the questions about subjective health both in 2003 and 2009 the relevant tax register information was available the tax register information was utilized for measuring the families economic resources in a way which reflects two considerations first a familys real economic strength may be inadequately indicated by oneyear snapshots or shortterm fluctuations from year to year therefore we have constructed a measurement which reflects the average economic situation during the years 20042008 ie the period between the interviews in 2003 and 2009 second as economic resources are not only incomerelated but depend also on monetary supplies besides income 4647 the measurement combines income information with financial asset information into one single scale the measurement was calculated by adding the sum of all family members posttax income and financial assets for each year 20042008 dividing each years sum by household composition weights making adjustments due to changes in price levels and finally averaging the equivalized and priceadjusted measurements across the five years 20042008 the mean value on this scale was norwegian kroner 406000 the median was considerably lower indicating the skewness of the distribution of economic resources drawing the line between relative poverty and nonpoverty will be somewhat arbitrary we chose to consider families with less than nok 200000 on average 20042008 as relatively poor this poverty line about 70 per cent of the samples median resulted in classifying 109 out of the 510 analyzed adolescents as living in relative poverty during the years prior to 2009 the estimation of propensity scores causal analysis by means of propensity score matching starts with an estimation of propensity scores 3439 in the context of this study this implies calculating the probability of being relatively poor in 20042008 for each individual adolescent in the sample in general all available variablesas many predictors as possible 35 which could be involved in or associated with the families entry into or avoidance of relative poverty should be included in this estimation the families previous economic situation the parents employment activity parental characteristics such as education and health family structure and family size are examples of variables which are likely to be associated with the probability of being relatively poor we the adolescents were classified as living with both parents with a single parent or in a stepfamily ie living with one parent and hisher new partner variables about overall selfassessed health among the adults in the family in 2003 and the interviewed adults mental health in 2003 were also made with information from the 2003 interviews with one of the parents in the estimation of propensity scores we also added a variable indicating subsample belonging categorical variables were indicated by dummy variables in the model missing values on the variables used for estimating propensity scores were generally few these were replaced by the samples median value in order to preserve all the 510 adolescents for further analyses the propensity score estimation was made by a probit regression model and the resulting coefficients were recalculated into probabilities assigned to each adolescent in the sample stata version 112 with the software psmatch2 was used for these estimations 40 estimating counterfactual effects by radius and kernel matching estimated propensity scores can be utilized in further analyses in several ways for instance as a stratifying tool 34 or as a covariate in ols multivariate regression 35 in this study we utilize more advanced techniques radius matching and kernel matching these two methods are variants of the matching algorithms included in statas software psmatch2 and recommended in the literature 343940 we chose to use two different techniques our sample is restricted in size and results may be subject to random errors and alternative estimation techniques may provide a robustness test of the findings below we describe a few main aspects of these two techniques the assumption underlying propensity score matching is that two samples with identical distributions of estimated propensity scores will be balanced with respect to a number of possible confounders the matching sample serves as a basis for the estimations of counterfactual effects the outcome value in the matching sample is likely to indicate what the outcome value would have been in the exposed sample in the hypothetical situation that exposure to the assumed causal factor had not taken place it is not unproblematic however to construct a matching sample for instance as the estimated propensity scores ie the probability of becoming relatively poor constitute a continuous scale there will often be instances where no exact match can be found an adolescent in the sample of relatively poor may for instance have 0333 in propensity score while among the nonpoor it could easily happen that no one has exactly this score but fairly close scores are present for instance in the 028032 range or the 034037 range which nonpoor adolescents should be included as matches and how should the matches be weighted matching algorithms provide different techniques for handling these questions in radius matching the selection of matches among the nonpoor adolescents are restricted to those with propensity scores within a certain range defined by a caliper value thus if an adolescent exposed to relative poverty has propensity score 0333 and the caliper value is set to 002 adolescents in the nonpoor sample with propensity scores in the 03130353 range will be selected as matches if no matches are found within the specified range the exposed unit will be excluded from further analyses because inclusion would threaten the comparability between the two samples a small caliper value will result in very similar distributions of propensity scores which may improve the estimations of counterfactual effects however more sample units will be excluded which may threaten the validity of the estimations and if the analyzed samples become too small random errors may increase a larger caliper value will on the other hand keep more sample units in the analyses at the cost of more differences between the two samples in the distribution of propensity scores in our estimation by means of radius matching we used caliper value 002 which provides a fair balance between the number of cases kept in the analysis and the similarity in propensity score distributions in kernel matching the value stipulated for bandwidth serves the same purpose as the caliper in radius matching ie designating what cases are to be included in the matching sample when using kernel matching we chose bandwidth value 003 in order to check whether the pattern of results remained when more cases were included in the analysis with kernel matching each unit included in the matching sample is weighted in proportion to the distance in propensity scores between the exposed unit and the matching units propensity score matching facilitates the estimation of whether effects differ between various subcategories here two types of effects are estimated the average treatment effect on the treated refers in this paper to the estimated effect of relative poverty on subjective health in the sample of relatively poor correspondingly the average treatment effect on the untreated refers to the hypothetical effect of relative poverty on the subjective health among those adolescents who were not poor during 20042008 these two effects may be different for several reasons it could happen for instance that the average effect of relative poverty among the relatively poor is influenced by a higher exposure to deprivation in a more general sense conversely the counterfactual effect of becoming relatively poor among those adolescents who actually were not poor might be less severe if neutralized by a generally more favourable life situation we have utilized the calculations of tvalues in stata psmatch2 software in order to evaluate the statistical significance of the two effects in order to broaden the basis for interpretations we will as mentioned above analyze adolescents subjective health not only by two different matching algorithms but also by measuring subjective health in two ways first as the level of subjective health in 2009 and secondly by taking advantage of the panel structure of the data and analyze change in subjective health from 2003 to 2009 the latter version has the advantage that it will approximate a removal of bias due to any stable unobserved characteristic that could have influenced subjective health at both time points results in the analyzed sample of 510 adolescents the mean value on the subjective health index was 996 in the 2009 interviews when the adolescents were aged 1618 the average change from 2003 to 2009 was 230 thus overall subjective health complaints increased from early to late adolescence gender differences were considerable in this study however the two genders will be analyzed together in order to preserve the size of the analyzed sample this will not influence the estimation of the effects of relative poverty since the proportion of girls in the two samples is quite similar table 1 shows the values for the outcome variables separately for the relatively poor and the nonpoor adolescents clearly the relatively poor adolescents reported more subjective health complaints in 2009 than the nonpoor adolescents when using the conventional p 005 threshold the difference was statistically significant also subjective health worsened more on average from 2003 to 2009 among the relatively poor the mean value increased by 370 compared to 192 among the nonpoor and also this difference was statistically significant furthermore table 1 shows how the two samples differed with respect to the variables which were utilized in the estimation of propensity scores the nonpoor sample had experienced a better family economy before 2004 and their parents were mostly better educated than the parents of the relatively poor adolescents the relatively poor adolescents had more often parents who were afflicted by health problems they lived more often in oneparent families andor in families with no employed adults and they had more often a nonwestern immigrant background table 1 illustrates the difficulties which have to be dealt with when trying to establish whether relative poverty by itself contributes to the higher level of subjective ill health among the relatively poor adolescents not only was the economic situation in the families of the nonpoor much better the nonpoor experienced more advantageous environments also regarding a series of other life circumstances such as the parents educational level employment and health the differences between the two samples are further demonstrated in figure 1 which indicates how the estimated propensity scores ie the probability of being relatively poor were distributed in the two samples among those who were relatively poor the mean estimated propensity score was 0490 among the nonpoor the mean was 0136 thus both samples are represented across a wide propensity score range but the shapes of the distributions are drastically different the nonpoor had fairly many with extremely low probability of being poor while a few of the relatively poor adolescents had a probability of being poor exceeding 09 figure 1 illustrates the large disparities between the two samples in their probabilities of becoming relatively poor and this underlines the challenge for causal analysis since the two samples were so dissimilar as to many life aspects which could influence their subjective health nevertheless figure 1 also demonstrates that for most propensity scores levels at least a few among the nonpoor have propensity scores which are similar to the propensity scores of some of the relatively poor adolescents there is therefore a considerable common support area ie in the probability range from 0033 to 0893 both poor and nonpoor can be found which allows for using the matching techniques we utilize the two methods described aboveradius and kernel matchingfor estimating the counterfactual effects of relative poverty the results are given in table 2 the estimated counterfactual effects of relative poverty among those adolescents who did not experience poverty during 20042008termed the average treatment effect on the untreated in section 34are clearly weaker the size of the effect on the 2009 level of subjective health does not seem negligible at first sight but they are far from statistically significant regarding change in subjective health during adolescence among the nonpoor adolescents the estimated effects indicate that for this category of adolescents the impact of a hypothetical exposure to relative poverty would have been practically nil discussion main results and interpretation this study has asked whether relatively poverty in contemporary norwegian society is detrimental for adolescents subjective health which was measured by their reporting of somatic and mental symptoms the findings indicate that for adolescents who lived in relatively poor families the economic situation in their families had a negative effect on their subjective health trajectory during adolescence from age 1012 to age 1618 also the results regarding the level of subjective health when these adolescents were 1618 years old suggest a similar conclusion about some negative effect of limited economic resources in the adolescents families although this latter effect was weaker this study has employed statistical techniques which aim at neutralizing the confounding influence from other factors than the assumed cause caution must always be applied when drawing causal conclusions from observational studies nevertheless the results are at least compatible with the hypothesis that among the adolescents who lived in relatively poor families the restricted economic resources in these families contributed to the causal processes which led up to their less favourable subjective health situation in late adolescence this conclusion can only be drawn for those adolescents who actually lived in relative poverty however for those adolescents who lived in families with economic resources above the relative poverty level the counterfactual modelling utilized in this study could not reveal any potential negative health effect in the hypothetical case that these families had been exposed to relative poverty thus the findings point towards a differentiated conclusion for those adolescents who actually experienced relative poverty their economic situation aggravated their subjective ill health for those adolescents who were not exposed to relative poverty it is not likely that their subjective health would have worsened if they actually had lived in relative poverty a possible interpretation of this empirical pattern could take into consideration that relatively poor adolescents are often experiencing other disadvantageous circumstances apart from their families economic situation they are for instance more often living in singleparent families they have often less educated parents or parents who are out of work or parents afflicted by health problems the nonpoor adolescents are less affected by such circumstances which could mean that there are more protective factors in their environments which buffer against the potential detrimental health consequences of few economic resources in the family among the relatively poor adolescents on the other hand who more often lack such protective environments relative poverty could add to their other disadvantages in a way which leads to deteriorated subjective health whether this occurs in line with the family economic stress model or the investment model 57 as discussed in the introduction or through some other type of process cannot be further pursued in this paper how important are these effects on the subjective health of relatively poor adolescents certainly an array of factors contribute to young peoples subjective health a familys economic situation in the context of the contemporary norwegian welfare state is only one of many factors which could contribute to adolescents symptom burden it should nevertheless be noted that the results of this study suggest that if the relatively poor adolescents had lived in nonpoor families their subjective health development during adolescence would not deviate on average from that experienced by other adolescents the observed difference between relatively poor and nonpoor adolescents with regard to the deterioration in subjective health 20032009 was smaller than the effects for the relatively poor adolescent estimated by propensity score matching the detrimental effect of relative poverty detected in this study seems therefore in statistical terms to account for the difference between relatively poor and nonpoor in how subjective health developed during adolescence strengths and limitations the data available for this study have several advantages information about subjective health has been obtained in personal interviewsnot with proxy respondents but with the adolescents themselves various other information about the adolescents situation was collected from one of the parents while the crucial independent variable in this study families economic resources was constructed on the basis of register data which probably are more objective and valid than survey answers the data were furthermore obtained from a prospective panel design enabling a fairly certain time ordering of variables thus these data avoid some of the sources of error which have plagued many youth studies 28 moreover the causal analyses have utilized the techniques of propensity score matching which arguably is a promising tool for social science when the purpose is to approximate estimations of causal effects in observational data 34 a critical aspect of propensity score matching is the procedure for estimating propensity scores ie the calculation of the probability of being assigned to the category exposed to the assumed cause this study has had access to rich information which could imply that the estimated probabilities do not deviate dramatically from the true propensity scores however an inclusion of more predictors in this calculationfor instance variables indicating parents personal characteristics their social skills and their previous working careercould certainly have improved the estimation of the propensity scores various limitations are also evident although the adolescents families represent many levels of economic circumstances we cannot reject the possibility that the selfselection of respondents which occurs in interview surveys has resulted in a sample bias which could influence the results sample attrition has been substantial and the analyse have been performed on a sample which is restricted in size this is clearly a source of uncertainty moreover the results from the two utilized propensity score matching techniques are not identical deviating results may occur in small samples because the techniques vary in terms of what units are included in the matching samples the basic similarity in the results from the two matching techniques gives however some credibility to the main findings still the propensity score matching technique cannot overcome the basic problem affecting all causal analyses based on observational studies the potential impact of unknown unobserved variables generalizing the results of the present study to the situation in other countries would imply assumptions which are difficult to assess the norwegian case with its special economic political and cultural situation could be special similar studies in other settings are needed in order to examine whether the effects on relatively poor adolescents subjective health which were detected in this study correspond to similar effects in other countries conclusions living in families with a limited access to economic resources in the contemporary norwegian social context appears to have detrimental effects on the development of subjective health during adolescence among those adolescents who are exposed to relative poverty in families with more economic resources it is likely that better access to other advantageous environments buffers against the potentially detrimental health effects of relative poverty the results indicate that inequalities in families economic resources contribute to the health inequalities among norwegian adolescents conflicts of interest the authors declare no conflicts of interest

studies have revealed that relative poverty is associated with ill health but the interpretations of this correlation vary this article asks whether relative poverty among norwegian adolescents is causally related to poor subjective health ie selfreported somatic and mental symptoms data consist of interview responses from a sample of adolescents n 510 and their parents combined with register data on the familys economic situation relatively poor adolescents had significantly worse subjective health than nonpoor adolescents relatively poor adolescents also experienced many other social disadvantages such as parental unemployment and parental ill health comparisons between the relatively poor and the nonpoor adolescents using propensity score matching indicated a negative impact of relative poverty on the subjective health among those adolescents who lived in families with relatively few economic resources the results suggest that there is a causal component in the association between relative poverty and the symptom burden of disadvantaged adolescents relative poverty is only one of many determinants of adolescents subjective health but its role should be acknowledged when policies for promoting adolescent health are designed

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recently a reality tv show featuring fatherchild interactions has sparked a heated debate about father involvement in family education as more and more men among the post70s or the post80s generation become fathers many traditional beliefs and practices in child upbringing start to change fathers have become more involved in family education in china correspondence concerning this article should be addressed to hsiuzu ho email i argue that the television series where are we going dad is an ideal cultural site to witness the discourse of the changing parenting practices and gender roles in contemporary china adapted from a south korean reality show the chinese version where are we going dad has gained huge popularity in mainland china ever since it premiered in october 2013 the show depicts the everyday interaction of five celebrity fathers with their children during a threeday countryside excursion it ranked as the top chinese tv show within two months after its first episode aired and spurred more than ten million comments on weibo igniting a popular debate not only on parenting but also on gender equality within the family the show has been popular not only in china but in other asian societies including hong kong singapore and taiwan the show has completed its sixth season attracting undiminished attention nationwide its immense success had also inspired along the way the creation of its movie version and another reality tv show called dad is back that similarly depicts fatherchildren relationship with a focus on mostly indoor activities in their daily family life according to yang what has had viewers hooked to the show is the lens it provides into the clash between the traditional and more progressive views on parenting specifically the role of the father yang notes that after each episode many avid users of the internet comment on weibo with regard to father involvement for example one netizen commented the real appeal of the show is that it teaches and prompts us dads to reflect on how to better communicate and interact with our kids another wrote endless work leaves me with little time with my kid i have no say in the family right now because my kid only listens to his mom after watching the show i really feel the need to spend more quality time with my kid one father reported that a homework assignment of his elementaryschoolaged son was to view and write about his feelings towards the new hit movie version of the television show the impact that this popular television series and movie is having on both the adult and younger generations of traditional patriarchal societies is of great interest and warrants further research with the rapid change in the economic political socialcultural and educational aspects in contemporary china the influence that this popular television show has on the current beliefs and practices regarding parenting roles in this traditionally patriarchal society are of great interest but so far underreported to address this gap in the literature and to further our understanding of parenting roles and involvement in chinese culture the present exploratory investigation examines the perspectives of mothers fathers as well as their thirdgrade children in a suburban area in china regarding their parenting role beliefs these parenting role beliefs refer to attitudes and values about the genderspecific responsibilities mothers and fathers take on in the familys childrearing practices parenting role beliefs may not always reflect the actual behaviors and practices conducted in the home therefore this research also compares the selfreported frequency with which mothers and fathers engage in various parenting activities sociocultural context of contemporary chinese society chinese society is strongly influenced by the teachings of the ancient philosopher confucius who emphasized interpersonal harmony and relational hierarchy the aspect of relational hierarchy delineates a strict order of authority and circumscribed social roles within the household particularly confucian patriarchal ideology considers women subordinate to men and emphasizes the fathers roles in the family as head of the household and provider and the mothers role as nurturer and caretaker these traditional gender role beliefs encourage women to manage household chores and raise children thereby allowing men to concentrate on work outside of the home as goes the old saying men are breadwinners women are homemakers while emotional support of children is traditionally the mothers responsibility in the home fathers are tasked with setting boundaries disciplining and teaching children the traditional chinese father role is considered authoritarianhighly controlling and demanding of their children yet emotionally distant and uninvolved since the 1950s the chinese communist government has enacted a series of policies that have made profound and swift societal impact in its first decade of power the chinese communist government announced less genderbound more egalitarian principles and offered equitable opportunities to women to be employed by state and collective firms the marriage law of 1950 promoted equal rights between genders that allowed and encouraged women to choose their own romantic partners rather than be placed in traditional arranged marriages as a result of those developments chinese women became more financially independent and less reliant on marriage as a means to economic survival related to the family unit researchers have also noted the impact of chinas family planning policy on family dynamics instituted in the 1978 to address societal and economic concerns this onechild policy has had the effect of cultivating a more childcentered family culture one in which both fathers and mothers invest greater time and attention on their children chinese gender and parenting role beliefs modern society has increasingly required men to take on more responsibilities at home an emerging body of international research across societies has demonstrated the importance of fathers emotional and physical involvement with their children several studies have indicated father involvement to play an important role in predicting childrens academic success and psychological wellbeing research conducted in shanghai have indicated that fathers are trying to be more emotionally involved and physically present by doing more activities and communicating more with their children assessments of parenting styles in the metropolitan area of shenzhen suggested the emergence of the supportive panda father archetype who uses less punitive and more reasoning strategies to manage their childrens behaviors there is evidence that chinese fathers and mothers are in greater alignment about parenting styles other research has also indicated that urban fathers are actively engaged with their children especially in play activities but also in caretaking activities such as feeding children helping them wake up and go to bed taking them to and from school and comforting them when they are ill despite reports of increased father involvement in parenting practices some studies have suggested that beliefs about gendered divisions of labor in parenting appear to change at a slower rate egalitarian perceptions can be defined as beliefs that parenting roles should not be separated by gender earlier research investigating the beliefs and thoughts about gender roles among the chinese population have found that women held more egalitarian perspectives on gender roles and endorsed fewer traditional gender role perspectives than did men ito and colleagues more recent investigation surveyed fathers in beijing about childcare responsibilities and parental role beliefs although many report they do participate in childcare tasks their paternal identities still revolve primarily around the roles of breadwinner head of household and teachermuch less so caregiver or supportive spouse explanations for this phenomenon have emphasized the intransigent nature of ideology wong argues that few parents will openly champion traditional confucian values but many still hold fast to genderstereotypical roles the daily practices and adjustments related to parenting are easier to negotiate than gender ideologies and expectations between spouses it is worth noting that parental role beliefs may vary depending on personal and environmental characteristics research suggests that employment status and education are positively related to egalitarian attitudes toward gender roles in china the vast majority of studies on parental role beliefs are conducted in urban areas but there is evidence that the level of industrialization and urbanization in the area affects gender ideologies in more industrialized and urbanized regions individuals tend to possess more egalitarian attitudes toward gender and parenting roles age also appears to play a part in tu and changs study younger women tended to be less conservative and less in favor of the traditional division of labor compared to their older peers plans to delay parenting may also positively predict progressivism in a study by zhang who examined gender beliefs of college students participants who anticipated delaying marriage and childbearing were more inclined toward egalitarian gender role viewpoints while studies have observed the effect of age too few have examined attitudes about gender roles in the younger generation parenting research is dominated by perspectives of mothers much less so fathers and far less often children zhangs work gains insights from the childrens point of view albeit from collegeage adult children we argue this paucity is a missed opportunity to investigate parental role beliefs from multiple perspectives the present study was conducted to expand the literature on parenting role beliefs and students academic performance and to fill the research gap about the influence of various factors in particular popular media on parenting role beliefs development this study is also a chance to capture multiple viewpoints on family dynamics from both generations of parents and childrenmothers and fathers sons and daughters a class of thirdgrade students and their parents were surveyed to answer the following questions do perceptions of parenting roles vary with gender that is chinese mothers vs fathers and chinese girls vs boys do levels of parental activity engagement differ between mothers and fathers is student academic performance related to parenting role beliefs as well as to parents level of activity engagement do various factors in particular popular media influence the parenting role beliefs of parents and their young children the present study the present study surveyed 34 thirdgrade students from a class in a public school located in a suburban area in nanhai guangdong province china both mothers and fathers of the students also participated in the survey process all participating mothers had completed at least high school and the majority of fathers had completed four years of postsecondary education thirty percent of mothers and 100 of fathers worked a fulltime job 70 of mothers did not work in addition each household had on average two children with one third of the families having only one child historically regarded as a rural area the suburban city of nanhai from which we drew our sample has experienced rapid economic development in recent years as the onechild policy has traditionally been less stringently upheld in rural areas families in nanhai have typically been allowed two children without incurring penalties particularly when their first child was a girl moreover with regards to household structure 45 of parents reported living in a multigenerational household while 55 of parents reported a nuclear family structure see table 1 for additional descriptive information on the participants the beliefs concerning the parental role scale was modified to assess gender role beliefs regarding parental responsibilities for our chinese sample the 25item survey elicited parent responses to address which parent is in charge of what childrearing tasks or are they equally engaged in certain tasks some examples of the items include when a child gets sick at school it is moms job to leave work or find someone to take care of the child in general the father should have more authority than the mother in deciding what extracurricular activities are appropriate for the child a fivepoint likert scale was used for each of the 25 items survey items that are worded in a reverse direction were recoded prior to scoring similar to the parent questionnaire a 25item survey was also developed to assess gender role beliefs of young students regarding their perceptions of who should do what in particular parenting responsibilities utilizing cronbachs alpha the reliability coefficients for the 25 items were 91 for the parents questionnaire and 78 for the students questionnaire indicating a high level of internal consistency for these measures parents were also surveyed on the frequency with which they engaged in twelve specific activities such as discussing social events working on homework discussing tv programs and movies and playing games the reliability coefficient using cronbachs alpha for the parental engagement activity items was 78 in order to tap into potential factors that may influence participants parental role beliefs nine items were included in the survey asking participants to rate the amount of influence that individuals such as grandparents parents spousesiblings and peers neighbors or colleagues pastcurrent school curriculum popular reality shows such as wawgd other types of media and social network services where 1 no influence to 5 extreme influence all parent and student assessments were translated into mandarin chinese and then backtranslated into english for verification results results of dependent ttests indicated no significant mean difference between the overall scores of mothers and fathers parenting role beliefs with respect to the association between fathers and mothers parenting role beliefs results of correlation analysis show a significant positive correlation 84 p 05 indicating that couples tended to have similar beliefs about who should do what in terms of caretaking tasks independent ttests results similarly revealed no significant mean differences in parenting role belief scores between girls and boys with respect to overall activity involvement of parents no mean differences were found between fathers and mothers among mothers age was negatively correlated with level of engagement activity 52 p 05 that is compared to older mothers in this study younger mothers tend to be more frequently engaged in activities with their children while the association of fathers age with level of engagement was also in the negative direction the correlation was not significant 21 p 34 correlation analysis revealed a significant association between childrens class rank and childrens own parenting roles beliefs 46 p 05 indicating that the higher the childs academic ranking in the class the more egalitarian the childs parenting role beliefs results also showed a significant association between mothers engagement and childrens class rank 40 p 05 indicating that the greater the mothers engagement in specific activities the higher childs academic ranking in the class the study further analyzed the influence of popular reality television shows on parents parenting role beliefs and found that parents perceived influence of such reality television shows was indeed positively correlated with their own parenting role beliefs 57 p 05 and for fathers r 68 p 05 that is the more the parents believed such television shows influenced their parenting role beliefs the more their assessed beliefs were indeed egalitarian furthermore students perception of parental influence was positively correlated with students own parenting role beliefs 44 p 05 that is the more children believed their parents played an important role in the development of their parenting role beliefs the more egalitarian were their beliefs discussion the present study sought to address research inquiries related to parenting role beliefs and practices in contemporary mainland suburban china through multiple perspectives the inclusion of mothers and fathers as well as daughters and sons provides a unique opportunity to compare and examine beliefs across genders and generations to address our first inquiry that there were no differences in parenting role beliefs between fathers and mothers in our findings provide support that suburban chinese mothers and fathers may hold similar egalitarian parenting role beliefs second the frequency with which fathers engaged with their children in various activities was similar to that for mothers these results are consistent with a growing trend found in the more recent literature that more and more chinese men and women are sharing responsibilities in the home domain there was also a strong positive association between parenting role beliefs of fathers and mothers that is the more strongly mothers endorsed progressive gender role attitudes the more likely fathers would also report such beliefs this finding is not altogether unexpected since individuals tend to seek likeminded others in spousal relationships nonetheless research on gender and parenting role beliefs have indicated more conservative views among chinese men while our finding suggests more congruent attitudes about parenting between spouses these first three findings may speak to the impact of rapid societal and economic transformations on cultural values such that both genders report viewpoints and behaviors in favor of shared financial and household responsibilities our findings also suggest that the changes in parenting role beliefs may in part be a consequence of popular cultural media specifically our results indicated that parents who believed television shows depicting progressive father roles were influential to their parenting beliefs were on average more likely to affirm egalitarian parenting role beliefs popular media is undoubtedly a reflection of sociocultural changes analyses have credited reforms such as the onechild policy with encouraging closer fatherchild relationships like those seen on wawgd while exceptions to the onechild policy were made in suburban areas like the site of the present study the impact of the policy in this community may be felt through media and cultural products while this study sheds some light on the impact of popular media on the attitudes of parents in china more research is needed to support these results chinas recent shift to a twochild policy presents promising opportunities to understand how policy affects the family unit and as well as how parenting roles play out in popular culture and in the home our interests also extended to the less frequently addressed topic of possible gender differences in parenting role perceptions among the younger generation in addressing this question we compared the overall parenting role beliefs scores of boys with girls and found that similar to their parents their attitudes about parenting behaviors did not significantly differ these results are particularly encouraging because research has shown that adults feel pressured to conform to new gender role norms and expectations chinese parents may also be vulnerable to social desirability and inflate their responses to questions about parenting responsibilities young children on the other hand may be less susceptible to these demands and more inclined to report gender attitudes based on their own observations of parents performance of social roles at home as found in the present study students who endorsed more egalitarian views tended to rate their parents as influential to their own parenting role beliefs therefore these findings lend credibility to the notion that egalitarian gender ideologies are becoming more prevalent among young people in similar communities in china and may in part reflect the realities of their home environment as well as messages of popular media corroborating prior research on the effect of parents involvement on students academic performance we found that parents engagement in specific activities with their children was positively associated with childrens school ranking our results suggest that childrens beliefs are also linked to this indicator of academic performance that is the higher their class ranking the greater the tendency for the students parenting role beliefs to be more progressive more evidence with other indicators of academic achievement is needed to determine the nature of the association whether the relationship is causal or whether these constructs are a function of other factors such as parents level of education if there is support for a causal relationship it behoves scholars to explore the meditational processes by which gender and parenting role beliefs lead to educational outcomes one limitation of the study relates to its context and sample the suburban location of our investigations has both advantages and disadvantages with most chinese parenting research taking place in more urbanized areas our research in nanhai serves the purpose of expanding understanding of parenting ideologies and practices in different settings still the location of the study coupled with its small sample size limits the generalizability of our findings future studies would benefit from testing these research inquiries in multiple urban suburban and rural environments and with larger sample sizes another limitation of this research is the selfreported nature of the data as discussed responses about gender and parenting role beliefs can be influenced by social desirability moreover selfreports of parenting responsibilities and frequency of involvement can be inaccurate further research would benefit from behavioral documentation of activity involvement similar to the time diaries parents kept in chuang and zhus study still the present study brings in a multitude of perspectives on parenting and gender role beliefs and suggests new links between these attitudes academic ranking and popular media which show promise as avenues for future investigation appendix parental role beliefs questionnaire 1 a father should pursue the career of his choice even if it cuts into the time he has to spend with his family

recent research examining beliefs about gender roles among the chinese population has shown that parenting roles are becoming less genderbound in contemporary chinese society in the context of socioeconomic and political changes fathers are becoming more engaged in their childrens lives as depicted in chinese media eg popular television shows and movies fatherchildren relationships in everyday family activities are being modeled utilizing a sample of 34 thirdgrade students from a suburban chinese classroom the present study investigated parenting role beliefs from multiple perspectivesthose of students distinguishing between boys and girls as well as their parents distinguishing between fathers and mothers results showed that parenting role beliefs did not significantly differ between fathers and mothers nor between young male and female students childrens academic ranking was found to be significantly associated with their own parenting role beliefs and their parents engagement in specific activities furthermore parents perceived influence of watching popular reality television shows was positively correlated with their parental role beliefs additionally parental influence as perceived by students was positively correlated with students own parental role beliefs such that the more children felt their parents played an important role in their parental role beliefs the more egalitarian their beliefs

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background glaucoma is an ophthalmologic disease which is characterized by progressive visual field defect corresponding to excavation of the optic disc 12 the number of patients who get medical service for glaucoma has been increasing sharply in the korean society 34 according to the claim data of korean national health insurance and health insurance review and assessment service 5 the number of those who get medical care for glaucoma was 699463 in 2014 925 increase from 363329 in 2007 what is more severe glaucoma can lead to permanent visual impairments unless it is managed based on the who global data bank statistics on blindness 6 about 52 million people have blindness caused by glaucoma which is about 15 of total blindness especially in korea hira data show that glaucoma is the most influential cause of visual impairments among all other diseases including diabetic retinopathy and retinitis 7 although it may cause immense loss to respective patients and severe burden to the society its clinical progress can be controlled after a few examining procedures 89 several factors are known to affect the glaucoma and socioeconomic status is one of the risk factors for glaucoma the effects of other factors such as sex and age have also been studied in accordance with the effect of socioeconomic factors 10 however few studies have discussed about the socioeconomic status in the risk of visual impairments in developed asian countries 1112 which have the real importance of studying glaucoma therefore in this study we checked the connection between socioeconomic status and the visual impairments caused by primary glaucoma classifying according to the order of two incidents a glaucoma diagnosis and an occurrence of visual impairments in addition we divided the research population into several subgroups by covariates of the insurance type and researched in the same way methods data source we used national health information claims data from knhi database from 2002 to 2013 korean national health information contains cohort data including information on insurance claims for individual medical service such as patient information disease code dates of the service and the types of medical facilities 13 these data can represent the whole korean population since the 1025340 subjects included in the data are stratified random sample and are selected from the total population based on the sex age income quintile region and health insurance type loss of the subjects by censored data is supplemented with newly sampled newborn babies based on the representativeness and stability of database several researches are published using the database 1415 we conducted a cohort study of newly diagnosed glaucoma patients with medication to identify the connection between socioeconomic status and the visual impairment sample selection among all the collected subjects in the database 1728 with newly diagnosed primary glaucoma from 2004 to 2013 were selected patients with other types of secondary glaucoma such as trauma inflammation and drugdriven glaucoma were excluded those who have diseases that can cause the visual impairment from any other cause such as diabetic retinopathy retinitis and disorders of vitreous body are also excluded from the selection we also verified that those patients are newly diagnosed by excluding those who had ever got a medical service for primary glaucoma recorded from 2002 to 2003 in the national health information data the glaucoma patients who already had visual impairment from 2002 to 2003 are also excluded since it requires persistent management to control the progress of glaucoma selecting those who have 2year absence of the medical care for glaucoma may assure the first diagnosis interesting variable as an indicator of the socioeconomic status we used an income level according to the data of national health information income levels are collected on the basis of the amount of monthly insurance premium the insurance premium is imposed based on salary real estates and other financial income these data are categorized into decile and include one additional group for those with the lowest income who get medical aid we reorganized the group into three categories low income middle income and high income for better analysis the effect of inflation can be neglected since the income groups are designated by relative proportion outcome variable the dependent variable of the study is whether the primary glaucoma patients are diagnosed with visual impairments or not ophthalmologists measured the best corrected visual acuity using snellen chart in terms of visual fields it is evaluated by the certified examination such as humphrey visual field goldmann perimetry and octopus perimetry then the national government decides the classification of grade based on the severity of visual acuity and available visual field as shown in table 1 1617 visual impairments are designated by visual acuity of eyes with best possible corrections such as eyeglasses contact lenses and surgical treatment vf is measured by kinetic perimetry prominent level vi should be confirmed with retinoscopy fundus examination and corneal test according to the international classification of diseases 10th edition the low vision includes categories 1 2 and 3 of visual impairment who defines low vision as a person with low vision is one who has impairment of visual functioning even after treatment andor standard refractive correction and has a visual acuity of less than 618 to light perception or a visual field of less than 10 degree from the point of fixation but who uses or is potentially able to use vision for planning andor execution of a task meanwhile the current definition of blindness contains either one or both eyes with no perception of light and less than 360 in better eye level vi in korea includes visual acuity impairment and visual field impairment in addition we supplemented temporal elements between the glaucoma diagnosis and the occurrence of visual impairments which incident does come prior to the other therefore three different levels of the dependent variable are designated those who are not diagnosed with visual impairments those with visual impairments before glaucoma diagnosis and those with visual impairments after glaucoma diagnosis other covariates age sex residential area insurance type for employees selfemployees and medical aid recipients hospital level charlson comorbidity index excluding hypertension and diabetes medical history of hypertension diabetes cataract and refractory error each year at diagnosis is also adjusted as a continuous variable statistical analysis to determine the differences in visual impairments among different socioeconomic statuses we performed a multiple logistic regression analysis since stepwise selection is described here a significance level of 01 is required to allow a variable into the model and one of 015 to stay in the model we also examined the full model under consideration of inflated variation in supplementary tables the group of glaucoma patients without visual impairments was used as the standard group and each of the group with visual impairment diagnosis before the glaucoma diagnosis or the group with visual impairment diagnosis after the glaucoma diagnosis was compared to the standard group all statistical analyses were conducted using sas 94 results table 2 displays the characteristics of selected population in korean patients with primary glaucoma from 2004 to 2013 the number of newly diagnosed patients with primary glaucoma was 1728 the percentage of age group with below 49 was 313 while that of age group over 50 was 687 male recorded higher percentage of total patients which were 517 among the patients 522 were classified as high income group while 284 for middle and 194 for low income group table 3 shows demographic characteristics based on the presence of visual impairment it turns out to be statistically significant in terms of age group sex income group insurance type diabetes by the global test multivariate analysis on odds ratio of visual impairment among the patients with primary glaucoma is shown in table 4 we used stepwise selection for preventing inflation of variance in case of the patients diagnosed with primary glaucoma after the occurrence of the visual impairment both low income group and middle income group have higher odds ratio of the visual impairment compared to the high income group we did not find statistical significance in case of the patients diagnosed with primary glaucoma before the occurrence of the visual impairment in terms of the differences in income group increased age is related to the higher odds ratio for visual impairment among particiants with previous visual impairment before glaucoma diagnosis considering the factors of diabetes glaucoma patients with diabetes unaccompanied by complications shows higher odds ratio of the impairment in case of the diagnosis of glaucoma followed after the occurrence of visual impairment although it is statistically insignificant slightly interestingly the presence of refractory error is related to the visual impairment after the diagnosis of glaucoma we also performed the full model under consideration of variance inflation sensitivity analysis on or of visual impairment between korean selfemployees and employees with primary glaucoma is presented in fig 1 based on information of insurance types collected from khni patients are classified into two different groups of insurance types selfemployees and employees with each of the insurance type groups we conducted a multivariate discussion throughout this study we determined the effect of socioeconomic status on the risk of visual impairment in patients with primary glaucoma in a cohort study using stratified random samples from korean health information collected by knhi as a result the effect of socioeconomic status on the risk of impairment was significant only when the occurrence of the visual impairment preceded the diagnosis of glaucoma primary glaucoma patients with lower income had significantly increased visual impairment when they had not diagnosed with the disease multivariate analysis with subgroups divided into two different groups of insurance type also showed the same aspect of the trend glaucoma is considered to have less noticeable symptoms that the patients with it can hardly recognize 1819 even though glaucoma is substantially worsened central vision is known to be maintained relatively longer among the result of multivariate analysis on visual impairment of newly diagnosed patients with primary glaucoma classified by the type of national health insurance the patients who are selfemployee of nhi and employee of nhi are examined separately a b fig 1 multinomial logistic regression analysis based on the national health insurance type a selfemployees and b employees compared to the high income group middle and low income group show higher odds ratios for visual impairment before the first diagnosis of glaucoma in both selfemployees and employees however the association is stronger in selfemployees than in employees different types of primary glaucoma chronic openangle glaucoma is hard to notice due to the adaptation of nerves to high intraocular pressure and the symptoms of acute closedangle glaucoma such as headache and nausea are easily confused with other diseases normaltension glaucoma another type of primary glaucoma is accompanied by relatively low intraocular pressure which makes it even hard to find out 20 it is crucial to figure out how socioeconomic status affects the visual impairments among glaucoma patients there are possibilities that the lack of awareness of glaucoma as serious disease may influence low detection rate basically there is low awareness of glaucoma in korean population according to korea national health and nutrition examination survey only 9 of glaucoma patients are aware of their diseases 310 in addition patients with lower economic status have even less perception of glaucoma according to the crosssectional study in us less affluent and less educated group of people has lower frequency of visiting eye care provider 21 accordingly people with low socioeconomic status and low frequency of using medical services have increased impairments of closedangle glaucoma the accessibility of using medical services affects the detection of glaucoma and that accessibility is influenced by socioeconomic status including income and education 2122 not only detection but also severity of glaucoma can be affected by socioeconomic factors 23 another study has examined the relationship between socioeconomic status and the ratio of severe glaucoma to total glaucoma and glaucoma patients with serious economic poverty has increased proportion of severe one 23 24 25 this strongly supports our findings since severe glaucoma can lead to visual loss if it is neglected however there is no significant connection between the visual impairment and the income in case of glaucoma patients who have already been diagnosed since the cost for glaucoma treatment is relatively less compared to healthcare for other eye conditions 26 and the universal health coverage in korea cover the medical cost almost 27 the patients with low income can also use proper medical care for glaucoma preventing it from worsening moreover we did not find any significance in the relationship between the impairment and the residential area or the size of medical facility glaucoma is kind of a lifelong disease that needs to be continuously managed and in general the excessive intraocular pressure can be controlled by medication interestingly we found the significance of mild diabetes in case of the occurrence of impairments that preceded the prevalence of glaucoma those glaucoma patients with mild diabetes had higher or of the occurrence of visual impairments if their glaucoma was not checked it is unclear whether the result of significance in glaucoma is a driver or a passenger factor of the occurrence of impairments if the diabetes acts as a driver factor of the occurrence of impairments diabetes may be the confounding variable that mediates the hidden relationship between socioeconomic status and the difference in the severity of the glaucoma in case of presuming the diabetes as a passenger factor of the impairments we can predict that poor concerns about health care and low frequency of using medical facilities may both influence patients lack of recognition of glaucoma and diabetes that they have there are a few studies that concern to the diabetes as a risk factor for glaucoma 28 29 30 but the causal relationship has not been proved clearly further analysis on the effect of diabetes on glaucoma is needed for lucid explanation before drawing conclusion from the results the limitation of this study should be discussed first considering low detection of glaucoma which is about 152 in korea 310 and those patients having glaucoma concurrently with visual impairments the absolute amounts of selected samples are not that a lot second we could not keep track of patients with glaucoma without symptoms those patients may not feel necessity to use medical service thus their information would not be collected and included in the database similarly some of the patients with visual impairments may not visit a clinic or a hospital to be diagnosed and the information of their impairments would not also be included in the data either third korean national health information claim data we used do not contain the information of medical records so we did not determine the severity of glaucoma of each patient thus we cannot completely neglect the possibility that the severity of glaucoma may differ between income groups even if there was no significance of visual impairment found in the case of the glaucoma that has already been diagnosed fourth there are still unmeasured confounders or unadjusted medical conditions related to visual impairment to overcome this shortcoming we excluded diabetic retinopathy retinitis disorders of vitreous body and aging macular degeneration which are the most common diseases causing visual impairment in korea the history of cataract and refractory errors are adjusted for multiple linear regression analysis fifth it is not able to consider age as a continuous variable for deidentification in database the korean government provides this public data with some limitations as part of these the data do not include the exact birth date rather it describes the age intervals although there is still some variance in the same category we have adjusted the age group of ten years interval in spite of the limitations there are several strengths in our study first this study was the first to examine the socioeconomic effects on the visual impairment by applying temporal order of the incidents there were many studies using crosssectional data to identify the correlation 31 but none of them classified samples into two different cases of the time order using cohort data since our study showed different aspects between different cases of time order it would be much meaningful to understand the influence of socioeconomic status on the visual impairments by glaucoma second our study not only dealt with the glaucoma but also focused on the visual impairments since glaucoma needs to be persistently managed and visual impairment itself is more direct issue that threats peoples quality of life our study approached more to practical matters the accessibility on the examination of glaucoma should also be enhanced as the developed clinical techniques in treatment third we excluded patients with other diseases that can cause visual impairments so we can verify that occurred visual impairments in the samples are solely driven by glaucoma conclusions in case of patients with primary glaucoma after visual impairment those with lower income are more vulnerable to the occurrence of visual impairments since disparities of the visual impairments by glaucoma are only detected when the glaucoma had not been diagnosed and recognized yet the differences may have been derived from the disparities of the awareness of the glaucoma these findings call attention to the correlation between socioeconomic factors and the visual impairments by glaucoma and raise public health needs over the importance of glaucoma awareness and early eye screening for glaucoma additional file additional file 1 table s1 authors contributions hs was a major contributor in writing the manuscript hhs and yb proposed the idea of the study and contributed in designing the methods gak and jsk provided ophthalmologic interpretation of the results ecp reviewed the study and the manuscript js performed statistical analysis and interpreted the data regarding socioeconomic status competing interests the authors declare that they have no competing interests

background glaucoma is one of the most leading causes of permanent visual impairments in korea and social expenses spent for the glaucoma are increasing this study is to identify association between socioeconomic status and the visual impairments caused by primary glaucoma in korea methods this study is based on a cohort study using stratified representative samples in the national health insurance claim data from 2002 to 2013 with 1025340 representative subjects target subjects were patients who are newly diagnosed with primary glaucoma from 2004 to 2013 we conducted a multiple logistic regression analysis depending on the occurrence of visual impairment and its temporal order compared to the glaucoma diagnosis results among 1728 patients with primary glaucoma those with low and middle income shows higher odds ratio or of the visual impairments than those with high income group low income or 342 95 confidential interval ci 206566 middle income or 213 95 ci 128355 in case of the occurrence of the visual impairments preceded the diagnosis of glaucoma conclusions glaucoma patients without preexisting glaucoma history before visual impairment have higher association between socioeconomic status and the occurrence of visual impairments by primary glaucoma since glaucoma had not been diagnosed and recognized yet the differences may have been derived from the disparities of the awareness of the glaucoma these findings call attention to the correlation between socioeconomic factors and the visual impairments by glaucoma and raise public health needs over the importance of glaucoma awareness and eye screening for glaucoma especially for low socioeconomic status

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introduction along with the mental health services reform and efforts to change the logic of care in this area was recognized the magnitude of the global burden of mental disorders and the need for integrated and intersectoral responses the proposed organization of mental health services under the network logic is one of the strategies to broaden the care access and change the focus of the disease to the psychosocial needs of people with mental disorders such a network should be structured with points of care focused on both health care and social reintegration of individuals and families this proposal corroborates the world health organization recommendations of consolidation of universal health systems from an integral interprofessional perspective with priority of community spaces the recognition of the psychosocial care network as one of the priority thematic networks by the brazilian state has contributed to the visibility of mental health demands and influenced the development of research in this area studies have shown the variety of compositions and interactions between mental health services in each locality as the network is woven into the daily routine of services and in relationships between structures and social agents workers and managers play a fundamental role in mobilizing resources to meet users demands different researchers have highlighted that psychosocial care is not limited to specialized mental health services and involves building relationships with health institutions and other sectors in order to put into practice the psychosocial rehabilitation and insertion into territories the articulation of mental health services in the logic of networks has been the object of several studies despite the recognized importance of normative definitions decrees and ordinances for composing the psychosocial care network the differentiation and relationships between the scientific field and the bureaucratic field must be highlighted as well as the influences of relations conflicts and tensions between the various social agents in the daily routine of services studies have been developed from documentary analysis andor interviews with managers and professionals of specific categories but only two studies involved different professional categories one of them was performed with workers and managers of type iii psychosocial care centers of the state of são paulo and the other with higher level professionals from various points of the psychosocial care network in the western region of são paulo thus this study is justified by the need to address the various points of the municipal care network in order to produce evidence on how the psychosocial care network has been implemented in different locations it is about the sedimentation of studies related to the constitution of the psychosocial field and the capture of relations between network structures and the mediations performed by social agents in this regard the framework of pierre bourdieus constructionist structuralism was adopted to delineate the guiding question of the study what is the perception of workers and managers about the psychosocial care network of a mediumsized municipality in the inlands of the state of minas gerais objective to analyze the perception of workers and managers about the psychosocial care network in a mediumsized municipality in the inlands of the state of minas gerais method ethical aspects the project was approved by the research ethics committee and complied with the ethical precepts recommended by resolution number 4662012 of the national health council participants signed an informed consent form and received a copy of it each participant was identified by a number to ensure anonymity theoretical framework and type of study this is a qualitative descriptive and exploratory study in which pierre bourdieus constructionist structuralism was adopted as a theoretical framework this approach recognizes the existence in the social world of objective structures independent of agents consciousness and willingness that can guide or coerce their practices and representations at the same time there is a social genesis of the schemes of perception thought and action that constitute the … habitus and on the other there are social structures in particular of fields and groups according to bourdieu the adoption of the habitus construct derived from his interest in breaking with structuralism without falling into subjectivism habitus is understood as a system of durable and transposable dispositions which by integrating all past experiences functions at each moment as a matrix of perceptions appreciations and actions such a system is updated and recomposed at each moment and implemented in specific fields the fields are understood as a field of forces of battles fought sometimes for their transformation sometimes for their reproduction the allocation of specific capital ofin the field will conform its structure thus understanding the field of psychosocial care contributes significantly to the analysis of managers and workers perception about the psychosocial care network in the municipality studied and more specifically to the delineation of tensions in this field the plurality of capitals is emphasized by bourdieu who presents the economic cultural social and symbolic capitals all agents in their path of training performance and economic condition elaborate their capitals from which we can understand the positions taken over in the field the capitals of agents of the present study come from different spaces and express the way they fit into social reality groups and institutions in turn the perception about the network is related to these agents capitals and their positions in the psychosocial field in line with the adopted theoretical framework we sought to identify the matrix of perceptions of social agents which guides their representations of the psychosocial care network and their actions in the field of psychosocial practice in the exercise of this analysis were considered the relationships and tensions in the field from which we sought to identify the disposition of these social agents in relation to the reproduction of the status quo or transformation of their practices study scenario the mediumsized municipality in the inlands of minas gerais was intentionally selected because of the implementation of substitutive services already in the 1990s and the diversity of points of the care network the municipality had two type ii psychosocial care centers one municipal and one philanthropic a child and youth psychosocial care center one type iii alcohol and drugs psychosocial care center a psychiatric hospital a team from the street office program a team of the mental health matrix strategy five therapeutic residence services of which three municipal and two philanthropic data source the eligibility criteria were to work as manager or technical reference at any point of the psychosocial care network and be in the exercise of these duties during the study period exclusion criteria were being away from work at the time of data collection due to sick leave or vacation there were nine managers at the time of data collection namely one director of psychosocial care three managers of municipal psychosocial care centers two managers of the philanthropic psychosocial care center one administrative worker and one clinical worker a manager of the psychiatric hospital a manager of the three municipal therapeutic residence services a manager of the two philanthropic therapeutic residence services as the staff of the street office program and the mental health matrix strategy did not have managers the social worker and the nurse of the street office program and the psychiatrist of the mental health matrix strategy were interviewed twelve workers were eligible to participate and all joined the study table 1 presents the profile of participants guiding questions were what are the services offered in the institution in your opinion does the network offer the necessary conditions for the care of people with mental disorders and their families how do you understand the challenges faced by the institution and by the psychosocial care network the interviews were conducted by the lead researcher who has a degree in social sciences a phd in sociology and experience in qualitative research in places defined by participants with conditions of confidentiality and privacy the average duration of interviews was ninety minutes after transcription the audios were deleted a copy of the transcript was delivered to each person involved which is one of the requirements for the rigor of qualitative research no entries or deletions of information were requested by respondents data analysis pierre bourdieus framework of constructionist structuralism was used for the analysis focused on capturing the multiple relationships and positions taken over by the study participants in the psychosocial field and how they interact with other fields the process of data interpretation and analysis was conducted based on the structuralist research protocol according to which it is necessary to understand the structuring of the field where social agents build their perceptions and position themselves initially the composition of the psychosocial care network of the municipality of minas gerais was outlined the psychosocial care network was considered as the field from which were captured the habitus and capital expressed by the social agents based on the positions of study participants were outlined the relationships of institutions of psychosocial care network with one another and with other institutions thematic structure 2 workers and users element 11 mental health at the different levels of care • expectations regarding expanded acess to mental health care • infrastructure of the network services and conditions for workers element 12 relationship between mental health services other health services education and social protection • positive relationships and tensions between health services and mental health services • positive relationships and tensions between mental health services education services and social protection services element 21 psychosocial care and tensions in the workeruser relationship • aspects that guide psychosocial care • challenges of dealing with families • the prejudice that permeates the relationships of health professional with users thematic structure 1 workers and services figure 1 thematic structures elements and results data collection and organization recruitment of participants took place at their workplace data collection was performed through semistructured interviews the of psychosocial care network managers perception and tensions of the field querino ra borges rs almeida ly oliveira jl souza j the lead researcher performed successive readings of the transcripts and highlighted recurring topics and themes after completing the individual readings the convergences and divergences identified were jointly evaluated in order to delineate a group of relationships between the elements for the development of thematic structures at the end of this process two thematic structures were defined workers and services workers and users results the thematic structures and main results are presented in figure 1 thematic structure 1 workers and services element 11mental health at the different levels of care the results contemplated here relate to how participants understand mental health in the psychosocial care network the expectations regarding expanded access to care and challenges related to the network consolidation overall participants mentioned mental health actions at the different levels of care despite the still prevailing idea that mental health demands should be met only in specialized services the health care unit does not provide care because there they say look mental illness is not in our scope because we have no psychiatrist its a network still with a culture of specialized care focused very much on psychosocial care centers and the psychiatric hospital … the matrix strategy and training of primary care teams were mentioned as efforts to fulfill these demands with expectations regarding the expansion of mental health actions in primary care regarding workers conditions the need for more qualification and the issue of remuneration were mentioned we have been working like warriors because we earn very little we face a heavy workload to serve a difficult to manage population element 12 relations between mental health services other health services education and social protection the results on participants perception of the relationship between mental health services and other health services are described in figure 2 which was prepared from the perspective of social network mapping the following statements illustrate the relationships presented in figure 2 interactions between family health team professionals and therapeutic residences were described as follows the family health team doctor comes here the nurse community agent the dentist comes here they brush patients teeth do the mouthwash program with residents do the treatment the outpatient clinics were highlighted as less integrated with other network services in the electronic waiting list after five months we dont even find the user anymore the relationships established between the various psychosocial care centers and between these and other mental health institutions were also cited some resources that facilitate the articulation between services were mentioned figure 3 presents the relationships of mental health services with legal education and social protection institutions as reported by study participants the statements below illustrate some interlocutions with leisure and social protection institutions mentioned by participants element 21 psychosocial care and tensions in the workeruser relationship respondents emphasized that user care is provided by multiprofessional teams with priority of group approaches and resocialization activities they also mentioned user embracement listening and establishing bonds as a priority in the care of users most activities are done in groups … therapeutic groups … relapse prevention twelvestep philosophy support group … resocialization activities outside the psychosocial care center visits to universities parks shopping tours museum … the service that aims at user embracement listening listening in every way even listening to the silence to the users body and providing care for what he needs there the way you receive the user with neutral eyes i need to see the user as a person … the psychiatric hospital manager described hospitalizations as flexible and aimed at reintegration into the network we provide care on a more flexible therapeutic plan in the sense of a hospitalization that they call integral … it is the withdrawn from the crisis stabilization referral to the mental health network for continuity of treatment in the outpatient system actions related to health recreation and daily organization were also mentioned as part of the psychosocial care offered by therapeutic residence services families were recognized as part of psychosocial care for users however the challenge of including families in this care and the need to expand the work with them were emphasized another challenge mentioned was the tension between families and users themselves care to the family is not easy you know because they dont come its not just up to us theres no adherence of the family a bit of this difficulty is to bring the family closer to treatment to collaborate more participate more in the reality of this treatment … because by the ordinance of the prosecution service the therapeutic residence would be for those who do not have family ties these people have family here … their main reason for being in the therapeutic residence is by court order as the family does not want to care for them the prosecution passes the torch to the municipality to residence services prejudice was mentioned as a barrier to the access to health services and social care certain professionals do not even come close at the time of care they prefer that the person accompanying them the nursing technician or the nurse tells everything that is happening to the resident they do not listen to the resident … discussion in light of pierre bourdieus theoretical construct it was possible to capture the articulation between the various capitals of the social agents participating in the study the cultural capital is a set of qualifications knowledge and skills constructed by agents in which different scientific areas that form the psychosocial field are articulated as described in the results the set of social accesses expressed in the variety of contacts and relationships of social agents was evident in the speeches of interviewees who brought to light the relevance of this capital for the articulation of the various networks the symbolic capital in turn refers to the recognition of these social agents expressed by the role played in institutions and programs whether as managers or socially authorized professionals to speak on behalf of the service the complexity and interaction of these capitals support these agents representations of the psychosocial care network as pointed out in the results two major groups of relationships were identified from the perception of social agents 1 of workers with services and 2 of workers with users in the first group terms such as partnership support coparticipation dialogue good communication joint discussions assistance asking for help providing support giving feedback triggering good relationship and participation in the therapeutic project give nuances to the matrix of perceptions that guide the professionals representation of psychosocial care networks in their municipality as the orientation of agents practices and representations is not exempt from the interests of the field it is a fact that this predominantly positive perception about mental health in care services is crossed by different limits and challenges arising from the counterhegemonic model proposed by the notion of psychosocial care participants expressed their expectations of a broader access to mental health care especially more mental health actions in primary care and optimism about the potentiality of this level for mental health this perspective is consistent with the proposed network action which values the specificities of each institution and service in addition the strengthening of mental health in primary care is in line with the community approach and the perception of territories as an existential territory that involves spaces constructed as material and affective elements of the environment that when appropriated and managed expressively constitute places to live such strengthening can also contribute to mobilize other community resources and expand the support network of users and families which are fundamental for psychosocial rehabilitation in the municipality studied this insertion has occurred through the team of the mental health matrix strategy and the family health strategy efforts to value and involve workers from family health support centers basic health units and matrix units are urgent to ensure the performance of different primary care workers in mental health care nevertheless the emphasis on primary care as a key aspect for improving the psychosocial care network and the criticism on the lack of some components suggest that participants improvement expectations are more focused on unconsolidated actions and services and they have little consideration for the potential of improvements in their own locus of activity which is essential to complement the network qualification the analysis also showed that the institutions establish deep relationships with other health services education and social protection services that are essential for psychosocial rehabilitation these relationships should be expanded by adding other territorial resources most described relationships need improvement and outpatient clinics were identified as the least integrated in the network it is worth highlighting the specificity of the outpatient work process to the detriment of psychosocial care center proposals highlighting the notion of intensive care of psychosocial care network managers perception and tensions of the field querino ra borges rs almeida ly oliveira jl souza j and prioritization of social reintegration rather than a medicalizing approach focused exclusively on symptom reduction although outpatient clinics have different characteristics in relation to the psychosocial rehabilitation proposal they have been the focus of recent policies that recommend their expansion and raise the issue of field strengths and disputes regarding transformations or reproductions of certain care models on the other hand participants also reported some tensions regarding the network structure in the perception of these agents aspects such as low participation of some institutions components poor communication between the elements that make up the structure referrals and difficult access barrier to the continuity of care and delay in counterreferral services outlined these tensions however the tensions mentioned were more related to service partners than to the own participant suggesting again a tendency to understand that the network improvement depends more on external transformations than on the more effective disposition of ones own experiences in a previous study poor communication and difficulties with the articulation between the various network services were identified as challenges of priority networks the literature has indicated the mobilization of light technologies as a possibility for the greater activation of institutions and monitoring of cases hence the importance of investments in workers continuing education according to study participants there are resistances and barriers to the care of people with mental disorders in nonspecialized services which strengthens the focus on specialties the reports emphasized difficulties to meet urgent and emergency care a topic addressed in other studies a study involving 156 workers from different regions of the country enrolled in the course crisis and urgency in mental health offered in partnership by a federal university and the ministry of health revealed that care was provided primarily with drugs mechanical containment and hospitalization this highlights the importance of strengthening the action in network and investing in continuing education to consolidate care and overcome the centrality of the psychiatric hospital in crisis management nevertheless previous studies have problematized the idea that the solution to most limitations in the field of mental health is training since even among some highly specialized teams such limits are present as indicated in an international study difficulties with attending stigmarelated comorbidities have resulted in neglect of clinical demands and excess mortality of people with mental disorders which is in flagrant disagreement with equity and human rights a study conducted in the brazilian context revealed the permanence of users in the psychosocial care center for long periods due to the few opportunities for insertion in institutions and services which indicates the importance of expanding community spaces the socalled chronification can contribute to problematize psychosocial rehabilitation which is the objective to be achieved in an intersectoral way with protagonism of users and their families in this sense the organization of services according to the logic of the territory has profound consequences not only for users lives but also for communities it is about rehabilitating the territories in order to collectively build new forms of living with difference in the second group of relationships tensions were also identified in the relationship between mental health professionals families and users the approach and involvement of families in the care process have been highlighted as important strategies for mental health care and the strengthening of policies and services it is relevant to overcome disciplinary control and tutelage strategies and foster their emancipation and autonomy the prejudice of some professionals towards people with mental disorder was also emphasized barriers related to prejudice occur in many countries and are a challenge for access to health and the search for assistance in a review study were highlighted different types of stigmas namely the perceived public stigma personal attitudes toward members of a stigmatized group internalized or anticipated stigma and attitudes toward seeking help this typology is interesting to understand the findings of this study since according to respondents there are stigmas in the community among health professionals as well as in users positions and attitudes identifying them can contribute to envision coping strategies thus the tensions and conflicts observed in the psychosocial care network arising from the habitus and the positions of social agents represent possibilities for change in contrast the actions offered by services within a perspective of resocialization user embracement group and multiprofessional care as well as approaches of harm reduction recreation and daily organization were the resourcescapitals mentioned by participants such resourcescapital are in line with the psychiatric reform and demonstrate the search for sedimentation of the psychosocial care model study limitations the collection of data with different interest groups such as users and workers would certainly enrich the list of results and enable the triangulation of perceptions especially considering that within the psychosocial field there is a variety of positions and wide differentiation of social agents the involvement of managers and workers from institutions with which the various points of the psychosocial care network articulate would contribute to broaden the intersectoral approach the choice of individual interviews can be considered as a limitation of the study design because collective strategies for data construction would foster a joint reflection about the psychosocial care network the data collection process preceded the mental health policy changes determined by the federal government that brought a lack of financing of community services and setbacks in relation to the care model with emphasis on hospitalization therefore participants considerations about advances in the psychosocial care network should be understood in context and referenced to the previous policy contributions to public mental health policy although data collection has been delimited within the municipality this study contributes to important reflections on relationships and tensions in the psychosocial field and may foster debates and action plans related to the optimization and strengthening of the psychosocial care network one of the highlights of the study design were the contributions of pierre bourdieus theoretical perspective for valuing the relationships between social agents and the structures of the psychosocial care network in mental health care and the importance of understanding the symbolic disputes in the psychosocial field of psychosocial care network managers perception and tensions of the field querino ra borges rs almeida ly oliveira jl souza j the present study indicated relevant actions of psychosocial care improvements and recognized the legal advances in the last three decades however the model of care based on community services has experienced setbacks in relation to institutionalization which reinforces the existence of conflicts and tensions in the psychosocial field and in its relations with the health and social care fields different perspectives are in conflict and dispute in the field and understanding them can contribute to advances in the care model final considerations the study findings show that the perception matrix of participants originates from their position in the psychosocial field since most of them are managers it was somewhat expected there would be more references to positive aspects of the services where they work than to the existing limits most tensions and difficulties mentioned were related to services other than their own especially to other sectors in general the habitus of social agents was expressed much more by their disposition to transform than to reproduce the status quo such disposition was perceived in statements with expectation for the expansion of primary care actions and optimism about improvements in the psychosocial care network social agents demonstrated disposition to contribute to change processes in order to overcome the focus on specialties lack of training of some teams and lack of infrastructure and some components especially those related to leisure and community life

objective to analyze the perception of workers and managers about the psychosocial care network in a mediumsized municipality in the inlands of the state of minas gerais method qualitative descriptive and exploratory study involving twelve participants from different points of the network the semistructured interviews were analyzed in the light of pierre bourdieus framework of constructionist structuralism results the actions offered by the services were based on the perspectives of resocialization user embracement group and multiprofessional care and on approaches to harm reduction recreation and daily organization these were configured as the network resourcescapital tensions were identified in family embracement and in relationships between families and users as well as in the prejudice towards people with mental disorders final considerations the social agents were willing to contribute to processes of change in order to overcome the focus on specialties the lack of training of some teams lack of infrastructure and of some components especially those related to leisure and community life

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introduction during the last decade loneliness has emerged as an important determinant of health 1 2 3 4 studies have suggested that loneliness is a major risk factor for morbidity and mortality 56 it seems that loneliness is indirectly associated with these outcomes through psychological and behavioral factors 6 during the covid19 pandemic loneliness was a major concern for public health increasing the need to understand the factors associated with it 7 most of the research regarding loneliness has been conducted in the developed world and individualistic societies however there are studies looking at other societies 8 in a study comparing loneliness across cultures in 237 countries findings showed that in societies that were more individualistic there were higher rates of loneliness that decreased with age 9 in a recent editorial a list of risk factors and negative effects associated with loneliness in old age was given the authors suggested that building a compassionate social community could be a key approach to dealing with loneliness 10 social capital may help build such communities identifying key elements within sc that may inhibit or promote the ill effects of loneliness would be helpful for future intervention social capital and health putnams sc is an umbrella term that draws together relationships within networks norms of reciprocity mutual support and trustworthiness 1112 social capital is often defined as the norms networks and associations that facilitate cooperative action 13 social capital can be divided into both structural dimensions and cognitive dimensions 14 the current study measures cognitive sc represented by trust and reciprocity and structural sc represented by social involvement 15 social capital is associated with many health outcomes 16 17 18 19 20 21 in a systematic review collplanas et al found mixed effects of sc interventions targeting older peoples quality of life wellbeing and selfperceived health 22 social capital is now considered a social determinant of the health discourse 23 social capital may serve as a protective factor for health and a resource for individuals and communities to improve quality of life 1219 however how this works and if this is generalizable between communities is not clear 24 the association between sc and health may be contextdependent depending on the specific community studied 1525 in a previous study in israel jews reported higher levels of sc compared to arabs except for higher rates of social contacts and all measures of sc were associated with selfrated health among jews however among arabs the association between sc measures and health was not significant except for social support therefore studying these two populations may have an added value for understanding the association between social attributes and health 25 social capital and loneliness loneliness and sc both seem to affect health moreover sc may serve as a resource by which individuals can decrease loneliness or prevent its ill effects studies suggest that there is an association between living in an area with high sc and lower levels of loneliness 26 27 28 this association may not be causal and there may be an interaction between socioeconomic status and age a study in a suburb of barcelona spain suggested that there was an interaction between ses neighborhood sc age and loneliness the authors suggest that increasing neighborhood sc could be an effective way of reducing the prevalence of loneliness 26 evidence is beginning to come out that promoting sc to tackle loneliness and its health effects could be an interesting approach to decrease inequalities 29 however not many studies have looked at all three variables simultaneously therefore there is a need for more information regarding the associations between these social factors to be able to estimate the generalizability to all communities over two decades of research with more than 850 studies looking at sc and health have resulted in elusive and contradictory results especially regarding interventions 30 shiell et al suggest interventions utilizing sc to improve health are especially contextspecific israel can serve as an interesting setting for studying different communities as it is a multicultural society with two major ethnocultural groups jews and arabs 3132 about one fifth of israels population comprises arabs of them about 85 are muslims and 15 are mainly christians and druze jews and arabs in israel differ in socioeconomic status religion culture and language the arab society is a more collectivist society in transition to a more western lifestyle health indicators in israel suggest poorer health among arabs compared to jews 3132 for this study we chose four towns that differed in ethnicity aim of the study the studys aim was to assess the association between loneliness cognitive and structural sc and health additionally we want to see whether these associations are similar in the different towns we hypothesize that the association between loneliness and health is mediated or moderated by both cognitive and structural sc the studys aim was to assess the association between loneliness cognitive and structural sc and health additionally we want to see whether these associations are similar in the different towns we hypothesize that the association between loneliness and health is mediated or moderated by both cognitive and structural sc figure 1 hypothesised model depicting the association between loneliness and health material and methods design and sample this study is a secondary analysis of data collected in crosssectional population surveys in four towns as part of their health profile and needs assessment this is performed as one of their commitments to the healthy city network 33 as the questionnaire is a uniform questionnaire it allows for analyzing and comparing data from the four towns four surveys were conducted in four israeli towns during the years 20112016 the study population was randomly selected in each town as a stratified sample of households by residential area age and sex by the israel central bureau of statistics which also provided a kish grid for a random selection of the interviewees out of a list of inhabitants aged 22 and above in each household the sample size calculation in each town relied upon the following 50 prevalence of a variable a 95 confidence interval a 5 relative sampling error and 70 compliance interviews were conducted in person using a structured questionnaire at participants residential locations by trained interviewers participation rates were 54 in the mixed arabjewish town 793 in town a and 89 in both towns d and b the sample included 1898 arabs and 2722 jews altogether being 4620 participants were residents of two arab towns one jewish town and one mixed town the towns in the study represent two lower socioeconomic status arab towns level 2 and 3 out of 10 a mixed town with arabs and jews and a jewish town 34 interviews were conducted in arabic or hebrew according to the town and preference of the individual material and methods design and sample this study is a secondary analysis of data collected in crosssectional population surveys in four towns as part of their health profile and needs assessment this is performed as one of their commitments to the healthy city network 33 as the questionnaire is a uniform questionnaire it allows for analyzing and comparing data from the four towns four surveys were conducted in four israeli towns during the years 20112016 the study population was randomly selected in each town as a stratified sample of households by residential area age and sex by the israel central bureau of statistics which also provided a kish grid for a random selection of the interviewees out of a list of inhabitants aged 22 and above in each household the sample size calculation in each town relied upon the following 50 prevalence of a variable a 95 confidence interval a 5 relative sampling error and 70 compliance interviews were conducted in person using a structured questionnaire at participants residential locations by trained interviewers participation rates were 54 in the mixed arabjewish town 793 in town a and 89 in both towns d and b the sample included 1898 arabs and 2722 jews altogether being 4620 participants were residents of two arab towns one jewish town and one mixed town the towns in the study represent two lower socioeconomic status arab towns level 2 and 3 out of 10 a mixed town with arabs and jews and a jewish town 34 interviews were conducted in arabic or hebrew according to the town and preference of the individual measures sociodemographic variables were collected in person via selfreport gender age and education in town c respondents were asked to define themselves as jews or arabs religiosity was assessed using two different versions of the question one for arabs and one for jews as the terms used in hebrew and arabic are different the variable was dichotomized as not religious 2 and religious 1 for arabs not religious included answers 3not so religious and 4not religious religious included 1very religious and 2religious for jews not religious included 4not so religious and 5not religious or secular and religious included 1ultraorthodox 2religious and 3traditional two health measures were analyzed a selfrated health was measured using the question how do you evaluate your general health status very good good not so good or not good the answers were dichotomized into very good and good and coded as a 1 while not so good and not good were coded as a 0 b mental health was measured by asking the following question during the last year have you suffered from the following problems irritabilitystressanxiety sleep problems sadnessdepression and tiredness respondents could answer yes or no to each problem the number of problems mentioned were summed to give a scale from 0 to 4 and dichotomized low mental health was defined as 0 and 1 and high24 these four items were taken from the national yearly social survey of the israeli central bureau of statistics 35 loneliness was assessed using one item are there situations in which you feel lonely 3637 with four response options ranging from never to often this was dichotomized to never or infrequently not lonely and feeling lonely often or sometimes lonely the cognitive measure of sc was measured asking a generally do you think 1 people can be trusted or 2 you have to be careful of trusting people b do you think that people in your town or neighborhood 1 usually help each other 2 usually only look after themselves a composite variable was defined by adding the number of positive answers which was further collapsed for the logistic regression as low and high structural sc was measured by asking about participation in eight social activities respondents were given a list of activities and asked if they had participated in each activity during the last year not at all infrequently frequently the answers were added up to give a scale from 1 to 24 the activities included sports events meeting friends going to the mosque or synagogue going to parties or performances going on hikes or tours with others attending political or professional activities volunteering meeting family that do not live with the respondent data analysis data were analyzed using spss25 chi 2 and oneway anova were conducted to examine differences among the four towns logistic regression models were run with cognitive sc srh and mental health dichotomized as the dependent variables for the two health measures the first step gender age education religiosity and loneliness were added to the regression for the second step structural or cognitive sc was added and in the third step an interaction between loneliness and structural or cognitive sc were added in order to test the moderation effect of sc on the association between loneliness and health see figure 1 this moderation effect was further elaborated by running separate regression for people with low and high sc linear regressions were run for structural sc as the dependent variable with the above mentioned independent variables a regression model was run separately for each town after finding significant interactions between town and loneliness the mediating models were calculated with the r mediation package version 402 the model was performed with the library mediation all variables were standardized the models were first calculated while controlling for gender age and education then the other variables were added the average causal mediation effect was the measure of the mediation effect 38 ethics exemption from ethical approval was granted by the university hospitals ethical committee the interviewees were told they were free to stop the interview at any time with no implications to them as the interviewees agreed to answer the questionnaire this suggests informed consent results altogether 4620 adults were interviewed in four towns two arab towns one mixed town with 804 jews and 246 arabs in the sample and one jewish town the samples from the towns differ significantly in all their characteristics except for the percent of men and women interviewed the two health measures were correlated better selfrated health was reported by arabs in the two arab towns and jews in town c compared to jews in town d arabs living in arab towns and arabs in town c report better mental health than the jews in towns c and d in town c the difference between jews and arabs for all measures was significant except for mental health where there was no significant difference between the two population groups it seems that both aspects of health in the two arab towns are better than in the jewish or mixed towns in a logistic regression of the total population adjusting for gender age and education there was no difference in srh between arabs and jews however mental health was worse among jews after the adjustment residents of town a by far reported higher levels of loneliness compared to the other respondents 384 reported feeling lonely often or sometimes whereas in the other towns both arab and jews reported between 141 and 253 feeling lonely often or sometimes respondents in town b reported the lowest levels of loneliness the cognitive measure of sc was highest in the arab towns a and b and lowest in jewish town d however within town c the arabs had significantly lower levels of cognitive sc compared to jews another measure of sc was the levels of participation in social activities these were higher in the two arab towns a and b in town c jews reported significantly higher levels of social activities compared to arabs generally respondents reported spending time with family and friends and going to parties most frequently the activities reported varied significantly between the towns going to a movie was more frequent in towns c and d spending time with family attending sports events parties and outings were more frequent in town a and attending prayers in a prayer house was the most frequent activity in town b compared to the rest this suggests the towns differ in their patterns of social lifestyle logistic and linear regressions with cognitive and structural sc respectively as the dependent variable were run adjusting for age gender education and religiosity loneliness is associated with cognitive sc only in town c where those reporting loneliness also reported lower cognitive sc being religious is significantly associated with high cognitive sc in the total sample and cities a and d gender age and education are not associated with cognitive sc in the total population and vary in their association by town structural sc was significantly inversely associated with loneliness in three of the four towns this association was not significantly different between the towns generally structural sc is more dependent on gender age and education compared to cognitive sc that is associated only with religiosity in the total population note the reference categories of the dichotomized variables are gender male religiosity religious loneliness not lonely p 005 bold table 4 presents the logistic regressions for all the study population and separately for each town with srh or mental health as the dependant variable and participation in social activities as the measure of structural sc in these logistic regressions we adjusted for gender age education and religiosity as expected when analysing all towns together the more respondents reported being lonely the worse was their selfrated health and they reported worse mental health structural sc was also significantly associated with srh and mental health in the total population we then added the interaction between loneliness and structural sc to test moderation effects the interaction between loneliness and structural sc was significant for both types of health measures while the strength of the association between structural sc and srh or mental health decreased in the total population to further explore the moderation effect we analysed the association between loneliness and srh and mental health of the total population in two separate logistic regressions one included respondents reporting low structural sc and another regression with respondents reporting high structural sc than among people with high structural sc similar results were revealed in relation to mental health the association between loneliness and mental health was stronger among people with low structural sc than among people with high structural sc there was no significant moderation effect with cognitive sc both for srh and mental health adding town to the interaction did not yield a significant interaction when running the regressions separately for each town with srh or mental health as the dependant variable loneliness was associated with srh and mental health in towns b c and d but not in town a structural sc was associated with srh in all towns in towns b c and d the addition of the interaction decreased the association between structural sc and srh leaving it not significant the interaction between loneliness and structural sc did not reach significance when the regressions were run separately for each town to test the mediation effect of structural sc on the association between loneliness and srh we calculated the mediation analysis for the total sample and each town separately the mediation effect of structural sc was significant for the total population when including the interaction between town and loneliness the acme was significant when running the regressions separately for each town the mediation remained significant for each town in town a town b town c town d therefore it seems that structural sc is a mediator in the association between loneliness and srh structural sc was also a significant mediator in the association between loneliness and mental health in the total population including the interaction between town and loneliness when running the regressions separately for each town the mediation was significant in town c and town d but not in the arab towns a and b table 5 presents the logistic regressions for all the study population and separately for each town with srh or mental health as the dependant variable and cognitive sc and loneliness as the independent variables again we adjusted for gender age education and religiosity cognitive sc was associated with both srh and mental health in the total population where respondents with higher cognitive sc reported better health adding the interaction of loneliness and cognitive sc to the model decreases the association leaving it nonsignificant the interaction was not significant both for mental health and srh in the total population cognitive sc was associated with srh in towns c and d however it was significant only in town d adding the interaction eliminated the significance the interaction was significant only in town c therefore there may be a significant moderating effect in town c cognitive sc was significantly associated with mental health in towns a c and d however the direction varied in town a the or was 142 whereas in towns c and d the or was 070 and 046 respectively adding the interaction eliminated the significance in all three towns the interaction was significant for the two towns c and d this suggests that cognitive sc may be a moderator in the association between loneliness and mental health in towns c and d to test the mediation effect of cognitive sc on the association between loneliness and srh we used the mediation analysis for the total sample and each town separately there was no significant mediating effect for cognitive sc in the association between loneliness and srh in the total sample or any of the towns separately cognitive sc was also not a significant mediator between loneliness and mental health in the total sample and in the towns separately structural sc may serve as a moderator and a mediator in the association between loneliness and health both srh and mental health this seems not to be true for all towns cognitive sc may be a moderator only for mental health and only in two of the towns however not a mediator it seems that the different components of sc vary in the way they mediate or moderate the ill effects of loneliness in the various communities and the two health measures the reference categories of the dichotomized variables are gender male religiosity religious loneliness not lonely p 005 bold discussion this study tries to understand if social capital both structural and cognitive can help alleviate some of the ill effects of loneliness on health in certain communities studying these associations might support communities and social services in directing their investments to prevent the ill effects of loneliness on health the model we tested which presents the association between loneliness and health and the effect of social capital on that association indicated differences between cities the direct association between loneliness and self reported health and mental health which was found in 3 of the 4 examined cities is consistent with many previous studies 103940 as for the effect of social capital on this association we separated the two components of social capital as was suggested by rodgers and colleagues that each component of social capital represents a very different attribute of the community and may have very different effects on people in general putting them together under the umbrella of social capital does not suggest they have the same impact on society 41 as part of the model we analyzed the association of each social capital component with srh and mental health as in most previous studies both cognitive and structural social capital were found to be positively associated with selfreported health in the total population and every town 16 17 18 19 20 21 less consistent findings were revealed for the association of social capital and mental health as was reported by de silva 15 in 3 out of 4 cities higher structural and cognitive social capital were associated with better mental health in a review of crosssectional and longitudinal studies measuring the association between social capital and common mental disorders 42 a negative association was found with cognitive social capital but they did not find associations with structural social capital except for studies among mothers in lowincome settings where participation in civic activities was positively associated with common mental disorders such a positive association we found only in town a it seems that the type of social activities may influence the direction of the association croezen and his coauthors found that participation in religious organizations is negatively associated with depressive symptoms while participating in sports or social clubs or political organizations are positively associated with depressive symptoms 43 in our analysis we did not differentiate between types of social activities findings suggest that structural social capital serves both as a significant mediator and a moderator in the association between loneliness and health both srh and mental health we found a stronger association between loneliness and srh and mental health among people with a low level of structural social capital compared to those with high structural social capital therefore it is possible that being in contact with other people via participation in social activities may serve as a possible intervention to dampen or alleviate the ill effects of loneliness on health collplanas et al suggest it is an understudied intervention strategy 29 in a qualitative focus group study they describe the ways in which a weekly groupbased program can alleviate loneliness among older adults by promoting peer support and participation 44 in our present study we suggest structural social capital may improve selfreported health in all communities however it may improve mental health only in two of the communities not in the arab communities it seems that generalizing from one community to the other is not possible and we suggest that before attempting to utilize a specific intervention it should be studied in that specific community in other words the contextual social environment is a major attribute to the way loneliness and social capital may affect health cognitive social capital does not have a mediating effect a moderation effect was found in relation to selfreported health in one town only and in relation to mental health in two of the towns in the communities studied in these crosssectional surveys trust in social surroundings does not necessarily improve health several interesting differences were found between the towns for example in town a which is the poorest town the highest rates of loneliness were reported this is consistent with the findings of the highest risk of loneliness in the least wealthy groups which were described in the survey of health ageing and retirement in europe 4546 loneliness in town a was negatively associated with structural social capital and the latter was associated with selfreported health but there was no direct association between loneliness and srh as was found in the other towns this may indicate that town a may differ from the other towns in its contextual social environment poverty may explain the differences to some extent but of course there may be other explanatory social factors not measured 47 the social and cultural differences between the two populations are large with the arabs being a poorer population and more collective 3132 the differences between the communities correspond with national data 48 however there were also differences between the two arab towns in our study the moderation effects identified in this study suggest that increasing the social contacts of lonely people who may have a decreased ability to utilize resources available to help with their health may affect their health by providing these resources to them cognitive social capital was significantly associated with both selfreported health and mental health in 3 out of the 4 towns in town a a weak association was detected with selfreported health and an association with mental health in the opposite direction similar to the results of town a in this study in a previous study trust was not associated with health among arabs however in the jewish community it was 25 the authors suggested that in more affluent communities such as the jewish communities social capital may be associated with health to a higher extent and less so in more traditional communities it may be that the concept of trust varies between the two communities the more individualistic community and the more collective community the lack of association between trust and selfreported health was reported in another study from south africa 49 where the authors state that the results contradict many studies that do show these associations 50 51 52 it seems that the impact of social capital on health varies with the setting population and health measure 53 religiosity may also serve as a factor in the social context as there were differences in religiosity between the towns therefore it was important to adjust for this measure studies have shown that loneliness is more common in people without strong religious beliefs 5455 in this study religiosity was associated with mental health in the total population and in the arab town a but not in the other towns religiosity was associated with selfreported health only in the jewish town d and not in any of the other towns again suggesting variations in the social context in the different towns further studies should look at levels of collectivism that could have an impact on these relationships dykstra suggested that contrary to the assumption that people in individualistic societies are more lonely northern europeans tend to be less lonely compared to the more familistic southern european countries 56 this corresponds with our results another aspect of the differences between the communities may be a cultural difference in how the different communities perceive loneliness the questions used in this survey may vary in their validity and reliability between the communities not only between arabs and jews as suggested in several previous studies 5758 but also between the arab communities themselves or the jewish communities in town a people may tend to express and complain about feeling alone more so than in other communities as people in town a reported higher levels of loneliness we would expect them to report less social activities however higher levels of participation in social activities were reported in town a compared to the other towns as social activities were associated with lower levels of loneliness in all towns the more activities within a community the less loneliness we would expect to find the fact that even though people in town a reported high levels of loneliness and high levels of social activities suggests that in town a social activities do not alleviate loneliness in the same way as in the other towns 5960 or as mentioned earlier it may depend on the types of social activities 43 both social capital measures were higher in the arab towns and lower in the mixed and jewish towns other studies in the past suggested otherwise where social capital measures were lower among arabs 25 the only measure of social capital that was higher among arabs was social contacts this measure may be a similar measure of social activities even though they are measured in a different way as the arab community is a more collective community where close contacts are frequent this is expected however in the previous study trust was higher in the jewish community compared to the arab community but not so in this study this may have changed with time and now present a true difference between the communities or it may also be that town d as the only jewish town present in this study do not represent other jewish towns in a study assessing acquiescence bias among arabs and jews we found that arabs tend to agree with questions more so than jews 58 therefore the higher rates among arabs in this study could be due to this bias and not a true measure of their social capital in town c the patterns of association between the variables in this study are similar to the jews in town d especially for the arab community when dividing the sample into the two communities arabs and jews living in close proximity in the same town may have an effect on both communities for example arabs in town c gave estimates of their health more similar to the jewish population than to the arab population in towns a and b this may only be the effect of the ses level but may also represent the effect of cohabitation in addition social capital was lower in town c compared to towns a and b and more similar to town d therefore it seems that living in a mixed town reduces social differences between the two ethnic communities we may conclude that communities differ in the way social capital serves as a resource within that specific community and depend on the context of a certain community for example socioeconomic status and levels of collectivism what specific attributes of a community are important in this context are not clear yet in an important paper shiell et al suggested rethinking social capital and social capital interventions aimed at improving health 30 they suggest that studies measuring social capital and health inadequately take into account the context in which the study takes place in their opinion the way forward requires a renewed focus on specific components of social capital and how context affects the interaction between social capital and health our study supports these assertions a few study limitations should be mentioned the study is a crosssectional study that cannot infer causality therefore follow up studies are needed to ascertain the directionality of the associations between social capital loneliness and health the crosssectional methodology is not the optimal methodology in many cases however according to spector 61 the crosssectional methodology is appropriate when the association between variables is not clear the timeframe for the effect is not known and we want to measure the association in four distinct communities this methodology can help assess preliminary ideas on how we can move forward to alleviate the ill effects of loneliness on health the measure of loneliness is a singleitem measure and as such is not ideal however there is no consensus on how to measure loneliness to date standardisation is needed 62 in other studies certain parts of social capital are incorporated into the loneliness measure such as frequency of contacts with friends family and children and participation in social activities 47 in this study we assessed perceived loneliness as a single item and refer to levels of contact with other people separately as structural social capital we do not regard this as a limitation of the study on the contrary separating the two aspects of loneliness provides a more indepth analysis of factors effecting of loneliness and health an additional limitation of the study is the possible difference in the validity and reliability of the measures in arabs and jews this has previously been discussed a broader look at the context of the communities is needed to further understand the complex dynamics between the studied variables and the possibility of how changing social capital can serve as an intervention to improve health 30 conclusions this study suggests that increasing structural social capital could possibly compensate for loneliness and alleviate the harm it can do to health however we cannot generalize from one community to the other or for the various components of social capital therefore this study reinforces the need for the performance of separate health profiles and the assessment of possible interventions in each community separately we may say that structural social capital is both a mediator and a moderator for the total sample with variations between the towns data availability statement data available on request

loneliness has been associated with poor health social capital sc could possibly prevent the ill effects of loneliness the study aims to assess the association of loneliness with physical and mental health in four different communities in israel and study the impact of structural and cognitive sc on that association a crosssectional facetoface survey with 4620 adults in four towns was conducted the questionnaire included selfrated health srh mental health mh loneliness cognitive and structural sc and socioeconomic characteristics logistic regression analysis and mediation and moderation effects were calculated loneliness was associated with worse srh or 0405 and worse mh or 2010 both sc variables were associated with health however towns differ in these associations structural sc serves as a significant mediator between loneliness and srh in all towns and is a mediator between loneliness and mh in two towns cognitive social capital was a moderator between loneliness and mh in two towns this study suggests that increasing sc could possibly compensate for loneliness and buffer its effect on health the study reinforces the need for the performance of separate health profiles to assess possible interventions for each community as not always can we generalize these results to all communities

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introduction this article reports on outcomes from a randomized effectiveness trial of the new beginnings program a program that has demonstrated positive effects in two randomized efficacy trials there are two primary functions of an effectiveness trial the first is to translate the intervention developed as an experimental prototype to a service that can be effective when delivered in community agencies the second is to test whether the positive effects observed in the efficacy trials can be generalized across a wide range of populations settings and times when the program is delivered as a community service the public health significance of this effectiveness trial is supported by the high prevalence of divorce in the united states and the increased risk divorce confers for children in multiple areas of functioning next we describe findings from the efficacy trials of the nbp we then summarize changes that were made to translate the program from an experimental prototype tested in the efficacy trials to a community service finally we describe the questions addressed in this evaluation of the nbp as a community service findings from randomized efficacy trials of the nbp the nbp is a groupbased program designed to impact two factors that have been empirically associated with child outcomes following divorcequality of parenting and child exposure to interparental conflict the theory of the program is that program effects to improve these factors will lead to improved child outcomes following divorce the initial randomized efficacy trial found that compared to families in a waitlist control group families in the nbp showed an improvement in parenting and a reduction in child mental health problems at posttest the second efficacy trial with mothers who had primary residency of children ages 912 tested the effects of the parenting program alone the parenting program plus a concurrently run child coping program and a literature control condition the results indicated that at posttest there was a significant effect of the parenting program to strengthen parenting and reduce childrens externalizing problems at the 6month followup the parenting program reduced childrens externalizing problems as reported by parents children and teachers followup evaluations at 6 years and 15 years found a broad range of benefits including reductions in mental health problems and disorders substance use and abuse and highrisk sexual behavior less involvement in the criminal justice system and use of mental health services as well as improvements in indicators of positive functioning such as selfesteem and grade point average consistent with the program theory many of these effects were mediated through improvements in quality of parenting the findings from this trial indicated no significant additive benefit of the child coping program at any assessment so most analyses compared the combined parenting program and the parentingpluschild coping program to the literature control translation from an experimental prototype to a community service the nbp was delivered in both efficacy trials at a university prevention research center and all aspects of implementation were controlled by the research team including recruitment of participants as well as selection training and supervision of leaders translating the program into a community service required developing collaborations with the family courts to recruit families and with community agencies to deliver the program a fuller description of the program translation process and the consumer research that informed these changes is presented elsewhere and is briefly reviewed next we collaborated with four family courts in arizona which agreed to show a 12min invitational dvd during the brief parent information program that was mandated for all divorcing and separating families with minor children for the program to be acceptable to the court we needed to offer the program to divorcing and separating families fathers as well as mothers and families with a broad age range of children further the number of eligibility criteria was greatly reduced compared to the efficacy trials thus the families in the effectiveness trial were expected to be quite different from those in the efficacy trials because arizona has a large hispanic population we expected the sample to be ethnically diverse as compared with the efficacy trials where the sample was primarily nonhispanic white as compared to the sample of primary residential mothers in the efficacy trials we accepted fathers and mothers with a broad range of parenting time as long as it was sufficient to practice the parenting skills taught in the program the collaboration with the court in inviting parents and the broadening of the eligibility criteria enabled us to offer the program to the population of divorcing and separating families thus greatly enhancing the potential public health benefit of the program the program was delivered by providers in community agencies the agencies were selected using a competitive solicitation process similar to the way the court normally solicits agencies to deliver services as compared to the efficacy trials where we screened and selected leaders the agencies selected the leaders to deliver the program as described next the program was modified to make it easier and less costly for communitybased providers to deliver the program and to make it appropriate for delivery to an ethnically diverse population evaluation of the effectiveness of the nbp an effectiveness trial provides a critical bridge between demonstrating a programs potential impact in an efficacy trial and assessing its impact when it is delivered at scale the current article addresses two sets of questions that are important in establishing effectiveness of the nbp first does the nbp improve protective factors and reduce risk factors as well as improve childrens adjustment program effects were assessed on the two theoretical mediators targeted by the programquality of parenting and child exposure to interparental conflict these mediators have been found to relate to outcomes for children of all ages so it was theoretically appropriate for the program to target a broad age range of children program effects on childrens mental health problems and competencies were assessed because shortterm effects on these variables have been found to predict longterm effects in cascading models over 15 years second are the effects of the nbp moderated by characteristics of the participants moderators of program effects were tested because prior evidence showed moderated program effects in the efficacy trials or because the sample included sufficient variability on participant characteristics to which we wished to generalize inferences about program impact testing generalizability of programs across populations is one of the major objectives of an effectiveness trial we also tested level of interparental conflict as a moderator because of the intense interest in high conflict as a risk factor for poor outcomes of children following divorce method participants the sample consisted of 830 families randomized to nbp or comparison in which either the mother or father enrolled the sample size was selected to have adequate power to detect main and moderated effects at the pretest assessment 262 of the 830 parents were divorced 442 were legally married but divorcing and 126 were never legally married but were in court to establish or change a parenting time agreement following separation parents were ethnically diverse the hispanic parents were primarily of mexican heritage with the remainder from puerto rico cuba or another latino country parents had a wide range of education parents ranged from 18 to 63 years old and children ranged from 3 to 18 years old 478 of the children in these families were female at the pretest assessment mothers reported more overnights with their children in the past month than did fathers t 1468 p 01 the trial was conducted in partnership with family courts in two urban and two smalltown rural counties in arizona parents were primarily recruited by viewing a 12min invitational dvd shown during a 4hr parent information program mandated for all parents seeking a divorce or separation parents provided demographic information completed a 15item risk index previously shown to predict childrens postdivorce adjustment and indicated their interest in participating in a randomized effectiveness trial parents were also recruited through judge lawyer and selfreferrals and through media announcements parents who expressed interest were screened by phone based on the following eligibility criteria filing for divorce or modification of a divorce decree within the past 2 years or if never married being in court in the past 2 years to establish or change a parenting time agreement following separation having at least one child age 3 to 18 with whom the parent spends 3 hours or more each week or one overnight every other week being able to complete the program and assessments in english and not being mandated to a parenting class by the juvenile court or child protective services following completion of the pretest interview 886 parents were randomly assigned using computergenerated random numbers with a 53 to47 ratio for the nbp to comparison condition these 886 parents included 112 paired parents in which both father and mother participated in either the nbp or comparison condition however we excluded data from the second parent enrolled in each of these 56 pairs resulting in a sample of 830 parents for our analyses the trial was conducted in four cohorts between 2012 and 2014 the consort diagram in figure 1 summarizes how many parents were invited screened randomized and assessed at pretest posttest and 10month followup data were collected in four arizona counties using telephone interviews with parents and children and using online or paperandpencil questionnaires for teachers during the pretest assessment parents were asked for permission to interview their 9to 18yearold children and for permission to interview the teacher of their 6to 18yearold children who were currently enrolled in school and not being homeschooled data were obtained at pretest posttest andor 10month followup from 559 of the 757 children age 9 or older and from teachers of 687 of the 712 eligible children whose parent provided permission to collect teacherreported data parents and children were paid 50 and 30 respectively for their interviews teachers in the first cohort were paid 10 and those in the second through fourth cohorts were paid 5 for their assessments interviewers were masked to condition success of masking was assessed at posttest and 10month followup by asking interviewers whether they thought they knew which condition the parent was in and if so which condition 954 at posttest and 953 at 10month followup reported not knowing or answered with the incorrect condition the study was approved by the institutional review board at arizona state university intervention and comparison conditions nbpthe nbp targeted three potentially modifiable parenting domainsparentchild relationship quality childrens exposure to interparental conflict and effective discipline all of which have been identified as being associated with childrens postdivorce adjustment the small theory of the intervention was that program effects to strengthen parentchild relationship quality and effectiveness of discipline and to reduce childrens exposure to interparental conflict would lead to a reduction of child mental health problems drawing from social learning and cognitivebehavioral approaches the nbp used parent training videotaped modeling roleplaying and weekly home practice to teach and review parenting skills during 10 group sessions and two individual phone sessions parents who did not attend a session were invited to come early to the following session and observe a 15to 20min selfadministered makeup dvd that presented the skill taught in the missed session the program was adapted from the nbp tested in the efficacy trials with divorced mothers of children ages 815 to prepare it for delivery on a much larger scale in community agencies parents received tips for using the program skills with children across the broad age range a comprehensive process to broaden the program material and skills to meet the needs of the parents from diverse cultural groups was undertaken data from these sources were used to make modifications that maintained fidelity to nbps core components but tailored presentation of the program skills to meet the needs of the parents from these groups prevention scientists and providers with expertise in working with mexican american and african american families reviewed the protocol and mexican american and african american parents who participated in a pilot test of the program provided feedback across all the cultural informant types the topics covered in the nbp were seen as appropriate crossculturally however numerous suggestions for surface structure changes were made and implemented for example the program was modified to include more culturally relevant examples the program activities were broadened to incorporate extended family members and the videotaped skills demonstrations included greater ethnic diversity of the actors other changes included offering culturally sensitive rationales and explanations of program skills that were compatible with goals and values of ethnic minority parents acknowledging the potential cultural barriers to specific program skills or recommendations such as systematic reinforcement for positive behaviors and the nbps recommendation against spanking and providing more opportunities for all parents to consider ways to make program skills fit their cultural styles and preferences for example extensive reliance on good listening skills was perceived as conflicting with mexican american and african american parents rolebased desires to provide advice and guidance to their children we followed our cultural informants suggestions to acknowledge these strong desires and the difficulty that parents might have using listening skills prior to or in place of parental advice and to augment the discussion of how just using good listening could benefit their children the manual was revised to ease leader burden by providing dvdassisted delivery and a more economical training protocol was developed that included online training for each session to reduce cost the program was shortened from 11 sessions to 10 sessions and was delivered by a single leader rather than two as in the efficacy trials the program was delivered to 26 mother groups and 24 father groups active comparisonwhereas prior efficacy trials of the nbp used a waitlist or literature control condition the effectiveness trial used an active comparison condition due to the necessity of offering a credible intervention to all families enrolled through the family courts during two group sessions the leader didactically presented the risk and protective factors targeted in the nbp parents were encouraged to exchange their ideas for strengthening postdivorce parenting skills and reducing childrens exposure to interparental conflict parents were also asked to set goals that they wanted to accomplish in the program important to note parents did not roleplay parenting skills and were not instructed to practice the parenting skills at home the program was delivered to 22 mother groups and 22 father groups group leadersthe programs were delivered by 38 group leaders leaders each led only one experimental condition measures the time frame used for all measures was within the past month parents completed the full battery of parenting skills and child behavior problem measures for a randomly selected target child parents also completed the child monitoring scale for all children age 9 or older1 data were also obtained from all children age 9 or older whose parent provided permission for the interview and from teachers of children age 6 or older who were enrolled in school and whose parent provided permission for the interview we report internal consistency reliability at pretest where applicable as well as references for reliability and validity of measures parenting skillsparents and children responded to several measures assessing two dimensions of parenting skills parentchild relationship quality and discipline the same measures were administered to parents and children unless specified family routines were assessed by a sevenitem adaptation of the family routines inventory which jensen james boyce and hartnett reported as having adequate reliability and validity involvement was measured by six items adapted from menning assessing activities parents engaged in with their children the scale has good predictive validity for father involvement following divorce communication was assessed by the 10item open communication subscale of the parentadolescent communication scale which barnes and olson reported as having adequate reliability and validity closeness was measured by a single item how close do you feel to your child parent which has been found to predict wellbeing of children following divorce parents and children completed an 11item version of the child monitoring scale which has been found to have good reliability and validity parents completed this measure for each target and nontarget child age 9 or older the remaining measures completed by parents and children each had good reliability and predicted outcomes in a previous efficacy trial of the nbp parents and children completed three subscales of the child report of parental behavior inventory acceptance faults parentreport α 87 childreport α 95 rejection and consistency of discipline parents completed three subscales of the oregon discipline scale followthrough should have been punished for α 75 in this sample appropriate use of discipline and inappropriate use of discipline a ratio of appropriate to appropriate plus inappropriate use of discipline was computed parentreport confirmatory factor analysis model parentreport of parentchild relationship quality and discipline were assessed using factor scores from a twofactor confirmatory factor analysis model estimated in mplus 73 indicators of parentchild relationship quality were involvement family routines parentchild communication closeness and acceptance indicators of discipline were consistency followthrough and appropriate use of discipline when fitting the twofactor model we allowed involvement and family routines to correlate due to their conceptual similarity and acceptance and consistency of discipline to correlate due to being measured by items on the same scale the twofactor model closely fit the data at pretest χ 2 6986 rmsea 06 cfi 96 posttest χ 2 5777 rmsea 06 cfi 97 and 10month followup χ 2 4125 rmsea 05 cfi 97 when investigating measurement invariance across parent gender the metric invariance model did not significantly deteriorate fit relative to the configural invariance model and the scalar invariance model did not significantly deteriorate fit relative to the metric invariance model the scalar invariance model closely fit the data at pretest χ 2 10218 rmsea 05 cfi 96 posttest χ 2 8476 rmsea 05 cfi 97 and 10month followup χ 2 9405 rmsea 06 cfi 95 when investigating measurement invariance across parent ethnicity the metric invariance model did not significantly deteriorate fit relative to the configural invariance model and the scalar invariance model did not significantly deteriorate fit relative to the metric invariance model the scalar invariance model closely fit the data at pretest χ 2 10253 rmsea 06 cfi 96 posttest χ 2 10135 rmsea 06 cfi 96 and 10month followup χ 2 7728 rmsea 05 cfi 96 thus the measurement model for parenting was invariant across parent gender and ethnicity parentreport of rejection and monitoring were analyzed as two separate measures beyond parentchild relationship quality and discipline we treated rejection as a separate measure because it did not load highly with the other indicators of parentchild relationship quality we treated monitoring as a separate measure because parents completed this measure only for children age 9 or older but completed all other measures for children of all ages childreport confirmatory factor analysis model consistent with parentreport we initially fit a twofactor model of parentchild relationship quality and discipline because these factors were highly correlated we then estimated a onefactor model of positive parenting indicators of positive parenting were involvement family routines parentchild communication closeness acceptance rejection consistency of discipline and monitoring when fitting the onefactor model we allowed involvement and family routines to correlate due to their conceptual similarity and acceptance rejection and consistency of discipline to correlate due to being measured by items on the same scale the onefactor model closely fit the data at pretest χ 2 5325 rmsea 07 cfi 98 posttest χ 2 3263 rmsea 05 cfi 99 and 10month followup χ 2 4458 rmsea 06 cfi 98 interparental conflictparents reported on interparental conflict using four items that asked about childrens exposure to conflict adapted from the childrens perception of interparental conflict scale that has previously been reported to have good reliability and validity plus two items written for this study that reported on arguing in front of the child only parentreports about arguing in front of the child were used because the program was designed to reduce exposure to conflict rather than the occurrence of conflict per se parents who reported no contact with the other parent were assigned the lowest score on this scale children reported on their exposure to interparental conflict using 13 items from the childrens perception of interparental conflict scale plus the two items concerning the parents arguing in front of them children also reported their perception of being caught between their parents using the sevenitem caught in the middle scale which has previously been found to have good reliability and validity and on their exposure to badmouthing using two items child mental health problemsparents completed the child behavior checklist for children aged 6 to 18 and the preschool cbcl for children ages 35 the t scores were calculated for cbcl and precbcl subscales based on child age and gender and combined to assess internalizing externalizing and total problems across the broad age range children ages 9 or older completed the brief problem monitor to assess internalizing externalizing and total problems teachers completed a parallel version of the brief problem monitor to assess internalizing externalizing and total problems for children age 6 or older who were currently enrolled in school the t scores for childand teacherreports were calculated based on child age and gender developmental competenciesteachers completed the teacherchild rating scale which has previously shown good reliability and validity to evaluate learning problems task orientation frustration tolerance assertive social skills and social competence data analytic strategy we assessed the equivalence of families randomized to the nbp and comparison conditions on 33 parentreported demographic and baseline measures using t tests and chisquare tests univariate and multivariate outlier analyses were conducted to identify influential data points to assess the impact of attrition on internal and external validity we compared the attrition rates across conditions using chisquare tests and performed 2 × 2 analysis of variance or logistic regression on each baseline measure intenttotreat analyses were conducted by regressing each parent child and teacherreported outcome on condition and the following baseline covariates baseline status on the outcome baseline risk county of residence parent gender and an indicator of whether both parents were enrolled in the effectiveness trial all analyses were performed in mplus73 using full information maximum likelihood estimation which includes cases with missing scores intraclass correlations by intervention group were low whereas iccs by family were high a sandwich estimator was used for the standard error computations to adjust for clustering by family for parentreport of monitoring childreport and teacherreport we investigated whether the program effects were moderated by baseline status on the outcome parent gender parent ethnicity child age and interparental conflict 3 one moderator at a time significant moderated effects were probed via simple main effects which were computed at the mean and at 1 sd abovebelow the mean of a continuous moderator and at each level of a categorical moderator to control the type i error rate we applied a false discovery rate correction separately for each domain of outcomes with multiple measures parentreport of parenting childreport of interparental conflict and parent child and teacherreports of child mental health problems and developmental competencies for these measures we report the main and moderated effects with fdr pvalues ≤ 10 for domains of outcomes with a single indicator we report main and moderated effects with ps ≤ 05 cohens d is reported for the significant main effects and simple main effects for all significant main or simple main effects on internalizing externalizing or total problems we assessed clinical significance by comparing the proportion of children in the nbp versus comparison who moved from the clinical or borderline clinical range at pretest to the normal range at posttest or 10month followup results preliminary analyses the two conditions significantly differed on three of the 33 demographic and baseline characteristics relative to those in the comparison condition parents in the nbp were higher on childreport of positive parenting and lower on childreport of interparental conflict and badmouthing at pretest to adjust for these imbalances we included these three baseline covariates in the outcome models and assessed the robustness of the results none of the conclusions changed so because including significant baseline characteristics to the outcome models is an inferior option to using covariates related to the outcome we report the results without including these three baseline covariates in the outcome models no influential data points were identified based on univariate or multivariate outlier analyses 2 parents completed all other measures only for the target child thus clustering by family did not apply for the other parent reported measures 3 parentreport of interparental conflict scale served as the moderator for program effects on parent and teacher reported outcomes when used as a moderator the full 13 items of the adapted child report of interparental conflict scale plus the two arguing in front of the child was used to best capture the full range of conflict as a moderator of program effects child report of interparental conflict scale served as the moderator for program effects on childreported outcomes the attrition rates did not significantly differ across conditions at posttest χ 2 044 p 51 or 10month followup χ 2 058 p 45 however four of the 60 attrition status main effects were significant and two of the 60 condition × attrition status interaction effects were significant on average parents who did not complete the posttest interview reported less education lower risk and fewer child internalizing problems at pretest than those who did and parents who did not complete the 10month followup interview reported less education than those who did parents in the comparison condition who did not complete the posttest interview reported fewer child externalizing and total problems at pretest than those who did parents in the nbp who did versus did not complete the posttest interview did not significantly differ on child externalizing or total problems at pretest treatment integrity of the 445 parents randomized to the nbp 107 never attended 92 attended between one and four sessions 192 attended between five and nine sessions and 54 attended all 10 sessions the mean number of sessions attended was 559 interested readers should refer to mauricio et al for additional information on mothers and fathers attendance as well as attendance trajectory class differences on baseline characteristics of the 385 parents in the comparison condition 65 never attended 55 attended one session and 265 attended both sessions a significantly greater proportion of nbp parents than comparison parents never attended χ 2 644 p 01 fidelity of implementation of the nbp was assessed by objective rater coding of leader behavior for one activity per session selected to represent the different kinds of program activities activities were coded as totally completed partially completed or not completed at all the mean fidelity of implementation score across activities was286 indicating a high level of fidelity to the manual effects on parenting skills and child exposure to interparental conflict table 1 presents the results of the analyses for parenting skills and child exposure to interparental conflict at posttest and 10month followup posttestparents in the nbp reported more effective discipline and greater monitoring relative to those in the comparison condition parent ethnicity moderated the effect of the program on parentreport of parentchild relationship quality and rejection such that nonhispanic white parents in the nbp reported greater parentchild relationship quality and lower rejection relative to those in the comparison condition there were no significant main or moderated effects of the program on childreport of exposure to interparental conflict at posttest 10month followupthe program effect on parentreport of monitoring was moderated by child age and baseline interparental conflict relative to those in the comparison condition parents in the nbp reported less monitoring of younger children but greater monitoring of older children parents in the nbp who were at the mean or at 1 sd above the mean of baseline interparental conflict reported greater monitoring of their children relative to those in the comparison condition at 10month followup there were no significant main or moderated effects of the program on parentreport of child exposure to interparental conflict or on childreport of parenting skills or exposure to interparental conflict effects on child mental health problems and developmental competencies table 2 presents the results of the analyses for child mental health problems and developmental competencies at posttest and 10month followup posttestparent ethnicity moderated the effect of the program on parentreport of internalizing problems externalizing problems and total problems nonhispanic white parents in the nbp reported fewer internalizing problems externalizing problems and total problems relative to those in the comparison condition child age moderated the effect of the program on childreport of internalizing problems such that younger children in the nbp reported fewer internalizing problems relative to those in the comparison condition child age also moderated the effect of the program on teacherreport of externalizing problems task orientation assertive social skills and frustration tolerance teachers reported more externalizing problems lower task orientation and lower assertive social skills in the nbp relative to the comparison condition teachers reported lower frustration tolerance for younger children in the nbp but higher frustration tolerance for older children in the nbp relative to those in the comparison condition 10month followupparent ethnicity moderated the effect of the program on parentreport of internalizing problems and childreport of internalizing problems and total problems relative to those in the comparison condition nonhispanic white parents in the nbp reported fewer internalizing problems and children of nonhispanic white parents in the nbp reported fewer internalizing problems and total problems there were no significant main or moderated effects of the program on teacherreport of child mental health problems or developmental competencies at 10month followup clinical significancefollowup analyses on the eight significant main or simple main effects on child mental health problems indicated that only two showed a significantly or marginally significantly greater proportion of nbp versus comparison children moving from the clinical or borderline clinical range at pretest to the normal range at posttest or 10month followup for parentreported externalizing problems a significantly greater proportion of nonhispanic white children in the nbp than in the comparison condition moved from the borderline or clinical range at pretest to the normal range at posttest χ 2 464 p 03164 versus 93 for childreported internalizing problems a marginally significantly greater proportion of nonhispanic white children in the nbp than in the comparison condition moved from the borderline or clinical range at pretest to the normal range at 10month followup χ 2 314 p 08 240 versus 148 the percentage of children who shifted from the borderline or clinical range to the normal range are based on the full samples where either the parent or the children completed the pretest and 10month followup assessments the percentage of children in the borderline or clinical range at pretest and thus were eligible to shift did not differ significantly between the nbp and comparison condition for either childreport of internalizing problems or parentreport of externalizing discussion this effectiveness trial tested whether the positive shortterm effects of the nbp found in two efficacy trials could be obtained when the program was delivered by community agencies to a heterogeneous population of divorced and separated families significant moderated effects of the nbp to strengthen postdivorce parenting and to reduce childrens mental health problems were found with ethnicity of the parents and age of the children being the primary significant moderators the findings are discussed in terms of explanations for the subgroup differences in effects and implications for translating the nbp into a community service similar to the two efficacy trials the nbp had a significant effect to strengthen multiple aspects of positive parenting as reported by both parents and children however the effect sizes were in the small range whereas they were in the medium range in the efficacy trials such decreases in effect sizes from efficacy to effectiveness trials are common when psychosocial interventions are implemented in community settings and may be due to differences in the implementation of the intervention or characteristics of the participants the fidelity of implementation in the current trial was quite high and comparable to that reported in the second efficacy trial however participant attendance was considerably lower in this trial as compared to the second efficacy trial in the current trial 240 of those randomly assigned to the nbp never attended a single session and 447 attended four or fewer sessions it is likely that effect sizes on parenting outcomes in the effectiveness trial were attenuated by families who attended no or very few sessions although the nbp led to positive changes in discipline and monitoring for nonhispanic white and hispanic parents the nbp improved two aspects of parenting and decreased child mental health problems at posttest and 10month followup for nonhispanic white parents only in addition to the program effects being nonsignificant for the hispanic parents the effect sizes were very small for this group and often favored the comparison condition these differential effects may be due to lower attendance among hispanic parents and a greater likelihood of dropping out after the first few sessions among hispanic mothers a second possible explanation is the lack of ethnic match between the hispanic parents and their group leaders for hispanic families 76 in the nbp had a nonhispanic group leader whereas only 57 had a nonhispanic group leader in the comparison condition these possibilities are not independent for example it may be that lack of ethnic match with group leaders had a negative impact on attendance of the hispanic families ongoing work is exploring these as possible explanations for the lack of program effects for hispanic families a third potential explanation for the lack of effects for hispanic families is lack of measurement equivalence however findings from the test of measurement invariance across ethnicity in the assessment of parenting just reported makes this explanation unlikely research is also needed to investigate whether the failure of the nbp to impact parentchild relationship quality and rejection for hispanic families might reflect cultural differences in the meaning of these constructs or a cultural mismatch with the intervention strategies the lack of program × parent gender interaction effects on parenting or child mental health outcomes indicates that the program which was originally tested with mothers is also appropriate for fathers the only indication of differential program effects across parent gender was a marginally significant program × parent gender interaction effect on childreport of positive parenting tests of the simple main effects indicate a positive effect of the program to improve childreport of father positive parenting but not mother positive parenting at posttest because divorced fathers have increasing parenting time over the past decades and prior interventions for divorced parents have focused on mothers there is a pressing need to understand the effects of preventive interventions for divorced fathers a separate publication focuses on the father subsample and presents additional encouraging evidence of nbp effectiveness on father parenting and child mental health for teacherreport there was a pattern of iatrogenic effects at posttest for children age 8 and younger on externalizing problems task orientation assertive social skills and frustration tolerance although there was a positive effect on frustration tolerance for the older children in the efficacy trial there was also a negative effect of nbp on teacherreported shyanxious behavior at posttest concern about longterm negative effects of nbp is mitigated because in the current trial none of the negative effects persisted at followup in the current trial the only marginally significant difference between the groups at 10month followup favors the nbp it may be that the changes parents engaged in during the program were difficult for younger children to integrate immediately and led to some shortterm distress on their part which was manifested in their behavior at school the fact that this effect was only reported by teachers may be because teacher ratings of child problems are only modestly correlated with those or parents or children indicating that teachers provide a unique perspective on child behavior problems the use of an active control condition is an important strength of this study other research has found that although there were positive effects of prevention programs when compared to passive controls there are often no significant effects when interventions are compared to active controls given that the active control condition and nbp both included didactic presentation of material on the risk and protective factors the positive effects of the program in the current trial may be due either to the dosage or to the active components of the nbp consistent with the latter explanation berkel et al found that effective home practice of program skills significantly predicted improvements in parenting in this sample two limitations of this study need to be noted first there were significant condition × posttest attrition status interaction effects on child externalizing and total problems at pretest which potentially threatens the internal validity of the findings at posttest however using full information maximum likelihood estimation and including baseline status on the outcome as a covariate in the model mitigate bias from this threat to internal validity program effects at the 10month followup are less likely to be affected by this threat to internal validity second it is not known whether the program effects generalize to other ethnic or demographic subgroups that were not tested although the current sample was diverse in terms of ethnicity age of child and gender of parent further research is needed to test program effects on other subgroups the findings from this effectiveness trial are encouraging of further work to translate the nbp from an experimental prototype to a community service similar to others we see the translation from efficacy to sustainable community service as an ongoing process guided by feedback from implementation in community settings three aspects of the feedback from the current trial will be critical for ongoing implementation of the nbp first the partnership with the family courts allowed the program to be presented to a large number of divorced and separated families building on this partnership is a promising direction for future implementation of the nbp second the low level of enrollment and attendance which is typical of implementation of parenting programs in the community indicates the need for research on ways to increase the uptake of this program third the lack of program effects on hispanic childrens outcomes indicates the need for further study on how to strengthen program effects with this subgroup and to study the nbps effects in other ethnic groups this research should be conducted within the framework of an ongoing collaboration with community providers with the goal of constantly learning how the nbp can best be used to improve outcomes for children following parental separation and divorce funding this research was funded by grant r01 dao26874 from the national institute of drug abuse which is gratefully acknowledged appendix a adjusted means by parent ethnicity for parent reported parentchild relationship quality at posttest note the asterisk denotes a significant mean difference between the new beginnings program and comparison conditions appendix b figure c2 adjusted means by parent ethnicity for parent reported rejection at posttest note the asterisk denotes a significant mean difference between the new beginnings program and comparison conditions figure c3 adjusted means by parent ethnicity for parent reported internalizing problems at 10month followupnote the asterisk denotes a significant mean difference between the new beginnings program and comparison conditions figure c4 adjusted means by parent ethnicity for child reported internalizing problems at 10month followupnote the asterisk denotes a significant mean difference between the new beginnings program and comparison conditions consort diagram summarizing how many parents were invited screened randomized and assessed at pretest posttest and 10month followup d hispanic 017 for parentreported internalizing problems at 10month followup d hispanic 020 and 023 for childreported internalizing and total problems at 10month followup specifically the direction of the simple main effects favored the comparison condition for parent reported externalizing problems at posttest parentreported internalizing problems at 10month followup and childreported internalizing and total problems at 10month followup

this study presents findings from a randomized effectiveness trial of the new beginnings program nbp which has demonstrated efficacy in 2 prior randomized efficacy trials family courts in 4 counties facilitated recruitment of divorcing and separating parents and providers in community agencies delivered the program participants were 830 parents of children ages 318 who were randomized to receive either the 10session nbp or an active 2session comparison condition in which parents learned about the same parenting skills but did not complete home practice of these skills parents were ethnically diverse 594 nonhispanic white 314 hispanic 92 other race or ethnicity multiple rater assessments of parenting interparental conflict and child mental health problems were conducted at pretest posttest and 10month followup the results indicated positive moderated effects of the nbp as compared with the active control condition to strengthen parenting at posttest and to reduce child mental health problems at posttest and 10 months many of these moderated effects showed positive benefits for nonhispanic white families but not for hispanic families the findings indicate support for the effectiveness of the nbp when delivered by communitybased agencies but also indicate the need for further adaptations to make the program effective for hispanic parents

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introduction cancer is a common health issue in latin america being the second cause of mortality in most of the region and causing 19 of all deaths in this region cancer mortality burden is considerable since its presentation often occurs at more advanced stages in a context of poor access to cancer care leaving patients and their families exposed to a poor quality of life and impoverishment due catastrophic expenditure although latin america has achieved important advances in palliative care there is still a considerable gap in pc access and coverage regarding to chile in a recent report describing the gaps in pc access there has been a progress in access to pc for cancer patients with a coverage of 93 but this coverage focuses mainly on pain management with little coverage for nonpain symptoms this scenario may be even more challenging for pc planning because of delayed cancer diagnosis due the covid19 pandemic patients with advanced cancer experience symptoms and functional decline throughout the course of their disease particularly during end of life requiring support to perform selfcare activities caregivers of cancer patients are usually family members or friends who provide uncompensated care to a patient helping with daily living activities such as bathing feeding or mobilization in performing nursing taskssuch as administration of medications or treatment monitoring and in providing emotional support when required among others as their primary source of support family caregivers are also exposed to several other strains such as rearrangement of functions and roles within the household and dealing with work issues and with own personal emotions addressing fcs burden must consider a very broad perspective using subjective and objective aspects subjective burden has been conceptualized as the perceived physical emotional social and financial distress as a result of caring for a person with a serious disease whereas objective burden refers to the amount of time spent on caregiving and the number of tasks that are performed to our knowledge few publications have described in latino communities the objective and subjective burden of care that fcs experience while caring for advanced cancer patients also limited reports have described simultaneously how caregiver and patient characteristics jointly influence caregiver burden experience since intensity of stressors vary across different ethnic and cultural groups among latinos cultural values familism must be considered indeed this value may increase fc distress according to the perceived family duties when caregiving difficulties arise as familism can be associated with strong feelings of reciprocity and loyalty among members of the same family it is possible that caregiving burden could be underperceived by fcs therefore it seems relevant to better understand the caregiving phenomenon among latinos to describe the frequency of perceived burden related to these tasks and to identify specific factors associated with it the aims of this study are to describe the caregiving phenomenon in a population of fcs of advanced cancer patients in a latino community and to identify patient and caregiver factors associated with subjective burden methods measures baseline assessments included demographic information such as age gender marital status education and religion of both patients and fcs in addition we included the following validated measures in spanish the abbreviated zarit caregiver burden scale the edmonton symptom assessment scale the hospital anxiety and depression scale and the eortc qlqc15pal data about financial distress spirituality and religiosity were collected from patients whereas fcs were asked to complete singleitem questions describing the tasks and activities they performed to characterize the phenomenon of caring zarit caregiver burden scale the abbreviated zarit caregiver burden scale was employed to assess the level of subjective caregiver burden it consists of a 7item questionnaire in which fcs are asked to rate in a 5item likert scale how much burden was perceived for different tasks scores range between 7 and 35 points with higher scores meaning higher subjective burden this instrument was validated in a chilean population of outpatient fcs it showed an internal consistency of 084 and defined a cutoff of 17 points to consider the fc as experiencing highintensity burden this cutoff was defined using an receiver operating characteristic curve and was similar to the cutoff obtained in a spanish validation of the instrument edmonton symptom assessment scale a spanish version of the esas was employed to examine the average intensity of 10 symptoms in advanced cancer patients over the past 24 hours each of these symptoms is rated from 0 to 10 on a numerical scale hospital anxiety and depression scale psychological distress was measured using the spanish version of the hads this 14item instrument consists of 2 subscales one for depression and one for anxiety a score of 8 or higher is considered clinically meaningful for each one of them the hads has been previously validated in spanish and the internal consistency was reported as 075 financial distress and spiritual pain were assessed with singleitem questions in which patients reported intensity of fd or sp in a 0 to 10 scale with 0 meaning that patient had no fd or sp and with 10 meaning that the patient had the worst possible fd or sp objective burden of care was assessed by singleitem questions that were asked to the fc and included have you taken care of the patient for at least one year do you live with the patient do you take care of the patient every day how many hours per day do you take care of the patient do you also hold a fulltimeparttime job do you share caregiving responsibilities with someone else and have you ever had any type of training in caring for people with cancer statistical considerations descriptive statistics were used to summarize our data for continuous variables we reported sample size mean and standard deviation for normally distributed variables and median and interquartile range for nonnormally distributed variables for categorical and binary variables frequency and percentage were reported univariate analysis was performed using the abbreviated zarit caregiver burden scale as the primary outcome we explored the association between each of the variables with subjective burden variable that was dichotomized into 2 categories fcs with intense subjective burden versus fcs without intense subjective burden ttest wilcoxon rank sum test or chisquare test were used as required we then performed a multivariate logistic regression analysis to assess the effect of categorical and continuous covariates on subjective caregiver burden intensity adjusting for possible confounders for the multivariate analysis we considered all patient and caregiver variables that were significantly associated with intense subjective burden of care in the univariate analysis except for patientreported symptom intensity due to the high correlation between caregiver and patientreported symptom intensity it is important to highlight that all variables included in the multivariate model theoretically could influence the experience of subjective burden for example it has been reported that spirituality as a proxy of religion is associated with caregiver burden in caregivers of chronic conditions then we proposed a model to predict intense subjective caregiving burden using backward and forward selection strategies with the whole model using both 005 and 01 cutoffs to create a new simpler model using likelihood ratio test we then assessed whether the final model was nested under the larger original model finally we estimated sensitivity specificity and discriminatory capacity of the final model using the roc curve all computations were carried out in a standard software package data protection and confidentiality the study was approved by the local ethics committee all participants provided signed informed consent health information was protected and data confidentiality was maintained throughout the study only trained personnel in maintaining confidentiality and the primary investigator had access to study records results a total of 207 advanced cancer patients in pc and their fcs were included caregiver and patient demographics are described in tables 1 and2 respectively the mean age of fcs was 50 years and 78 were women the most common relationships with the patients were being the spouse or children sixtysix out of 207 fcs reported highintensity subjective burden of care figure 1 shows the distribution of the abbreviated zarit scale scores regarding questions assessing objective burden of care we found that 82 of the fcs take care of the patient daily with a mean karnofsky performance status mean 67 68 66 024 quality of life mean 65 68 27 has taken care of the patient 1 year or more percentage intense caregiving burden no caregiving burden in the univariate analysis between caregiver burden with fcs characteristics highintensity subjective burden of care was associated with caregiver depression and anxiety also subjective burden of care was significantly associated with fcs higher perception of patient fatigue drowsiness depression anxiety and poor wellbeing regarding patients characteristics highintensity subjective burden of care was significantly associated with patientreported religion and lower patientreported qol although not statistically significant there was a trend between highintensity subjective burden of care and patientreported sp intense subjective burden was also associated with patientreported fatigue drowsiness anxiety depression and poor wellbeing intense burden was also more frequent among fcs who took care of the patient without help and a trend among fcs who take care of the patient daily but was not associated with other variables reporting objective burden of care in the multivariate analysis we found that caregiver depression caregiver anxiety taking care of the patient alone caregiver perception of patients fatigue and having a religion other than christian or being atheist remained independently associated with high subjective caregiver burden to create a simpler model we performed both backward and forward selection strategies and different cutoffs as described in the methods section using the different strategies we identified a final model that included 4 variables we found that caregivers with depression had 245 odds of reporting high subjective burden than caregivers without depression and that caregivers with anxiety had 249 odds of reporting high subjective burden compared with those without anxiety we also found that caregivers who took care of the patient alone had 273 odds of reporting high subjective burden than those who had help finally we found that the odds of high subjective burden among caregivers increased 131 times per each 1 point increase in caregivers perception of patient fatigue using the lr test we found that a simpler model was nested under the larger model suggesting that the final model is more parsimonious and therefore better to estimate the usefulness of this model we estimated its sensitivity and the specificity to predict intense caregiving burden the sensitivity of the model was 48 and the specificity was 90 the positive predictive value was 69 and the negative predictive value was 79 the area under the roc curve was 078 indicating that the model had a good discrimination capacity discussion this study reveals that fcs of advanced cancer patients from a latino community experienced highintensity subjective burden which is associated with increased objective burden such as taking care of the patient alone as well with caregiver psychological distress and caregiver perceived patient fatigue this finding adds to current literature demonstrating that caregiver burden intensity is not only associated with caregiver psychological distress but also independently associated with objective measures of caregiving burden highlighting the relevance of these 2 components in the experience of fcs our proposed model has good discriminatory capacity and has a high specificity allowing the model to identify fcs with lower probability of highintensity subjective burden in a highrisk population to our knowledge this study is the first to find these associations in an advanced cancer population in latin america in our study most of fcs are female and firstdegree relatives similar to what has been described elsewhere prevalence of burden observed in this study is also consistent with previous global evidence showing that the proportion of fcs who reported high levels of subjective burden varied from 35 to 56 these results confirm that this population share a common experience with fcs around the world we also report that a large proportion of fcs experience a considerable objective burden of care including an extended period taking care of the patient taking care of their loved ones in a daily basis and with lengthy daily schedules and most of them actually living with the patient interestingly we find that objective burden is higher among fcs who did not have someone to share caregiving responsibilities with and this association remains significant in the multivariate analysis this finding is related with a report by park and colleagues who observed in a korean population that fcs of cancer patients who shared caring responsibilities were less likely to experience the negative aspects of caregiving we also observe a nonsignificant trend in the univariate analysis showing that providing care during a considerable number of hourssuggesting a high level of caregiver engagement could also influence caregiving burden experience the proportion of fcs reporting a considerable objective burden of care reflects that this is a homogeneous population which may have challenged our ability to find other associations between high subjective burden of care and other objective burden variables these results together suggest that it is likely that intense caregiving burden is underreported in this population as only a third of fcs are categorized as experiencing highintensity burden although individual variables related to objective burden are much more frequent latinos have strong family relationships in which providing care to both healthy and sick relatives is considered a part of it reporting caring as burden could be seen as not loving their family member or could also being experienced as guilt studies on chinese population also show the protective factor of filial piety against the level of subjective burden another hypothesis could be that other factors besides objective burden could influence the experience of care literature from dementia patients suggests that the caregiving experience whether it is perceived as a burden or not is influenced not only by objective factors such as patient symptoms or the intensity of the caregiving demands caregiving was also influenced by more qualitative factors such as the quality of prior relations the meaning attributed to caring and the experience of reward in taking care of a loved one literature among fcs of cancer patients addressing this phenomenon should be studied in the future another concerning finding in this study is that most fcs have not had training in caregiving skills this shows that fcs are disregarded by the healthcare system even when they are a cardinal part in it besides experiencing objective burden this population does not have support in improving their abilities to take care of their loved ones exposing them interventions in caregiving skills social support or respite care could be possible alternatives to support this vulnerable group fcs with symptoms of anxiety and depression are more likely to report a highintensity subjective burden of care similar findings were noted in several previous studies only one publication has reported this finding in people from latin america it is well known that cancer is a highly stressful event which may constitute a traumatic stressor for many people including family members therefore psychological problems in fcs of advanced cancer patients such as depression and anxiety could be increased due to high intensity of care needs and a dramatically increased use of formal services at eol patient symptoms such as fatigue drowsiness depression anxiety and poor wellbeing and caregiver perception of those symptoms are also associated with high subjective caregiver burden this is in line with findings from previous studies in pc it is common that patients experience various physical and psychological symptoms therefore fcs who assume the task of interpreting and monitoring patients status reported a considerable burden high levels of burden is associated with fcs whose patients reported poor qol this finding contrasts with a german study by krug and colleagues in which caregiving burden was not associated with a decrease in patient qol it is known that qol of advanced cancer patients is directly related to the number of symptoms and the possibility of improving symptom control it is possible to hypothesize that burden of care increases as fcs realize that regardless of the activities performed none of them improves qol of their patients during the eol some authors indicate the importance of understanding reciprocal suffering in the caregiverpatient relationship this supports the idea that all efforts of pc teams should focus on the dyad rather than the patient or caregiver separately one novel aspect of this study is the proposal of a model to identify fcs with high burden this model includes the presence of depression anxiety taking care of the patient alone and caregiver perception of patient fatigue the presence of any or more than one criterion in each caregiver increases their likelihood of experiencing highintensity burden as the model has a good specificity it can be thought of as a diagnostic rather than a screening tool all these findings are relevant for latin american countries as caregiving is usually performed by family members who lack support from public institutions from the community or other family members and therefore is commonly underrecognized as a health problem highlighting this issue in the region could contribute to increasing awareness of its frequency and impact in this population to reveal its relevance as a health issue in the public discussion and promote the implementation of policies to prevent this experience before burden becomes critical limitations of this study must be noted first this study involves secondary data therefore the study was not powered to detect associations with specific variables of note the unequal distribution of the sample sizes of the main outcome could have decreased the ability to detect other statistically significant differences regardless of this limitation we were able to detect some difference between the groups making these findings relevant second the crosssectional nature of this research does not allow us to suggest causality however the exploratory nature of this analysis allows us to generate new hypothesis for future research third all patients recruited to this project were receiving pc in a single public hospital thus our findings should not be generalizable to all chilean or latin american population in summary fcs of advanced cancer patients enrolled in a pc unit from a public hospital in santiago de chile experience high burden of care frequently which is independently associated with caregiver anxiety and depression lack of help with caregiving an indicator of objective burden and fcs perception of patient fatigue these findings suggest the need of psychosocial support to fcs to improve mental health outcomes and decrease caregiver burden it also suggests that strategies should be implemented at the institutional level to better support fcs to prevent or decrease burden of care competing interests none

pérezcruz pe 2023 objective burden caregiver psychological distress and patient religion and quality of life are associated with highintensity burden of care among caregivers of advanced cancer patients in a latino population palliative and supportive care

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introduction health inequities must be analyzed from the angles of critical epidemiology and intersectionality in a simultaneous totalizing and dialectical manner therefore a joint effort must be made to appreciate the richness contained in the transversality of gender social class occupation ethnicity and spatial position in the social determination of health power relations permeate the entire framework that determines inequities in society in an intersectoral perspective overflowing their effects on the health levels 1 2 3 in the case of gender and ethnic differences in the productive insertion it is necessary to take into account the qualification and discrimination levels which are reflected in the design of positions salaries and institutional hierarchies against a patriarchal and racist society determining the genderimposed role choices it is known that the discrimination factors in the world of work are greater in relation to gender than to ethnicity as the latter suffers a more profound type of discrimination related to education and qualification which has its roots in social and power relations of the historically constructed slave society 45 the ideal society for the capitalist system to function is the patriarchal society with the white man exercising control over others including nature 67 incidentally from the point of view of socioenvironmental determination the capitalist accumulation system is characterized by exhibiting an oppression exploitation and expropriation model with consequences for health the right to health becomes increasingly frail with the commodification and privatization of essential services previously provided by the public sector increasingly fraying the social fabric on which it is anchored 8 9 10 intersectionality on the other hand is based on the understanding that we are shaped by the interaction of distinct social positions which occur in an environment and power structure context such as laws policies governments social institutions religion and media through these processes independent forms of privilege and oppression are created under colonialimperialism racism and patriarchy 11 these relationships are expressed from the very conception of the right to health and its respective implemented health policies to health access and actions favoring or hampering its promotion prevention and recovery 12 moreover the time period required for inequity to manifest itself in population health levels would be of five years with a peak at seven years and decreasing after twelve years 13 in the perspective of understanding how inequities germinate in the brazilian socioenvironmental space and that of the state of sao paulo we start out from its socioeconomic background which is marked by a dependent model of capitalism some of its characteristics are the distancing of the internal productive structure from the workers collective needs the workforce overexploitation and the premature wearing out of workers with low wages and local taxes that are more advantageous to central economies 14 regarding the state of sao paulo brazil which accounts for 3193 of the brazilian gross domestic product 15 its development model with decentralized industrialization since the 1970s has brought many benefits but also many contradictions we point out that the cities of campinas and ribeirão preto benefited from industrial and agroindustrial development in a more equitable model bringing wellbeing to the countryside with smaller agglomerations than those surrounding the capital city thus the model developed in the metropolis was quite harmful to its surroundings which despite achieving high success rates in education failed to distribute its income in an adequate manner those regions that grew in a complementary way to the capital city had its advantages as long as they were not too close where the model acquired serious contradictions and generated dependencies 16 including health care to analyze how the social determination of health is inscribed in the territory of the state of sao paulo it is necessary to understand the configuration of the brazilian unified health system in networks and regions aiming to guarantee the principles of universality integrality and equity the brazilian health system is a dual system with a public health system denominated sus free and universal which is 32 years old and coexists with the private sector in a complex dynamic with 75 of its population depending solely on the public sector despite its principles of universality integrality and equity it struggles with reduced health financing and a rather insufficient proportion of public expenditure less than half of brazils total health spending as a proportion of gdp of 8 17 the sus regardless of its chronic lack of funding has greatly improved the populations health conditions ensuring increased access to health services altogether and specifically to primary care 18 this is due to the fact that it offers an important proximity to the local population with a great amount of capillarity especially in its primary health care services it has also greatly increased ambulatory and specialized procedures although being constantly threatened by privatepublic provision arrangements which try to shift its healthcare model and do not relieve the public system these arrangements depict the articulation between three complexes the medicalindustrial the medicalfinancial and that of support services contributing to further increase inequities in funding access and utilization of health services 17 the sus regionalization process has been going through different phases since its implementation which took place rather late and slowly but with considerable advances it is important to emphasize that the current phase derives from the implementation of ordinance n 42792010 and decree 75082011 with successive changes in network and region conceptions until they reached the health care networks in negotiated and contracted regions this pact occurs between the government levels and brings greater flexibility and gains due to scale with resources bounded to thematic networks extrapolating health regions and reconfiguring them aiming to reduce disparities in the provision of health services but also bringing about the need for finer adjustments between levels 19 in 2011 the criteria and strategies for the construction of regionalized health care networks were gathered in the state of sao paulo based on the sufficiency of primary medium and part of high complexity care population between 1 and 35 million economy of scale and maintenance of the territory of previously constructed health regions and their assistance flows they are characterized by their complex design which combines homogeneous services in heterogeneous areas considering thematic networks and the diversity of institutions and actors in addition to conflicts between regions fragmented in their equality or united in their differences with major governance challenges 20 considering the different sus network and region conceptions we realize that the main sociospatial and access inequities in health care were addressed nevertheless health levels inequities were completely disregarded therefore the mismatches between efficiency effectiveness and equity were thoroughly experienced during this process moreover the relation between these concepts is complex and specifically for brazil few studies on local health efficiency have been carried out nearly twothirds of the efficiency studies performed globally 21 were about productive technical or scale efficiency in health services furthermore these kinds of efficiency analyses with the frontier methods seek a more organizational view whereas effectiveness and allocative efficiency stand on a programmatic level very few studies were based on health systems and to our knowledge even fewer were developed on local health systems or on a systemic level which includes health equity as a crosssectional dimension as examples of wellfounded studies at the local level we point out that of sousa et al 22 who presented efficiency scores about general services in brazilian municipalities marinho 23 who analyzed the efficiency of the provision of health services in municipalities in rio de janeiro and souza et al 24 who sought to assess the productive efficiency of the public hospital sector in the cities of são paulo stochastic and nonstochastic efficiency frontier methodologies were used combined with regression models as well as bootstrap and jackknife methods in order to reduce the effects of outliers there are also studies focusing on primary health care which attempted to differentiate the relative efficiency of health actions and health outcomes in brazilian municipalities 25 and relate efficiency to the view of health professionals in order to assess health promotion in selected municipalities in minas gerais 26 in addition to the small number of brazilian studies that specifically address health efficiency in addition to simply testing the methodology or working particularly on productive technical and scale efficiency most of them address aspects more focused on health service outcomes and not health system outcomes at the local level the aim of this article therefore is to assess the role of equity in health in determining societal health levels in a local effectiveness and efficiency analysis of brazils sus among sao paulo state municipalities hence we intend to strengthen the analysis of the association between social inequities and vulnerabilities and the effects experienced in health and in life taking into account the particular organizational design of sao paulo state method in order to assess local health efficiency in a comprehensive equityconcerned framework the following dimensions were considered material and financial resources products and services of health production and intersectoral variables this selection allows evaluating the efficiency of input resources at health levels with technical and allocation efficiencies combined as well as productivity in health and effectiveness associating health intermediate results to its final impacts 27 the effect variables considered were life expectancy at birth and infant mortality for all the statistical models the variable selected to measure inequity was chosen in a intersectional perspective associated with inequity by gender and ethnicity from a socioeconomic and cultural point of view along these lines other intersectoral variables tested were inequity by ethnicity in the proportion of vulnerability and unemployment from the governance perspective the municipalitys transparency index was evaluated according to an instrument of the federal prosecution ministry unlike most international panels there is no solid set of indicators in this area much less at the municipal level from the environmental point of view variables related to basic sanitation were tested such as water supply waste disposal and the existence of sanitary sewage the time period considered was ten years with observations ranging from 2000 to 2010 for all municipalities with data available for the studied variables the divisions used were the rras and its respective health regions in the following locations great sp santos and registro sorocaba bauru marilia presidente prudente araçatuba and são josé do rio preto ribeirão preto and surroundings piracicaba campinas and são joão da boa vista and taubaté these divisions allowed grouping the municipalities according to their health care structure and the possibility of gains in scale historical and cultural heritage with a greater diversity than merely geographical divisions better discriminating the differences between groups the techniques applied were the fixed effects panel data model and the data envelopment analysis in a dynamic and network slackbased model 28 in addition to a correlation analysis between methods the chances of improvement in the final results and their impact on health are presented such as the potential years of life gained and the reduction in im rates referenced by the municipalities that were benchmarks for efficiency it is important to note that while the fe model has a dual utility of presenting an effectiveness analysis in a temporal fashion coupled with efficiency the dea particularly the dynamic and network model used allows for assessing efficiency considering all stages of the production of health in a dynamic timedriven manner the fe model admits the following premises each locality has its own characteristics that could influence the dependent variables some aspects of the unit can bias or weaken the interpretive power of the variables and control for this effect is mandatory the fe model controls the timeinvariant attributes of the independent variables so that it permits a net effect interpretation the locality specific effect was obtained by the sum of the municipality fixed effects and its residuals which apply to inefficiencies at its upper limit softening the effect of unknown variables and errors in measurement 29 another relevant assumption is that these unique timeinvariant attributes are specific to the municipalities and do not correlate among them stata se 101 software was selected to perform the analysis of the fixed effects panel models the following equation allowed for the complete models y it β 0 β 1 x 1 it • • • β k x kit γ 2 ε 2 • • • γ n ε n δ 2 t 2 δ t t t µ it where y it is the dependent variable where i unit and t time x kit represents the independent variables β k is the iv coefficient µ it is the error term ε n is the n unit γ 2 is the unit coefficient t t is the time δ t is the timerelated coefficient for each dependent variable the bivariate association with the explanatory variables in addition to the multivariate modelby dimension and for the complete setwas obtained by means of the fe method additional tests were performed the hausman test which permits to contrast the fe with the random effects model and the heteroscedasticity assessment of variance constancy the next step was to obtain the specific effects for each municipality as the sum of its fixed effects and residuals as a post hoc analysis the complete model includes the efficiency gains values benchmarked by the most efficient municipalities the main advantage of the network dea model is its multiple stages analysis which surmounts the usual restrictions of the static models and leads to a greater correspondence to actual systems 30 consequently in order to be considered efficient the decisionmaking unit must be efficient in all of its production phases moreover this technique enables revealing inefficiencies in a nonradial mode this method assumes intermediate products to be produced and consumed inside the dmu whereas inputs and outputs are external to its structure the network model offers efficiency indices calculated at each point besides the overall efficiency indices the maxdea 8 ultra software was chosen for the network slack approach the outputoriented model with k stages was considered with the following equation 1 τ 0 max σ k k1 w k 1 1 r k ∑ h ∈ f k t k h h0 z h0 subject to z o z λ k s o z λ h z λ k s o ≥ 0 where w k is the relative weight of each section f k is the set of phases with connection points ∑ k k1 w k 1 w k ≥ 0 s k are the product slack vectors r k is the number of outputs at point k t is the number of intermediate results in the connection between phases k and h s o slack vectors at the connections and z stands for the intermediate products for leb the resource variables considered were average income and proportion of vulnerability and those related to inequity were measured by means of education and income differentials by gender and ethnicity as intermediate products we selected breast cancer screening the proportion of newborns whose mothers had at least seven prenatal visits and the proportion of caesarean sections we also tested intersectoral variables such as aging unemployment and illiteracy rates as well as the proportion of adolescent mothers and water supply in the case of im the same variables were tested in addition to the proportion of children aged zero to five years out of school and people without electricity access after analyzing the health impacts derived from the efficiency models through the potential years of life gained and the reduction in infant mortality rates we proceeded in relating them to the levels of different aggregate variables such as health and education levels opportunities living conditions and social vulnerability and equity further detailed analyses were performed with the visualization of são paulo state maps displaying the different levels of the effect variables among regions and municipalities as well as the health impacts obtained through both methods and the equity variables spearmans nonparametric correlations tests were performed to compare the techniques regarding impact results for both dependent variables results the statistical models the effects on health levels the results obtained through the bivariate analysis of the fe panel model demonstrate that the financial resources had more significant results than the physical ones the health production dimension on the other hand had little participation in determining the results for the set of municipalities in order to decide which variables were to be tested for the distinct dimensions as well as the complete set model we selected the relevant variables from the bivariate analysis the aggregate results in table 2 depict that genderethnicity inequities in education as well as income distribution unemployment illiteracy and aging rates were significant for both effect variables in the intersectoral dimension with the latter remaining in the final model of the leb variable together with the social vulnerability and environmental variables such as the proportion of adolescent mothers on the other hand the im variable included ethnicity and workrelated income inequalities in association with social vulnerability and intersectoral dimension variables such as the proportion of children out of school both models reached high values of r 2 close to 80 a relevant finding related to the financial resources dimension is that the gdp per capita and the density of nurses proved to be determinants of im whereas only the vulnerability variables were important for leb regarding health production screening for breast and cervical cancer in addition to the proportion of caesarean sections and of newborns whose mothers had at least seven prenatal consultations were decisive for both effect variables but with a very low r 2 of around 5 in the environmental dimension water supply and electricity access appear respectively as relevant variables for leb and im regarding governance it is worth noting that the variable related to transparency did not remain in the final models among the dimensions the intersectoral one showed the highest r 2 values close to 80 followed by physical and financial resources close to 70 we should emphasize that some variables were significant only at the bivariate analysis not persisting in the final models such as per capita health expenditures derived from local tax revenues the proportion of gdp related to services the gini index and the distribution of income by quintiles dependency ratio proportion of the population dependent on the elderly proportion of the population with at least one disability variables related to the municipal human development index and its components in addition to those related to social responsibility for a complete view of all variables tested in the bivariate analysis please consult the supplementary tables s1s3 a first glance at the health impacts derived from the models the final models equipped us with the health impacts and offered us a first glance at the potential years of life gained and the reduction in the infant mortality rates across the regions figure 1 below shows the potential years of life gained in leb according to the regionalized health care networks it can be observed that the distributions obtained according to the fe model were more rigorous and showed higher values than in the dea model including more localities displaying extreme values it is noteworthy that the mananciais region exhibits proximate distributions for both methods figure 2 then shows the potential reductions in the im rates for the rras unlike leb the distributions showed higher values in the dea model than in the fe model the best results according to the fe model for both effects were observed in greater sp in registro and santos and taubaté the worst ones are in the capital regarding life expectancy and in marilia for infant mortality this is due to an imbalance in the distribution of wealth and education in these places with the worst inequity results even with high wealth or proportionally with less wealth but also with an unequal distribution especially in relation to education reflected both in the high rates of illiteracy and in genderethnicity inequities with the dea model the best results for life expectancy were found in campinas while the capital had the best results for the infant mortality rate while the worst results in life expectancy were found for the alto tietê regionrras 2 and the worst infant mortality rates were found in sorocaba rras 8 wealth and education in these places with the worst inequity results even with high wealth or proportionally with less wealth but also with an unequal distribution especially in relation to education reflected both in the high rates of illiteracy and in genderethnicity inequities with the dea model the best results for life expectancy were found in campinas while the capital had the best results for the infant mortality rate while the worst results in life expectancy were found for the alto tietê regionrras 2 and the worst infant mortality rates were found in sorocaba rras 8 when the stages of health production in the dea methodology were analyzed there was a substantial reduction in efficiency demonstrating that health care did not contribute to the final health results as expected when considering the health production variables a lot of efficiency is lost and in this case the best results are from presidente prudente in relation to leb and from the capital for the im rate whereas the worst ones are in the capital this time for leb and araçatuba for the im rate the efficiency averages were generally higher for leb with smaller disparities than the im rates considering the discrepancies in the efficiency indices between the effect variables they ranged up to 40 pp between the two variables in some locations regarding the regions araçatuba and ribeirão preto and adjacent areas were the ones with the smallest differences followed by sorocaba and bauru at the opposite direction greater sao paulo had the biggest differences putting it all together further views and synthesis after analyzing the differences between regions and its rankings on both health impacts and selected aggregate variables we verified five distinct typologies for the regions first of all the least efficient locations are those that although presenting better levels of health living conditions and education exhibit high social vulnerability medium opportunities and large inequities in income and education by gender and ethnicity such as the capital city of sp and part of its surroundings demonstrating that health care did not contribute to the final health results as expected when considering the health production variables a lot of efficiency is lost and in this case the best results are from presidente prudente in relation to leb and from the capital for the im rate whereas the worst ones are in the capital this time for leb and araçatuba for the im rate the efficiency averages were generally higher for leb with smaller disparities than the im rates considering the discrepancies in the efficiency indices between the effect variables they ranged up to 40 pp between the two variables in some locations regarding the regions araçatuba and ribeirão preto and adjacent areas were the ones with the smallest differences followed by sorocaba and bauru at the opposite direction greater sao paulo had the biggest differences putting it all together further views and synthesis after analyzing the differences between regions and its rankings on both health impacts and selected aggregate variables we verified five distinct typologies for the regions first of all the least efficient locations are those that although presenting better levels of health living conditions and education exhibit high social vulnerability medium opportunities and large inequities in income and education by gender and ethnicity such as the capital city of sp and part of its surroundings these regions in comparison to the capital have worse education levels and living conditions but higher equity levels or worse social vulnerabilities and opportunities but higher equity and education levels the central region of the state and the western fringe also showed great potential for improvement in efficiency exhibiting worse levels of living and health conditions but with less inequity of income and vulnerability and better opportunities but with worse levels of education with inequities regarding gender and ethnicity on the contrary the last typology includes the south vector especially to the southeast and the northwest vector especially to the west which show a better balance between these variables as well as the region of campinas and ribeirão preto for a complete view of the impacts in the health levels based on the efficiency models performed in all health regions and regionalized health networks in detail please consult the supplementary figure s1 we gathered that in all rras the municipalities that show the lowest efficiency rates and therefore the greatest potential for improvement are those with the highest level of vulnerability or inequities in addition to the existence of conflicts toxic economic development models workers overexploitation and environmental disasters showing an equivalence between the statistical methods employed we can observe based on the constructed maps that the distributions of the potential years of life gained are inverse to the average leb results that is in the opposite direction to the expected one the opposite happens to the distribution of the potential reduction in the im rates and its average results we gathered that in all rras the municipalities that show the lowest efficiency rates and therefore the greatest potential for improvement are those with the highest level of vulnerability or inequities in addition to the existence of conflicts toxic economic development models workers overexploitation and environmental disasters showing an equivalence between the statistical methods employed we can observe based on the constructed maps that the distributions of the potential years of life gained are inverse to the average leb results that is in the opposite direction to the expected one the opposite happens to the distribution of the potential reduction in the im rates and its average results most strikingly is the fact that the lower the inequities the greater the efficiency as for the theil index distributions we may note a closer similarity to the dea results we also tested the correlations between the results of the applied methods for the variable leb the results were only satisfactory 0532 for the im rate this correlation was significantly higher reaching 0803 figure 3 distribution map of potential years of life gained in municipalities in the state of sp fixed effects note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 3 distribution map of potential years of life gained in municipalities in the state of sp fixed effects note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division source created by the authors based on the performed regression models and the efficiency analysis note the above score results from the ranking among the rras equity variables derive from the distribution of general income work and ethnicity and the distribution of education by gender and ethnicity highlighting the worst regional distributions vulnerability variables refer to ipvs6 and the proportion of the population that receives 1 4 mw education variables derive from the literacy rate of nonadolescent mothers and of children aged 05 years attending school opportunities refer to employment and aging the ones related to living conditions refer to average per capita income and adequate sanitation paulo dea method note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 5 distribution map of life expectancy average results in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division paulo dea method note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 5 distribution map of life expectancy average results in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 6 distribution map of the potential reduction in im rates in the municipalities of the state of sp fixed effects note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 7 distribution map of the potential reduction in the im rates in the municipalities of the state of sp dea method note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 6 distribution map of the potential reduction in im rates in the municipalities of the state of sp fixed effects note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 6 distribution map of the potential reduction in im rates in the municipalities of the state of sp fixed effects note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 7 distribution map of the potential reduction in the im rates in the municipalities of the state of sp dea method note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division distribution map of the potential reduction in the im rates in the municipalities of the state of sp dea method note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 9 distribution of genderethnicity educational inequity in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division most strikingly is the fact that the lower the inequities the greater the efficiency as shown in the inequity maps of the level of education by gender and ethnicity and the overall and work income theil index the intersectional educational inequities exhibit a very close resemblance to the fixed effects impacts for both effects as for the theil index distributions we may note a closer similarity to the dea results choropleth maps consisting of six divisions using the following limitsminimum value 5th pe centile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval th number of municipalities their mean and standard deviation are described the hist grams contain bars proportional to the number of localities in each division figure 9 distribution of genderethnicity educational inequity in the municipalities of the state sp note choropleth maps consisting of six divisions using the following limitsminimum valu 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each inte val the number of municipalities their mean and standard deviation are described th histograms contain bars proportional to the number of localities in each division of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 10 distribution of inequity regarding overall income distribution in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 11 distribution of inequity regarding work income distribution in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division discussion the models and techniques what do they tell us health equity from a critical perspective is essential in order to attain good final results for society whereas the balance between wealth and its equitable distribution undoubtedly influences health efficiency its most relevant aspect lies within the tripartite equity weaving the categories of social class gender and ethnicity 1 especially in comparisons under the same general framework such as the local health system analysis we performed the municipalities with the best health results were not always the most efficient ones this occurred exactly because of the gap regarding the variables related to equity especially the difference in education between gender and ethnicity this is a more structural variable than simple income differences 4 such as theils indexes tested overall and workrelated income it is noteworthy that intersectional equity did not achieve the figure 10 distribution of inequity regarding overall income distribution in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 10 distribution of inequity regarding overall income distribution in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division figure 11 distribution of inequity regarding work income distribution in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division discussion the models and techniques what do they tell us health equity from a critical perspective is essential in order to attain good final results for society whereas the balance between wealth and its equitable distribution undoubtedly influences health efficiency its most relevant aspect lies within the tripartite equity weaving the categories of social class gender and ethnicity 1 especially in comparisons under the same general framework such as the local health system analysis we performed the municipalities with the best health results were not always the most efficient ones this occurred exactly because of the gap regarding the variables related to equity especially the difference in education between gender and ethnicity this is a more structural variable than simple income differences 4 such as theils indexes tested overall and workrelated income it is noteworthy that intersectional equity did not achieve the figure 11 distribution of inequity regarding work income distribution in the municipalities of the state of sp note choropleth maps consisting of six divisions using the following limitsminimum value 5th percentile 25th 50th and 75th percentiles 95th percentile and maximum value for each interval the number of municipalities their mean and standard deviation are described the histograms contain bars proportional to the number of localities in each division we also tested the correlations between the results of the applied methods for the variable leb the results were only satisfactory 0532 for the im rate this correlation was significantly higher reaching 0803 discussion the models and techniques what do they tell us health equity from a critical perspective is essential in order to attain good final results for society whereas the balance between wealth and its equitable distribution undoubtedly influences health efficiency its most relevant aspect lies within the tripartite equity weaving the categories of social class gender and ethnicity 1 especially in comparisons under the same general framework such as the local health system analysis we performed the municipalities with the best health results were not always the most efficient ones this occurred exactly because of the gap regarding the variables related to equity especially the difference in education between gender and ethnicity this is a more structural variable than simple income differences 4 such as theils indexes tested overall and workrelated income it is noteworthy that intersectional equity did not achieve the same importance in our previous analysis of efficiency at the global level 31 which allows us to assume that the local level is the ideal locus for these differences to gain visibility in our models health care did not explain efficiency enough which showed a high association with the intersectoral dimension this is because municipalities are being compared within the same health system although exhibiting locoregional differences they were not differentiated in the model with the healthcare variables tested this may also be due to not assessing healthcare utilization according to the populations needs which would maybe unveil these differences on a local scale 3233 on another note we did not find a relationship between financial resources and health levels in the overall models on the contrary they were strongly related to the dimension of health production or were only present in the dimension of resources for the im variable however inequity and vulnerability were strongly related to health levels in this sense biggs et al 34 indicated that the positive association between material living conditions and health levels revealed itself only when reduction or stabilization of poverty and inequity were also present interposed by leb and im demonstrating they were effect modifier variables the differences observed in the results were due to the fact that the fe method showed an imbalance in the distribution of wealth and education in the assessed locations whereas in the dea the differences were due to the wealth and results already achieved in large cities which are more valued by the method even with high levels of inequity therefore they should both be used as they depict different complementary aspects especially at the local level examples of economic development models in sao paulo the state of sao paulo produced a unique invention in its decentralization and regionalization process in the sense of integrating the concepts of network and region in a rras promoting the integrality of health care units with universality and equity at its base the problem is that the territory brings inequities and social dynamics which are not always incorporated into the planning or its selected delimitations furthermore it involves multiple actors and institutions the state society and the market with particular interests therefore there are many extreme values in the analyzed distributions as the rras were not conceived for their equitable homogeneity but for geoeconomic and politicaladministrative issues in addition to sociocultural identities and the sharing of infrastructure communication and logistics networks 1935 the diverse historical and economic development as well as the predominant economic activity in the most efficient regions show great variations and we should concentrate and examine a couple of examples in order to illustrate the results it is above all important to highlight the contradictions found such as the promotion of arts culture and ecological tourism in the region of mananciais coexisting with a high proportion of districts with very high vulnerability and a large proportion of the population that receives less than 1 4 of the minimum wage housing shortage deforestation and irregular settlements and rural regions the ecoforest system activity in registro and the diversified economic development centers in taubaté using mediumhigh technology and the large offer of formal jobs in the oil and gas sector in santos but also surrounded by environmental conflicts related to the expansion of the port area and the presalt exploration the region of franco da rocha should also be underlined as it has the highest equity and scored well in efficiency close to mananciais mainly due to reaching both the lowest ethnicity income ratio and the theil index related to work income it is a region with tourism and secondary residences extractivism and cellulose but with high social vulnerability and many environmental disasters such as floods and landslides and precarious infrastructure and access and with a historical and symbolic molding related to the juquery psychiatric hospital it is also important to emphasize that the araçatuba region had the best result regarding the gini and theil indexes as well as in vulnerability followed by the presidente prudente region which shows however lower efficiency results mainly due to the high illiteracy rates the campinas and ribeirão preto regions showed intermediate efficiency results considering the high wealth and medium distribution with urban agglomerations resulting from their long and sustained growth and concentration of transport logistics and economy of scale they have also suffered some depletion of the capacity to radiate wellbeing as originally planned by regional development policies these contradictions between appearance and essence of the capitalist mode of production lead to the deterioration of the environment and manifest themselves in cognitive social and economic ways 36 the typologies on how social inequity and vulnerability interplay in the context of capitalism the different typologies observed in the state of sao paulo depict how the structural causes are important in determining the health levels we verified a strong imbalance between health and education levels and living conditions on one side and opportunities vulnerabilities and social equity on the other it is clear from our results that social sectors should be organized in such a way as to improve this balance rather than having its design based solely on administrative proximities we have found greater potentials for life expectancy improvements and infant mortality reductions exactly in those more developed localities that reached high average health levels but based upon income and work inequities and social vulnerabilities or on those less developed countryside localities with lower health and education levels and living conditions but with less social vulnerabilities and more opportunities our great concern is that these localities although with less overall inequities present themselves with more structural inequities such as gender and ethnicity on education and income levels it is crucial to understand how the concept of social vulnerability is inscribed in the dynamics of capital with the dominance of fictitious capital and green economy along with the large growth of the service sector constraining the spatial circuits of socioeconomic production according to critical geography 37 the superior circuit subsists on the inferior one which submits for fear of falling back into the sphere of complete exclusion as we have described social vulnerability is all the more present in the localities with the greatest health levels and living conditions though badly distributed or the medium levels of these dimensions but with a greater proximity to the central regions especially the capital in that sense we can observe two different situations being close to the capital and having at least the benefits of higher education levels although not of income and that of being depleted on education and income levels with important overall and work income inequities which is the worst scenario at the same time the socioenvironmental relationship is weakened by the intensification of use and depletion of the soil and workers exposed to pesticides and forced to abandon traditional and ecological forms of production in the countryside to favor a brutal model of indifferent extractivism and the commodification of what was obtained naturally from the soil in the past 3839 likewise the health sector commodification intensifies social vulnerability as what was offered in the past to workers to improve quality of life has been decreasing greatly 10 encompassing a slower growth on health levels and a poorer distribution of its benefits to society 40 the pendular movement of the brazilian internal bourgeoisie also helps us understand this dynamic of imperialist capital occupying an intermediate position between the former national bourgeoisie and the buying bourgeoisie class associated with imperialism their social position oscillates between dependence and contradiction with foreign capital accepting the subordinate place in the international division of labor and always keeping their interests above all on the expanded reproduction of capital without any socialization of risks despite accepting to be dependent on the state and public funds 41 the relation between social position and inequities found in our study were mainly due to ethnicityoriented income inequities overall and from work currently the productive capital is an increasingly smaller part of the system dominated by financial capital mainly the fictitious one which by the hand of the market and the state makes promises to investors through financial collateral arrangements and public debt bonds expropriating the workers future according to fontes 42 the flight forward through state indebtedness on a delusional scale means the commitment of the states themselves in a direct manner with the exacerbation of the future extraction of value thus if currently the premature exhaustion of the workforce does not imply a decrease in the average life expectancy the quality of life and health has dropped considerably as well as the full consumption capacity generating situations of social vulnerability 14 our results embrace this concept as we have noted that the highest average results in life expectancy occur exactly in the most unequal localities along with high levels of social vulnerability social vulnerability must be understood within its historical and social dimensions as a deprivation of the power to act to demand the guarantee of social rights and to take care of ones health within a logic of relations of oppression domination stigmatization manipulation and exclusion with socioeconomic and civil aspects moreover it is accompanied by an ideology of blaming the socially frail without taking into account their capacity for resistance and change crosssectioned by gender ethnicity and social class relations 1243 we have found that gender and ethnicity related inequities in educational levels and income inequities affect local health efficiency greatly within the logic of serving the financial capital and justifying fiscal adjustment measures regardless of social vulnerability an efficiency study was carried out by the world bank 44 using the dea methodology to evaluate the efficiency of brazilian municipalities according to the levels of attention and the macroregions the key finding that phc is efficient in terms of productivity but not performance demonstrates the underutilization of its potential to improve equity moreover it contends that the secondary and tertiary levels are less efficient due to the small hospitals which do not have an economy of scale but are located in more remote regions promoting equity in access these considerations show the contradiction of the study that proposed a fair adjustment with equity and efficiency regarding public spending the analyses were not controlled by intersectoral and crosssectional equity variables and it was finally proposed to increase phc productivity with more procedures reducing the costs with small hospitals totally contrary to the sense of universal access and integrality which go much beyond the procedures and the economy of scale the lack of an equity adjusted model and of an effectivenessoriented analysis failed to produce a fair adjustment altogether in contrast in our study both methods showed that the municipalities with the highest degrees of inequities associated or not with social vulnerability exhibited the lowest efficiency indices not attaining its full potential for health effects we would like to point out that extreme poverty and selective social policies particularly for the health and education sectors have also been established as essential causal mechanisms in the association between social inequity and health levels 45 as well as livelihoods and structural material and symbolic conditions especially the educational level acting independently going far beyond the per capita income at the local and global level 46 therefore we must look for new ways to measure the final impact results on peoples lives and health far from the usual measures of quality of life or happiness we need new measurement tools that can apprehend the contradictions contrasts wearing out and above all the sinuous crosssectional movements within the categories in which we are all stratified 11 study limitations it was not possible to assess the governance variables except for the mpf transparency index for a future study a proper way to do so would be to study the effectiveness of the action of municipal health councils in the monitoring and inspection of health actions which would be a more objective way of evaluating governance and the prevention of corruption in the health area 47 there are very few brazilian studies on efficiency at the municipal level and the few that have been carried out were related to efficiency in public management in general 22 or related to the technical efficiency of hospital health services 2324 or primary health care 2526 what we proposed was to define the efficiency of local health systems which was in part hindered by the fact that all municipalities belong to the same health system on the other hand due to local heterogeneities regarding the intersectional aspects it was possible to apprehend differences in social inequities and vulnerabilities as much as the authors have tried to encompass the different dimensions of real life we know that no method is capable of reconstituting the totality our effortin this study was to look through the openings catching a glimpse of the gaps and potential of the methods used to unveil existing mechanisms and contradictions as stated by nietzsche we wanted to stir up what was previously considered motionless to fragment what was thought to be united to show the heterogeneity of what was imagined in conformity with itself 48 conclusions in view of our findings we demonstrated that structural issues are essential in the association between equity and efficiency and that intersectionality along with its implications on health effectiveness may be more comprehensively understood at the local level furthermore the contradictions in the capital of the state of sp revealed that overcoming mortality in the first year of life does not guarantee living longer and better in this urban space where wealth and vulnerability opportunities and unemployment coexist the cost to society is extremely high perverse and cruel considering the chasm between the small average increments in life expectancy which only a minority will be able to enjoy and the precarious living and health conditions of those who sustain such gains this happens exactly because the logic of capital has extended itself to all social relations and dominates all aspects of life these inequities are also reproduced inside the organizational arrangements of health actions and services in sp as the expected equity was projected at the level of access to health and not the final results this is an intersectoral aspect that should sensitize health managers along with public local authorities in providing adequate local services and implementing public policies for improving living conditions as well as tackling the existing social vulnerabilities and inequities offering employment opportunities and adequate environmental conditions in order to permit a thriving society it cannot be stated in any way that the most efficient regions are the ones with the best living conditions but that they are social spaces that use their resources in a more distributive way therefore we can verify the importance of intersectional equity for achieving efficiency and effectiveness in local health systems which is related to the choice of different political options of economic development models radiating wellbeing comprehensively or concentrating it for only a privileged few supplementary materials the following supporting information can be downloaded at table s1 results of the bivariate analysis fixed effects model for the variables life expectancy and infant mortality resources health and intersectoral dimensions sao paulo municipalities 2000 and 2010 description all variables tested initially in the fixed effects bivariate analysis can be consulted in these tables according to the physical and financial resources the health production and the intersectoral dimension note that only some variables were directed to the initial multivariate models table s2 results of the bivariate analysis fixed effects model for the variables life expectancy and infant mortalityintersectoral dimension sao paulo municipalities 2000 and 2010 table s3 results of the bivariate analysis fixed effects model for the variables life expectancy and infant mortalityhealth production dimension sao paulo municipalities 2000 and 2010 figure s1 potential years gained in life expectancy at birth and reduction in infant mortality rates regionalized healthcare networks and health regions comparison between methods description this file depicts the number of potential years gained in life expectancy at birth and the potential reduction in infant mortality rates calculated with both techniques used permitting comparisons between municipalities within health regions data availability statement the datasets used during the current study are available from the corresponding author upon reasonable request the consulted data sources are open to public access and can be reached at the following websites ibgebrazilian institute of geography and statistics 9662censodemografico2010html toquee datasussus information technology department sesspsao paulo state health department seadestate system foundation of data analysis mpffederal prosecution ministry siopspublic health budget information system serhistmunicipioindicadoreshtm stnmfnational treasure departmentministry of finance all data analyzed during this study are included in this published article

health equity is cross sectioned by the reproduction of social relations of gender ethnicity and power the purpose of this article is to assess how intersectional health equity determines societal health levels in a local efficiency analysis within brazils unified health system sus among sao paulo state municipalities fixed panel effects model and data envelopment analysis techniques were applied according to resources health production and intersectoral dimensions the effect variables considered were expectation of life at birth and infant mortality rates in 2000 and 2010 according to local health regions hr and regionalized healthcare networks rras inequity was assessed both socioeconomically and culturally income education ethnicity and gender both methods demonstrated that localities with higher inequities income and education gender and ethnicity oriented associated or not to vulnerability young and lowincome families in subnormal urban agglomerations were the least efficient health production contributes too little to health levels especially at the local level which is highly correlated to the intersectoral dimension intersectional health equity reinforced in its intertwining with ethnicity gender and social position is essential in order to achieve adequate societal health levels beyond health access or sanitary and clinical efficacy

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background there has been a reported inextricable connection between peoples behaviours and their environment therefore macro and microecological phenomena influence behaviours including alcohol consumption among diverse groups and populations consequently environmental and personal behaviours that influence alcohol consumption could be contextualized in terms of the social ecological model indeed and in the context of this study the model accounts for multiple correlates associated with alcohol consumption among the youth urie bronfenbrenner coined the ecological model in 1974 to explain the role of familial and other social contacts in child development since then the model has been expanded and used by scholars from different disciplines in examining multitudes of behaviours among populations of interest the model for example could be employed in examining social media use among the youth and alcohol consumption for this paper alcohol consumption means the use of beverages containing alcohol as an ingredient alcoholic beverages in this case were taken to mean beers wines and spirits previous studies have used the social ecological model in examining decisions and behaviours of diverse groups of people hickey harrison and sumsion for example used the model in explaining career choices of nursing students other studies applied the model in examining alcohol consumption although mainly among adult populations and without clear regard for the microsystems such as religion and gender as primary contexts for alcohol consumption two studies for example applied the model in examining alcohol consumptionrelated decisionmaking and in assessing the relationships of demographic and personality characteristics another study adopted the model in explaining harmful alcohol consumption in delta state nigeria the gruenewald remer and lascala study that considered demographic characteristics as the present study did was unable to single out adolescents as a point of focus yet adolescence as a developmental period is one stage most likely to be influenced by the human ecological systems into alcohol consumption and other maladaptive behaviours based on the ecological model we asked what are the sociodemographic correlates of consumption of alcoholic beverages among adolescents in public secondary schools in uganda as earlier typified this paper anchors on the social ecological model to explore the prevalence and ecological correlates of alcohol consumption among adolescents the social ecological model is reliable in explaining complex behaviours such as alcohol consumption the paper considers a social ecological discourse as it manifests the various levels with which adolescents interact and potentially influence their drinking behaviours for instance the microsystem of the ecological model could explain variables such as gender involvement in places of entertainment use of social media friendship dynamics and level of studying against alcohol consumption while measures such as brief interventions have been in place to address youth drinking less is known about the application of contemporary theoretical frameworks in remedying alcohol use among the youth in schools in developing countries possibly the social ecological model would serve as an addition to the available options for advocacy against youth drinking and better prioritize demographic antecedents in the prevention of alcohol consumption the ecological spaces notwithstanding alcohol consumption is identified as responsible for the estimated increase in the global disease burden consequently alcohol consumption especially among the youth remains one of the key health concerns moreover alcohol consumption is hazardous at the most formative stage of adolescence often in the context of a developing country like uganda alcohol consumption has resulted in hazardous and negative outcomes including increased road traffic injuries erosion of sociocultural norms involvement in risky sexual behaviours premature death poor health interpersonal violence and selfharm in the face of the negative outcomes of alcohol consumption among adolescents there is no known study using the socioecological model to examine alcohol consumption among adolescents in uganda moreover as kabwama et al among the youth but only considered vulnerable groups like those living in slums and fish landing sites other studies were conducted among the general population notably abbo et al considered demographic correlates of alcohol consumption among secondary school students however their study considered only two districts kampala and gulu therefore using the social ecological theory to explain the consumption of alcoholic beverages among the youth in public schools was necessary the present study is anchored on a socioecological model to explore the prevalence and identify protective and risky demographic correlates of alcohol consumption among secondary school adolescents the socioecological model posits that individual and environmental variables account for alcohol consumption among students the model comprises five layers within which interaction occurs the microsystem mesosystem exosystem macrosystem and chronosystem the fifth layer may not be applicable in examining correlates of alcohol consumption with crosssectional data therefore this study is anchored on the first four layers of the ecological model the concern here is that alcohol consumption among the youth is manifold to the extent of drawing from social and environmental influences to that end correlates of alcohol consumption among students mirror individual interpersonal institutional communal and societal echelons particularly for the interaction between individual students the first and second levels seem relevant in examining alcohol consumption among students issues of age gender religious affiliation and practices and the way these antecedents interact with students socioeconomic and neighbourhood spaces contribute greatly to expounding alcohol consumption among students therefore in the context of the socioecological model this paper underscores students age gender religious affiliation and friendship involvement in places of entertainment use of social media and form of students classes as possible correlates of alcohol consumption among students by and large characteristics of students serve as a basis for adducing differences among alcohol consumers regarding prevalence and as previously noted alcohol is the leading substance of abuse among adolescents in uganda in fact in a smallscale study abbo et al found that the most common substance used among students in kampala and gulu districts was alcohol the who global schoolbased student health survey reports that 128 of the students in uganda had at least one alcoholic drink on one or more days during the past 30 days however the survey lacked pinpointing ecological correlates of consumption of the different types of alcohol other studies point to the prevalence of alcohol consumption as superseding the use of other psychoactive substances in schools among developed and developing countries for instance alcohol consumption is highly prevalent among students in the united states in a study conducted by fuhr fleischmann riley kann poznyak current alcohol consumption was highest compared to current and lifetime drug use in their study regarding alcohol consumption and treatmentseeking behaviour among young people in sydney australia lea reynolds and dewit found that 83 of their participants consumed alcohol crooke et al in addition to the prevalence reported above students characteristics form a significant component of protective or risk factors for alcohol consumption kabwama et al identified that regionally ugandans from the central and western regions were more likely to be medium to high drinkers compared to their counterparts in the eastern region however according to tumwesigye kasirye and nansubuga qeios ccby 40 • article december 4 2023 differences in drinking contexts were mainly attributable to social interactions especially among different social classes in a study to review psychosocial risk factors for alcohol consumption donovan reports that only two studies examined age as a predictor of alcohol use initiation in a comparable context rodham hawton evans and weatherall found clear gender differences in alcohol consumption among adolescents more males than females reported drinking the studies recorded above however were lacking in consideration of adolescents in secondary schools likewise most studies in africa and beyond only consider age and gender as the correlates influencing alcohol consumption among adolescents key and informative demographic areas like students level of study and religious background are not accounted for by previous studies largely religious inclination and faith tend to influence youths decisions to consume or not consume alcohol church attendance in childhood is presumably protective against the early onset of alcohol consumption and the later development of alcoholrelated problems moreover evidence is available that youths who identify themselves as being strongly committed to particular faiths are less likely to consume alcohol in the study to establish grade differences in alcohol consumption lakew et al found significant findings although the results were nonsignificant in multivariate models further evidence shows that weekly alcohol consumers in the us constituted about oneseventh of drinkers in the 9th grade but onefourth in the 11th grade in echo with ahlström and österberg most studies regarding alcohol consumption among adolescents are situated in developed economies as earlier recounted most studies in uganda adolescents in public schools in uganda this study was instituted to examine ecological phenomena after a considerable number of ugandanbased reports underscored alcohol consumption for psychosocial challenges among adolescents in schools the present paper considers a sample from four geographical regions namely northern western central and eastern uganda notably uganda is an amalgam of multitribal and multicultural societies the present study premises on an understanding that each of the regions is a unique locality with atypical sociocultural settings with that in mind students in their respective regions show diversity in alcohol consumption in relation to demographic attributes diversity in students backgrounds and school dynamics is the primary basis for our anticipation of the association between select sociodemographic correlates and alcohol consumption the secondary school system in uganda consists of three distinct categories in the first category are schools founded by religious entities and aided by either the founding bodies or the government on behalf of those entities in the second category are schools founded and run by individual private investors the third category the schools regarded in the study as public secondary schools were purposely considered and drawn from ugandas capital city kampala and ten other major towns the schools considered by the present study were owned and managed by the government this category of schools was considered based on a number of their unique characteristics for instance the schools were historically established to provide affordable education to urban poor children as such they were located in the periphery of major towns across uganda further students in these schools were mainly nonresidents that implies that students in those schools constantly and freely interact with the rest of the society where alcoholic beverages are mainly found most of the students involved in this study were adolescents with an age range of 13 to 20 all students above the age of 20 were hence regarded as emerging adults although the mention of emerging adults for a study in schools sounds odd clarification needs to be made that the status of most public schools in uganda considers a universalised education system the school system allows students beyond school age mainly from poor families to access free education therefore finding students well above the age of 20 in ugandan schools is not surprising design this was a cross sectional study a cross sectional design enabled collection of large dataset at a single moment in time further with this design we were able to consider many attributes of students at ago quantitative techniques were used for data collection and analysis quantitative techniques were used to generate objective and more generalizable results the technique of using quantitative tools and randomized processes removed bias from the dataset of the study and ensured reliable observations further a quantitative approach enabled statistical generalization of our findings to the entire population of students in public schools measures participants completed a selfadministered questionnaire the instrument was administered in classrooms or other convenient places within the schools the instrument contained items to capture students demographics including region 2003 on conducting school surveys on drug abuse specifically students were asked whether they had consumed each of the alcoholrelated substances in the previous 12 months for instance students were asked for the previous 12 months how frequently have you taken beers the initial items regarding alcohol consumption were based on a likert scale carrying five responses namely 1 never 2 rarely 3 sometimes 4 often and 5 very often responses to each of the items were transformed into a binary scale response category 1 was dummied to denote no or never used and the other categories of 2 3 4 and 5 were dummied to denote yes or ever used that was done to generate a response pattern suitable for the computation of prevalence rates and to compare alcohol consumers and nonconsumers the items were written in simple language to improve interpretability among students from different classes and schools names of local brews of alcohol in different regions of uganda were included in the questionnaire as synonyms for respective items based on data provided by the national care centre for instance local names for spirits were given as enguliwaragikasese names of locally made alcohol were included to improve the validity of the responses generated during the analyses alcohol consumption items were dummied to consider students who consumed one or more types of alcohol polyalcohol consumption sample selection part of the sample and sampling technique described in this paper is reported elsewhere nevertheless the sampling strategy was thought out and coined after consideration of the distribution of public schools across the geographical space to that end the sample was obtained by first clustering schools within their respective regions thirteen schools were purposively and then proportionately sampled three from each of the northern western and central regions four schools were sampled from the eastern region purposive sampling considered only coeducational urban schools proportionate sampling was used to strike a balance between kampala city which had many schools and other towns that had one school each the sampled schools emerged from kampala city and the following towns entebbe in the central region jinja mbale soroti and tororo in the eastern region gulu moyo and arua in the northern region fort portal kabale and mbarara in the western region the number of students in all schools was obtained using proportionate sampling the overall sample was obtained using leslies method of sample size determination samples from their respective classes were obtained using simple random sampling each student present in the classroom was given a number and then the numbers were selected at random a total of 1982 participants were sampled to participate in answering the questionnaire however 1819 returned the completed questionnaires making a response rate of 918 data collection took place mainly in classrooms however in some circumstances other places eg school compounds and laboratories were used to avoid the distraction of school activities inclusion and exclusion criteria all students in senior two and above present at the time of data collection were eligible for the study students absent from school at the point of data collection were excluded from the study the study items asked about the experience of alcohol consumption within the previous 12 months of secondary school life therefore senior one students were excluded from the study data analysis data were first entered into ibm statistical package for the social sciences version 200 and then exported to stata version 150 for analysis missing values were excluded using listwise deletion descriptive data were summarized and categorized in terms of frequencies and weighted percentages to correct for sampling errors the weighting of data was based on students region of origin and age as a clustering variable the prevalence of consumption of the different types of alcohol was explored using descriptive statistics percentages were used to report the prevalence of consumption of beers wines and spirits the statistical significance of the proportions of alcohol consumers was examined using chisquare pvalues descriptive statistics of the study sample are presented in table 1 analyses were set at a 5 confidence interval associations of the students sociodemographics with the consumption of beers wines and spirits were explored using bivariable and multivariable logistic regressions all covariates were entered into the multivariate model as they were all plausible correlates of alcohol consumption the models were adjusted for students age and region of origin part of the technique and data reported in this paper have been previously considered elsewhere results this paper anchors on the socioecological model to expound on the prevalence and demographic correlates of consumption of alcohol among adolescents in public secondary schools bivariable and multivariable logistic regression among the participants included in the analyses the majority were males had 2 or more friends liked visiting places of entertainment and were very religious the overall prevalence of the consumption of beer was 2793 lower extent of religiousness somewhat aor 16 95 ci 127212 p 0001 and not religious aor 25 95 ci 125499 p 01 was associated with a higher likelihood of beer consumption additionally students who identified as loving places of entertainment were twofold more involved in beer consumption regarding the consumption of wines it was established that the overall prevalence of wine consumption was 3756 the independent sociodemographic determinants of wine consumption were religious affiliation loving places of entertainment and use of social media students of roman catholic religious affiliation had a higher likelihood of wine consumption compared to muslims and pentecostals in addition a lower extent of religiosity was associated with a higher likelihood of wine consumption additionally students who loved being in places of entertainment were twofold more involved in wine consumption however students who often used social media were 16 times more likely to be involved in wine consumption compared to those who did not the prevalence of consumption of spirits was 1808 the sociodemographic correlates of consumption of spirits were gender religious affiliation religiosity love of being in places of entertainment and use of social media the likelihood of consumption of spirits was 07 times lower among females compared to males compared to students from the roman catholic affiliation there was a lower likelihood of consumption of spirits among students affiliated with other denominations moreover a lower extent of religiousness was associated with a higher likelihood of consumption of spirits additionally students who liked being in places of entertainment were more than twofold more involved in the consumption of spirits regarding the use of social media students who often used media were 16 times more likely to be involved in the consumption of spirits compared to those who did not after excluding the nonconsumers it was found that students who consumed more than two types of alcohol were 8538 the sociodemographic correlates of polyalcohol type consumption were religious affiliation religiousness and use of social media compared to students from the roman catholic affiliation there was a higher likelihood of polyalcohol type consumption among other religions moreover a lower religiousness was associated with a lower likelihood of polyalcohol type consumption somewhat aor 07 95 ci 047091 p 05 not religious aor 05 95 ci 016130 additionally students who often used social media were less likely to be involved in polyalcohol type consumption discussion the aim of this paper is to use the socioecological model to expound on the prevalence and sociodemographic correlates of alcohol consumption among school adolescents percentages and logistic regressions were used in achieving the study objective in the results consumption of wines and beers was higher compared to the use of spirits the findings may not be surprising as the students considered in this study were largely in urban and day schools moreover alcohol is readily available to ugandan youth both in local brews and industrially following the abundance of different types of alcohol the who gshs survey among students in uganda approximates that 128 of the students had at least one alcoholic drink on one or more days during the past 30 days thus the rate was expected to be a little higher in a study conducted a decade later probably the result that consumption of alcoholic beverages was high could imply that students get access to highdensity alcohol outlets in their localities which sell both regulated and unregulated beverages production of locally made alcohol in uganda is practically not regulated as many youths turn to alcohol consumption it has previously been reported that many homesteads ferment and distil local brands from the abundant fruits the variations in religious affiliation and students alcohol consumption come after a fair body of literature relating religion and alcohol consumption among the youth for instance previous studies show that religious inclination and particular faiths tend to influence youths decisions to consume or not consume alcohol accordingly studies show that attendance at church during childhood was protective against early onset of alcohol consumption church attendance further protects the youths against later development of alcoholrelated problems consequently youths who selfidentified as having strong commitment to particular faiths were evidently less likely to consume alcohol alternatively students could be accessing alcohol through cultural rituals and ceremonies consumption of church wine for example is well ritualized among christian faithful and often alcohol is integrated into religious ceremonies notably the findings could be located in the socioecological theory of alcohol use according to the theory individual students behaviours interact with the institutions where the adolescents belong churches and their ritualized ceremonies may not be the exception all the same the present studys findings on the prevalence of alcohol consumption are supported by similar studies elsewhere accordingly alcohol is the most consumed substance among adolescents in developing countries and in highly developed countries in the neighbourhood of uganda kenya othieno ofulla support the present studys results reporting that alcohol consumption among students was most prevalent similar studies predict that alcohol consumption among adolescents is higher than the consumption of other drugs the results regarding sociodemographic correlates of alcohol consumption were significant at both the individual and institutional ecological levels adjusted logistic regression models show significant gender differences in the consumption of beers and spirits but not in the consumption of wines in addition males had higher odds of consuming beers and spirits gender differences in alcohol consumption have been reported previously rodham et al found that more males than females reported drinking hahn et al also found significant gender differences in current hazardous and nonhazardous drinking male students were more likely than females to report drinking although only by a relatively small margin kabwama et al found that in comparison with their female counterparts males were more likely to be medium and high alcohol consumers the findings regarding gender could be explained based on socioecological theory at the nucleus of the socioecological model students microcharacteristics including gender define differences between males and females and between individuals of a particular gender as well moreover the model seems to account for the way the microsystem nurtures different genders hence the difference in the consumption of alcoholic beverages however the present studys findings contradict those of wu et al in their study to establish correlates of protective motivation theory to adolescents drug use intention nevertheless the present studys results affirm previous studies in revealing that being male was a risk factor for alcohol consumption the female gender on the other hand was protective against alcohol consumption relatedly manyike et al found that male students were about six times more likely to use psychoactive substances than females in fact manyike and colleagues pointed out that the male gender and living in hostels were associated with alcohol consumption the present study however significantly differs from the preceding report as we did not consider living in a hostel as a risk or protective factor the differentials in gender could be attributable to the first level of the ecological model for instance differential parenting interpersonal and institutional norms might nurture drinking more in males than in females further differentials in significant findings were found in the exploration of religious affiliation and religiousness with regard to alcohol consumption in terms of the social ecological model of alcohol consumption religion as an institution and part of the mesosystem predicts or protects students against alcohol consumption it explains the interaction between the innermost of a student and the factors in the surroundings related to alcohol consumption on the other hand religiousness is reflected in the inner self of the students and represents core values that protect against or promote alcohol consumption institutional ecological factors compare with vantamay the study found that students in muslim and pentecostal dominions were less likely to consume beers wines and spirits than their catholic and anglican counterparts roman catholics in particular had higher odds of alcohol consumption than any other religion the result that roman catholics were more likely to consume alcohol than other religions conforms to common practices and previous literature practically some religions such as pentecostals unequivocally loathe the consumption of alcohol among their faithful to the end of the islamic faith the consumption of alcohol is strictly taboo islam is generally considered to have strong proscriptive norms against the consumption of all types of alcohol the roman catholic church on the other hand neither condemns nor discourages alcohol consumption among the faithful that could be the reason why compared to other religions more students who identified with the dominion were more likely to consume alcohol than students could indeed evidence shows that youth who prescribe to the roman catholic dominion are at a greater risk of falling victim to alcohol abuse and associated problems on the other hand belonging to the muslim dominion is protective against alcohol consumption furthermore stafström and agardh in their study to assess socioeconomic determinants of alcohol consumption among ugandan university students found that being a muslim was negatively associated with alcohol consumption however stafström and agardh made a rare observation that male muslims were at a significant risk of engaging in monthly heavy episodic drinking an observation the present study was unable to adduce loving to be in places of entertainment and using social media significantly predicted alcohol consumption in terms of the socioecological model the two correlates explained alcohol consumption at the level of interaction between the students and the exosystemic environment indeed activity in places of entertainment could be accompanied by alcohol consumption and other social behaviours therefore it is likely that those adolescents who love such places could be drinkers as well moreover students who go to places of entertainment have high chances of meeting their peers who influence them towards drinking in addition it could be possible that students who use social media interface with alcoholrelated messages that stimulate students drinking as several studies have suggested generally the socioecological model explicates the significant study results in terms of the variables in the immediate and extant student environment limitations like many other surveys the present study does not go without setbacks in the first instance the study relies on selfreported experiences from students we recommend that future studies use more detailed measures of alcohol consumption among students in public schools such as quantities of consumed types of alcohol and frequency of alcohol for the present study some of the dynamics of the socioecological model such as familial influence were not given attention due to the nature of the dataset hitherto the influence of the family dynamics such as family type family structure psychosocial family environment and family socioeconomic status could be predictive of alcohol consumption among young people further in using the socioecological model for this study the influence of peers and groups were partly studied the frequency of meetings with friends for example and consumption of peers could have been significantly associated we recommend that future studies explore such factors in sufficient detail conclusions the social ecological theory could account for the correlates of alcohol consumption among students individual studentlevel factors and institutional factors expound on alcohol consumption among the students specifically gender religion religiousness loving to be in places of entertainment and use of social media significantly predicted alcohol consumption among students genderspecific and religiousrelated interventions could mitigate alcohol consumption among students implications significant study findings on the consumption of different types of alcohol bear educational and adolescent mental health implications the results may demand benchmarking ecologically specific advocacy against alcohol consumption in schools in comparison with the socioecological model the study results imply that the alcohol industry could include not only the producers of alcohol but also a large network of distributors wholesalers bars and advertisers therefore interventions for inschool youth drinking may need to be developed by benchmarking with and involving institutions at different levels of the ecological model such as religious institutions healthcare services media and village councils moreover gendered models could be explored to have some genderspecific messages that bring out the negative consequences of youth drinking further the genderspecific messages could focus on the differential effects of drinking among girls and boys statements and declarations national council ratified institutional approval for science and technology under number ss 3423 and the office of the president of the republic of uganda at data collection students consent was obtained using the approved institutional review committee consent form version number 13 for students under the age of 18 their respective school head teachers provided consent on behalf of their parents competing interests we declare no competing interests regarding the authorship of this research and the content reported herein authors contributions ar conceived the study idea collected and analysed the data and wrote the manuscript for publication gk guided the writing of the concept data collection and analysis she participated in the writing of the manuscript am participated in writing the discussion of results and reviewed the final manuscript

introduction consumption of alcohol among the youth could be attributable to sociodemographic characteristics this paper anchors on the socioecological model to expound on the prevalence and sociodemographic correlates of alcohol consumption among adolescents in public secondary schools specifically the model was used to explore gender religious affiliation form or class of study social media use friendships and involvement in places of entertainment as possible predictors of alcohol consumptionwe employed a crosssectional survey with quantitative methods the sample comprised 1819 participants yielding a 918 response rate males were relatively more numerous 593 and the mean age was 173 sd 19 bivariate and multivariate logistic regressions were employed to deduce the association of selected demographics with the consumption of beer wine and spiritsthe prevalence of alcohol consumption was generally high multivariate logistic regression showed a significant gender difference in the consumption of beer and spirits females had lower odds of consuming beer and spirits students in the muslim and pentecostal dominions were less likely to consume beer wine and spirits than their roman catholic and anglican counterparts students in the roman catholic dominion had higher odds of consuming any type of alcohol compared to other religions loving to be in places of entertainment and the use of social media significantly predicted the consumption of beer wine and spiritsat the multivariate level some socioecological factors could account for differential alcohol consumption among the students individual studentlevel factors such as gender and the institutional factor of religion could explain alcohol consumption among the students specifically gender and religion were significantly associated with alcohol consumption it is recommended that ecological differences and gendered models are considered as part of the interventions for inschool youth drinking

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introduction suicide is a significant global public health problem with nearly one million suicide deaths reported worldwide annually and is the second leading cause of death among adolescents and young adults aged between 15 and 29 years a similar study noted that actual suicide attempts have become more prevalent among young people and are the main signals of further suicidal risk while suicide is also a national concern in china there is a dearth of culturallyrelevant research particularly in assessment and intervention for years suicide prevention programs have been difficult to formulate as no single risk factor could predict suicide with great accuracy it pertains even to common proposed risk factors such as suicidal ideation which still could not consistently or independently predict suicide behaviour suicide behavior has been included in the classification systems of mental disorders specifically the diagnostic and statistical manual of mental disorders as a psychiatric compilation that requires further study a diagnosis of suicide behaviour disorder would require meeting all the following five diagnostic criteria within the last 24 months the individual has attempted suicide on at least one instance the act does not meet criteria for nonsuicidal selfinjury the diagnosis does not apply to suicidal ideation or preparatory acts the act was not carried out during a state of delirium or confusion and the act was motivated by purely political or religious objective notably this proposed diagnosis entails the importance of the individuals intent in defining suicidal behaviour and the individuals expectation that the sequence or set of actions could potentially lead to their own death thus it also differentiates from another nonsuicidal selfinjury additionally kendler et al highlighted potential antecedent risk factors or criteria concurrent criteria suicide risk assessment as part of the suicide risk assessment suicidal ideation and suicide attempts are two significant factors suicidal ideation refers to thoughts and desires to end ones life this ranges from relatively passive ideation to active ideation past research in community settings showed that youth typically reported suicidal ideation at a moderate frequency with intensity ranging between mild to moderate frequency a suicide attempt is an action motivated to end ones life a classical threestep theory of suicide asserts the role of pain in understanding suicide it theorizes that the combination of pain and hopelessness is vital for developing suicide ideation which a lack of social connectedness would aggravate this theory construes suicidal ideation and behavior as distinct research indicated that frequent intense and chronic suicidal ideation is related to subsequent suicide attempts due to this intertwined relationship suicidal intent and suicidal ideation are two main assessment areas in psychometric instruments for suicide risk assessment it is essential to review some risk factors pertaining to suicide such risk was found to be greater in males than females similar to the general suicide cases another prominent finding was that the level of increased risk was related to the history of suicide attempts and more so when there was a familys psychiatric history further clinical depression symptoms were salient risk factors especially for more severe psychopathology a sense of hopelessness and suicidal ideation tendencies likewise suicide with coexisting disorders was associated with higher risk including substance misuse for specific alcohol and drugs anxiety and personality disorder notably suicidal ideation and prevalence increase sharply during the teenage years such suicidal ideation persists even after youths hospitalization over onethird of adolescents who reported suicidal ideation they eventually attempted suicide another research showed that young adults with suicidal ideation are estimated to be 12 times more likely to attempt suicide by the age of 30 it is notable that the majority of teenagers with suicidal ideation would eventually attempt suicide within 12 years of such suicidal ideation onset and they are commonly characterized by specific clinical issues particularly depression or dysthymia other studies have also documented that suicides cases between 98 years and have become more and more common by 1519 years these findings pointed out the role of social and emotional processing in the development of suicidal thoughts which could lead to suicide behavior indeed the role of suicide intent on eventual suicide is more significant than previous attempts or a sense of hopelessness thus it has been recommended for the measurement of suicide intent be included in clinical practices for suicide at the same time clinical depression appears to be a key precursor to suicide it is therefore essential to elucidate the relationship between major depressive disorder and suicide further such development warrants the urgency and pertinence of developing effective assessment and intervention asian culture and collectivism a review of risk factors for young adults suicidality highlighted that psychiatric or mental disorders coupled with a prognosis of suicidal behavior and suicide are significant predictors of suicide behavior and mortality by suicide it also further argued about the role of social and interpersonal factors in understanding and predicting suicidal behavior most research on suicide risk assessment adopts an individualistic and deterministic view of human psychology and behaviour nevertheless bronfenbrenners ecological model posited the role of 1054392ajir2333 multiple ecological contexts in shaping an individuals wellbeing and indeed evidence has suggested the importance of the biopsychological model in accounting and conceptualizing the dynamic nature of suicide behavior interpersonal theory of suicide outlined the suicidal risk as a combination of frustration or lack of social connection and a sense of low selfworth and perceived burdensome this further suggested that suicide entails a relational and social element in this paper the focus would be on risk assessment in the context of asian society particularly in china this is an area of interest as there has been a high suicide ideation rate and incidences among chinese in recent years recently there is a sharp increase in report cases of depression and suicide in asian population particularly in overseas chinese societies like singapore which have seen fast industrial and economic development the quest to assess and prevent suicide have not been effective particularly among youth and children as they are not proactive or less vocal in reporting their suicidal risk hence their parents and guardian often overlook the potential risk to their children thus it is essential to adopt a culturallyinformed and relevant approach in formulating assessment instruments and in understanding suicide youth face the developmental task of developing their identity through individuation and independence from their family such emotional autonomy was found to be related to depressive symptomatology unlike westerners asians strive for integration instead of individuation therefore social approval and concern over interpersonal relationships would be key areas in influencing depressive symptoms and suicidal risk in chinese societies influenced by confucian heritage culture students face societal pressure to excel academically crosscultural research suggested that western youth have more interest in pursuing individuation and romantic relationship as compared to singaporean adolescents the high value in socialoriented achievement such as academic competence and cognitive skills related to academic achievement would be significant in shaping chineses mental wellbeing hence the development of a culturally relevant instrument for mental welling and suicide would take into account the manifestation and phenomenological experiences which are shaped by adolescents developmental and culture tasks during adolescence the individual is facing the challenge of developing his unique identity through individuation and becoming independent of his family chou also found that depressive symptomatology was associated with 2 aspects of emotional autonomy ie individuation and deidealization of parents in a collectivist asian society where the emphasis is on integration rather than individuation we questioned if identity formation would become a challenge to asian adolescents and lead to depression on the other hand since others are of high importance in the selfconstruct of collectivist asians we speculated that concern over selfother relationships might be a critical concomitant of depression for asian adolescents adolescents in asia especially in the confucian heritage cultural communities such as japan taiwan hong kong and singapore also face tremendous pressure for academic achievement a study comparing stress and coping in singaporean and american adolescents found that academic pressure was the most frequently experienced stressor for singaporean adolescents in contrast to american adolescents who were more concerned over romantic relationships and individuation from parents we therefore proposed that concerns over academic competence and the cognitive skills related to academic success or failure might be significant for singaporean adolescents depression is a condition whose manifestations and phenomenological experiences are intimately formed by the culture and the developmental tasks faced by adolescents having outlined the significance of a culturalrelevant perspective it is essential to examine how sociocultural influences the manifestation of depression symptoms behavior and potential suicidal development major depression is a psychological disorder with impairments in cognitive emotional and neurobiological domains several etiological models indicated that an amalgamation of developmental psychosocial neurobiological and genetic factors leads to major depressive disorder across cultures key symptoms of major depression are persistent low mood a sharp reduction in energy and interest intense feelings of worthlessness hopelessness and some reported excessive guilt these symptoms are observed crossculturally however subjective experiences and symptom presentation can vary across cultures and this could pose a challenge in assessing depression in nonwestern cultural groups it is postulated that the relationship between culture and depression is mediated by individuals selfconstrual the collectivistic nature of chinese communities entails relatively more interdependent selfconstrual and their idiom of distress were found to contain more symptoms regarding social aspects of the self in such culture social contexts are deemed as an integrative part of selfconstruct indeed the values and belief systems of a culture influence individuals goals and motivational efforts thus their psychological state would be influenced by interpersonal and social processes for instance the perception of a lack of parental support and peer acceptance are found to be predictive of depressive mood among hong kong chinese adolescents so it is meaningful to incorporate interpersonal elements of depression as these are culturally sensitive and relevant to depressive symptomatology however these constructs are often absent in most assessments developed in the west other sociocultural research found that asian tend to place less emphasis on affective symptoms instead they tend to present somatized complaints chang found that asian americans demonstrated higher salience for psychosomatic symptoms as compared to ethnic americans likewise east asian and asian american reported similar psychosomatic depressive symptoms but less affective or emotional symptoms other relevant sociocultural research suggested that guilt and shame appear to influence chinese suicidal tendencies several scholars have begun to highlight the salience of shame among asian americans due to its presence in several asian languages and parenting techniques and higher levels of shame experiences compared to caucasians the collectivistic nature of asian also influences their high need for social approval and desire to fulfill socially prescribed duties hence leading to a sense of shame when they are unable to meet social expectation wong et al conceptualized shame as an interpersonal experience which comprises two dimensions external shame and family shame research showed that external and family shame was positively correlated with depression and suicidal ideation but negatively correlated with selfesteem selfconscious moral emotions such as guilt and shame have been found to be particularly salient during major depressive disorder metaanalysis studies showed that those who reported high levels of shame were less effective in communicating their suicidal intent and often could not be understood when they seek help through indirect means studies in community settings and college students showed that shame was positively associated with suicide ideation similarly excessive persistent and inappropriate sense of guilt is considered as a clinical symptom of mdd particularly for melancholic subtype a recent metaanalysis showed that younger adults with current major depression reported higher levels of guilt as compared to older adults another research indicated that a sense of guilt was characterized by female mdd patients who had a history of suicide attempts past research also revealed that patients with current mdd reported significantly high levels of guilt development of a culturalrelevant assessment it is important to review the current suicide risk assessment scales in past research baek et al noted that selfreporting is the common method to identify symptoms related to suicide risk this is a common approach to screening suicide risk groups and interviews would be carried out to assess the severity of suicidal ideation such structured interview tool aims to minimize the subjectivity of experts judgment other researchers have investigated the factors predictive of suicidal behavior and found that major depression impulsiveness life events and sociodemographic factors thus it is essential to include major depressive disorder particularly culturally relevant factors in the development of suicide assessment instruments indeed there is a lack of consensus over diagnostic criteria an absence of culturally appropriate norms and a dearth of cultural validity in the assessment recent research examined the validity and reliability of a chinese language suicide screening questionnaireobserver rating assessment for children and youth however this research largely considered the linguistic equivalence of assessment scale items in chinese culture and did not integrate sociocultural relevant constructs such as major depressive symptoms interpersonal and psychosomatic constructs which had been found to be a precursor to suicide and predictive of suicide perhaps such inclusion would bolster the diagnostic capacity and improve the preventative effort as it reflects a shared asian cultural emphasis the aim of this theoretical paper is to develop a culturalrelevant suicide assessment scale with sound psychometric properties and incremental validity over previous instruments developed in the west incremental validity refers to the extent a scale confers predictive validity over existing scales kate et al and other research typically included becks inventory of depression and hopelessness with suicide risk assessment we argue that this might not be appropriate as these did not sufficiently consider the cultural experience and values of asians such as concern over interpersonal relationships psychosomatic manifestation emphasis on socially approved success such as achievement and developmental concern for social integration instead of individuation other research which attempted to adopt western scales in the past was mainly concerned with linguistic equivalence and translational issues but failed to take into account salient culturalsensitive and relevant nuances which would no doubt affect the effectiveness of the assessment measures the first part of the questionnaire would encompass the chinese suicide intent scale which has been validated in chinese society the study adapted and extracted 7 statement groups each assessing various aspects of suicidal ideation each statement group consists of three sentences that describe different intensities of suicidal ideation representing a threepoint scale the prospects are instructed to select the specific statement of each group that is most applicable to them with higher values indicating a greater risk of suicide we do not distinguish different degrees of suicidal risk nor set a cutoff criterion as even very low total scores can be associated with significant risks of suicide these items would serve as a screening instrument for suicidal ideation this scale would cover three factors precautions planning and seriousness for high variance and such high construct validity would provide the support that csis has sound psychometric properties thus it is a qualified and appropriate measure for assessing suicidal behavior in the chinese population unlike the previous studies done by gau et al and zhang and jia this study did not draw depressive symptoms items from beck depression inventory instead the study would include salient cultural factors from singapore depression scale and the asian adolescent depression scale for the asian depression scale this author has drawn two sociopsychological constructs as follows loss of meaning of life and affectivesomatic symptoms from the asian adolescent depression scale this author has also drawn the following cognitive inefficiency negative selfevaluation chang and koh s assessment of the psychometric properties showed that these constructs provide a more accurate assessment and more effectively capture the cultural experience of asians participants are asked to rate each item on the extent to which they generally feel on a fivepoint scale with higher values indicating a higher level of depressive symptoms in this study the asian suicide risk assessment comprises items from the chinese suicide intent scale and asian depression scale which fulfill the authors quest to develop a culturalrelevant questionnaire for his suicide risk assessment both scale items have been validated within the asian and chinese cultural settings and showed sound psychometric properties for assessment purposes as reiterated suicide and depression are sociopsychological phenomena that manifest within a culture beyond only striving for translation accuracy and linguistic equivalence this study bolsters the clinical utility by incorporating culturallyspecific and relevant constructs particularly interpersonal and social perception toward self and life purpose psychosomatization and cognitive efficiency indeed such a scale is vital and relevant in capturing the sociocultural suicidal and depressive experience integrating culturalrelevant depression assessment constructs it would bolster the predictive power of the instrument in capturing episodes of depressive thoughts which would inevitably lead to a sense of despair and hopelessness and eventually suicide in most instances thus it also confers further clinical utility in the aspect of earlier suicide detection and prevention asian suicide risk assessment scale instruction participants are to choose a particular statement out of 3 choices in each group that is most applicable to them scoring scheme for items 1 to 7 each item consists of three sentences that describe different intensities of suicidal ideation representing a 3point likert rating scale the higher the score the higher likelihood of suicidal tendency i objective circumstances related to suicide attempt ii asian depression symptoms instruction this section assesses depressive symptoms in adolescents and higher scores in respective depressive categories indicate the severity of the depressivesuicidal risk scoring scheme participants are asked to rate each item on the extent to which they generally feel on a 5point likert rating scale the maximum score is 90 with a cutoff score at 45 the higher the score the more depressive a person is with a higher indication of depressivesuicidal risk no conclusion the study adopted a culturalrelevant approach to developing an asian suicide risk assessment instrument it considers the role of sociocultural influence in shaping the manifestation and development of suicidal and depressive symptoms by drawing from instruments that have been validated within asian culture this study aims to formulate a culturally relevant scale that appropriately captures the cultural nuances thereby exhibiting greater clinical utility and incremental validity over present instruments generally speaking asians are less expressive and often take a more collectivistic stand this author proposed and included culturally salient factors such as affectivesomatic symptoms and interpersonal and socialoriented evaluation which were previously lacking in previous suicide risk assessment items in addition it included a developmentally salient factor that aptly characterizes young asians industrious nature and emphasis on achievement in career and academics with these the authors believe that it would be a versatile instrument to test for suicidaldepressive risks within asian culture

suicide is a serious social and psychological issue that has a devastating socioeconomic impact globally however it remains elusive as mental health professionals grapple to formulate effective assessment and intervention strategies particularly there is a dearth of culturalrelevant suicide risk assessment scales as most instruments were developed in western culture even with translation and linguistic equivalence present suicide risk assessment scales do not encompass culturally salient and relevant psychological constructs this study adopted a sociocultural approach to develop a suicide risk assessment with sound psychometric properties and also to capture the culturalspecific symptomatology of suicide as well as depressive asians

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background addressing gender inequality is recognized as essential to health and sustainable development gender inequality and early marriage are obstacles to womens life chances as they impact negatively on education and lead to early childbearing and increased risk of maternal and child morbidity and mortality 1 adverse consequences persist across the womans lifecourse and into the next generation perpetuating cycles of poverty and illhealth among the poorest in india marriage before age 18 is legally banned widespread efforts by both government and nongovernment organisations to curtail early marriage are helped by strong economic growth and increased education indeed the latest national family health survey in 2015 reports significant progress in delaying marriage and improving levels of education in urban maharashtra the proportion of women age 2024 years who married before age 18 dropped from 29 to 18 in 10 years the overall proportion of women with 10 years of education increased from 31 to 42 and is at 52 in urban areas 2 for marginalised slum communities conditions are less favourable with other structural inequalities compounding gender inequality gender norms are powerful pervasive beliefs about genderbased social roles and practices that are deeply embedded in social structures norms are produced by patriarchal powerrelations and maintained in part by selfsurveillance as girls follow internalised gender scripts in india gender norms produce outcomes that disadvantage girls and women norms reinforce womens caregiving and reproductive roles and limit their access to public space genderrelated scripts were found more significant than either economic rationales or womens empowerment in explaining variations in age at marriage across india 3 while empowerment theories have explored womens subordination within the household social institutions and the state they have paid insufficient attention to the symbolic aspects of gender 3 according to the performance theory of gender girls learn to perform gender roles and adopt gender identities that regulate social interactions and limit options including the freedom to move and be visible in public space 4 5 6 it shapes their choices in ways that continuously reproduce gendered pattern of behaviour in daytoday social interactions it is the visible display of gender that allows neighbours and communities to police womens actions the anticipation of social sanctions or rewards with the need for belonging and approval from the group is one of the key motivators for compliance 7 once a girl reaches menarche in india parents get concerned about demonstrating her good virtue an essential aspect for finding a good matrimonial match 3 good virtue requires modesty a deferential demeanour proficiency in household chores and above all sexual purity early marriage becomes part and parcel of the symbolic display of segregation modesty and chastity the supremacy of virginity means unmarried girls are in need of both restraint and protection limiting their access to public spaces 3 gendered power dynamics are embedded in space organised into the masculine public domain and the feminine private sphere 8 popular discourse associates womens safety with the modesty of her clothing with burkhas and salwar kameez designed to hide the female body from public view as custodians of family honour girls are socialised to fear not only potential violence in public spaces but also the threat of public censure that will impact her reputation 5 the fear of sexual harassment maintains male privilege diminishes womens feelings of safety and belonging in public places and restricts their freedom of movement 9 fear and social control significantly limit girls individual agency to access public space a structural barrier in any intervention aiming to increase female education and participation as citizens in society any emancipatory change among adolescent girls thus requires concurrent social change gender constructions can be challenged and redefined when performance of gendered identity transgresses established norms 10 where individual agency is largely constrained by structural factors social change starts at the level of social practices via changes in daytoday social relations that individuals and communities cultivate 11 there is very little detailed description and analyses of the subtle changes that occur when women contest discriminatory norms in gender programmes and this paper addresses this gap using research data collected in the context of an intervention that encourages the inclusion of young women and girls in public spaces parivartan change at play is a sportsbased programme among adolescent girls age 1216 implemented in a slum community in mumbai young women were recruited from within the slum community to serve as mentors to younger girls they were trained to lead reflection sessions on gender and to coach kabaddi a contact team sport they then delivered a carefully structured programme of life skills and gender training to younger girls interspersed with weekly games of kabaddi concepts from social norms theory 712 were used to shape the content and implementation of the programme to perform their responsibilities mentors needed to challenge mobility restrictions and negotiate their visibility in public space in this paper we focus on the change process among mentors noting how the programme enhanced their agency to strategize and negotiate greater freedom and visibility in their community we emphasize changes in daytoday social interactions at home and in public spaces methods study setting and design the parivartan programme was located in four plots at the periphery of shivaji nagar one of mumbais largest urban slums the community consists predominantly of muslim migrant families mainly from uttar pradesh working in the unorganized sector and living in substandard housing with poor water supply and sanitation the wards included in this study are near a dumping ground and some lanes are seen as unsafe because drug users frequently loiter there various ngos have been implementing a range of health and development projects including a sportsbased programme for boys increasingly community development programmes work at both the individual and community level men in the communities are mobilised mainly via the imams in the mosques and women via mahila mandals which are small groups of neighbours residing in the same lanes public spaces are dominated by men and after menarche girls mobility and visibility are restricted as is their interaction with boys burkhas or salwar kameez with headscarf are the requisite dress code outside the home apnalaya a grassroots ngo with longstanding presence and credibility in the community implemented the intervention the research was implemented by the international centre for research on women in collaboration with the strive research consortium we adopted a prospective qualitative research design to study the interaction between the intervention and the changing context within which it was implemented 13 case studies were done with 10 mentors and 15 girls during the implementation phase preceded by participatory research among girls mentors mothers and fathers at the design stage written consent to participate was obtained from all research participants sampling mentors for the intervention were recruited from within the slum with eligibility based on age and education as identified by apnalaya out of 40 applicants 15 young women were selected as mentors after three rounds of personal interviews to establish their interest in sports level of aspiration their commitment towards the programme and their position on the rights of women and girls they were coached on kabaddi mentorship and leadership skills and trained in a gender and gender equality curriculum during the initial 5day residential programme there were 4 more 2day workshops on using the intervention tools with their group of athletes all mentors were responsible for conducting two sessions per week with their group of female athletes the full programme consisted of a wellstructured curriculum encouraging reflection on gender expectations and myths human rights and life skills delivered over 15 months the tools designed for these sessions consisted of 21 card sessions presenting topics and 19 group education sessions with role plays and games to facilitate practice and reflection on issues introduced the previous week mentors received a monthly stipend of inr 3000 implementation challenges were discussed during weekly meetings with apnalaya staff who were available throughout the project to help mentors problem solve project staff placed special emphasis on helping mentors ensure their personal safety and that of their athletes data collection by the time the implementation of programme started five mentors had dropped out and the data used for this analysis draws exclusively on 2 rounds of facetoface indepth interviews with the 10 remaining mentors the interview guides were developed based on literature on gender practices in india and understanding of the community based on formative research guides for the second round were personalised with followup of particular issues of interest arising in the first round while keeping style of interviewing and issues covered consistent interviews were shaped around a semistructured interview guide with openended questions on gains achievements difficulties and challenges encountered as parivartan mentors safety and security commitment to and outcomes associated with their mentor roles freedom to move around in the community and relaxation of restrictions perceptions of changes in themselves and in the relationships with parents and caretakers and changes in those whose opinion the mentors valued in terms of their own behaviour all interviews were done by the first author at the icrw field office a comfortable and relaxing environment which enabled confidentiality at a time convenient to them interviews were digitally recorded transcribed and translated verbatim analysis we combined thematic and narrative analyses 14 the transcripts were reviewed and themes discussed continuously during data collection by the authors we followed a stepwise procedure of familiarising ourselves with the data identifying a thematic framework and developing a coding frame using atlasti for data management we also developed spreadsheets to explore commonalities and differences across mentors while ensuring that the context and integrity of each narrative was maintained across both data rounds we looked for patterns in how mentors negotiated space and exerted agency paying attention to the interactional context acknowledging that narrative identities are shaped and coconstructed between mentor and interviewer 14 interpretation was influenced by insights gained during observations in the community and during regular meetings with mentors for this paper we investigate the theme of mobility identifying how mentors negotiated the relaxation of mobility and visibility restrictions both at home and in the community we explore the extent to which the parivartan programme gave them the skills and opportunities to do so and how their personal history and circumstances may have impacted the trajectory of their transformation we also examine the various strategies mentors developed as a group to contest norms and the factors contributing to breakdowns and setbacks of achieved freedoms results profile of mentors table 1 gives the profile of the 15 mentors who enrolled as mentors and started the residential training this is a select sample of young women welleducated compared to their contemporaries in the slum with several pursuing a university degree mentor 1 and 5 were the only ones who had dropped out before finishing 12th class mobility restrictions had stopped mentor 4 from attending mainstream school after 10th class but she studied from home and sat 12th class exams though unfortunately failed mentors 10 and 14 studied at university level from home only mentor 11 was married at the time of recruitment and lived with her inlaws most other mentors lived with both parents except for mentor 2 whose parents had both died and mentor 10 who lost her father all families had previous contact with apnalaya some as active members of selfhelp groups while others had been beneficiaries of schemes including scholarships for childrens education mentors expressed different motives for becoming mentorsfor some it was additional family income for others it represented an opportunity to learn and come out of the house mentors 11 to 15 dropped out before the implementation started and were not interviewed for the case studies after the first day of the intensive training m11s family decided they could not deal with the logistics of caring for her small baby the time commitment required to recruit athletes far exceeded what m14 and m15 could accommodate given their study and work commitments two sisters m12 and m13 had to withdraw as they went to live in their native village variations and changes in mobility restrictions in shivaji nagar parents restrict the movement of young women through male public spaces and their behaviour is closely policed by neighbours and relatives any deviation from expected patterns raises suspicion about relations with men or boys and is interpreted by neighbours as a marker of bad parenting the severity of mobility restrictions depends on the purpose of the outing the time of day and the distance a girl travels going to school or work are considered valid reasons but leisure time with friends or acquaintances is not at night when it is dark and during the heat of the afternoon when streets are relatively deserted are times seen as especially unsafe the immediate neighbourhood is considered safer than places further away like markets and public transport which are associated with men and boys measures to protect a womans safety in public include sending an escort with her mostly an older relative though a younger brother is also acceptable the extent of mobility restrictions varied among mentors before and during the programme we summarize variation in restrictions for moving to various places by depicting whether she needed an escort at all times during unsafe times in afternoon and evening only after dark or not at all the graphic below visualises the variation in mobility restrictions before respondents began as mentors and 18 months later it demonstrates clearly that mentors were able to negotiate permission to move more freely on their own both to pursue programmerelated activities and beyond despite progress limitations remained mobility restrictions were reimposed upon those mentors who dropped out of the programme during implementation various demands came with the role of mentor with the need to move around in the community the most prominent one we analyse the programmes expectations and the challenges mentors encountered at sequential stages of training and implementation initial residential gender training at the start of the programme a 5day residential training on gender equality life skills and rights was held in a location outside the community staying away from home overnight predictably raised suspicion as expressed by one of the mentors i was not sure if i would be allowed to be out for this training as it was for 5 days and we had to stay there you know the people here talk so much about girls if a girl is not seen in the house for one night they come asking where is your daughter she is not seen they have nothing to do with it yet they will come and ask the mother or at least gossip with other women in the area this is bad… with this fear of bad name parents dont send their daughter out in the night to stay somewhere else this strong community policing of womens movement made negotiating mentors attendance difficult nevertheless for nine of the 15 young women invited to the training apnalayas credibility as a respected grassroots organisation engendered sufficient trust for the other six mentors apnalaya staff were involved in several levels of negotiation to persuade parents to let their daughter participate m6s mother was supportive but insisted that apnalaya staff sought permission from the father and the elder brother this took multiple home visits up to the last day before the training when the elder brother was available a long conversation was interrupted by the arrival of a visitor at which point the brother suddenly agreed and signed the consent form later that evening he forbade his sister to go as he had only agreed to avoid a discussion in front of visitors however m6 quietly left the house early in the morning while others were asleep letting only her mother know this resulted in an aggressive response from the father and elder brother banning the mother and younger brother from the home for three days upon her return home after the training they did not speak to her for several days yet m6 moved on to the next step in the programme recruitment of young girls spending 5 days and 4 nights together in a nonrestrictive environment provided a safe space for the young women to discuss and question mobility and visibility restrictions imposed on them while practicing negotiation skills to push boundaries another major outcome of the residential training was the building of strong personal bonds between the mentors a powerful resource of social support for the recruitment and implementation stages of the programme recruitment process of young girls into the parivartan programme a lot of the narratives on how mentors managed to push boundaries refer back to this period the recruitment of athletes involved obtaining consent from families a process that took much longer than anticipated mentors had to visit the families of the girls multiple times initially accompanied by apnalaya staff but later by themselves apart from contravening prevailing mobility norms these visits encroached on time spent on household chores both required negotiation at home while some parents asked their daughter to quit the programme as time commitments far exceeded what had been communicated to them the mentors stood their ground as mentors felt safer to move through the community in little groups they coordinated visiting the families together eventually the inconvenience of organising times resulted in them going on their own sometimes unbeknownst to the parents losing the safety of the group did feel uncomfortable and gave cause for anxiety they feared both harassment by men and boys and being seen by acquaintances and neighbours in areas where they are not expected to come on their own all 10 mentors reported being confronted with these issues but all came through adopting their own strategies to avoid harassment by men mentors approached their destinations through different roads or bylanes when alone actually the first time i went to xx without another mentor i was also very scared the entire area xx you will only see men around and to go through this crowd initially was a big challenge we had so we would get out through the internal lanes because we did not want to go through them this is how it worked for us for 23 months but now we can easily tell the men to move and we make our way through the crowd even when alone fig 1 variations and changes in mobility restrictions several mentors reflected on the constant negotiation with parents to counteract the effect of neighbours commenting on their movements through the community trust developed gradually through communication as the parents came to understand that the role as mentor demanded this level of mobility neighbours remained keen to police her movements requiring further negotiations during the actual implementation of parivartan sports and reflective sessions with the athletes as the actual programme started mentors accompanied girls from their homes and dropped them back after each session sessions ran in the afternoon when streets and alleys are relatively deserted and her visible presence lead parents neighbours and relatives to request timings that seemed more appropriate or the company of an escort instead of compromising mentors took it as a challenge to overcome these barriers the fearless attitude displayed by some mentors catalysed others to resist interference too many mentors acknowledged the power of sharing both the challenges and solutions from fellow mentors leading to increased confidence as a group and as individuals framing the greater mobility and visible presence in the community as a duty of being a mentor and a requisite for doing good work was the main strategy used in negotiating with parents and in silencing neighbours whenever i am late at the sessions or the meetings that apnalaya has for us in this programme the women around my house come and ask my mother where is she it is so late when will she come she should not be out of the house for such long hours that is when my mother tells them straight in their face she is out doing some good work and i am proud of my daughter we trust her when my mother says this they keep quiet for a moment but the next time i am late they come and ask again but my mother stands by me i am happy that she understands my role as a mentor reaching the school grounds where the sports sessions were held required a 45 min walk through markets and passing bus stopsall places crowded by men and boys mentors again coordinated with fellow mentors to travel together to accompany groups of athletes while they reported incidents of teasing namecalling or stalking mentors and their athletes developed the ability to handle the harassment with increasing confidence mentors perceived their increased confidence as the main personal benefit from their association with parivartan and this boosted their commitment to the programme as they examined the previously imposed restrictions on their mobility they felt convinced that change was desirable and justified from this position it was easier to negotiate parents support to fulfil their mentor responsibilities further training programmes outside the community eight months into the intervention the programme needed the mentors to attend three nonresidential trainings each lasting 2 days and one 2day residential training conducted outside the community this required them to travel independently using public transport and coming home late in the evening for mentors m1 m4 m5 and m6 this was the first time they travelled out of the community without a family member accompanying them yet the company of other mentors provided them with confidence and readiness to handle any harassment they might encounter hopes strategies parents have clearly been pivotal in supporting their daughter to take on the role of mentor mentors attributed their parents support to the way they had strategically shared some of the content on gender and rights included in the reflection sessions for athletes i discuss the topics that are in the module with my mother… but not everything together i give her small small doses this will help her understand what i am working towards and also know where my thinking is coming from i have to see her mood and then go ahead talking to her… if i talk everything to her at the same time and it becomes an overdose then she can ask me to shut up the process of building trust was clearly a gradual one navigated with care and predominantly via the mother as social customs restrict direct interaction between young women and older men in the household it was the mother who negotiated with her husband and sons yet five mentors did report changes in direct communication with their father and all with their elder brothers to negotiate pushing boundaries several mentors narrated their father rebuffing neighbours and justifying her participation in the programme and movement through the community … like if i would go out he would be worried and keep calling me but now he knows that i know what to do when so he is not much worried even if someone asks him what i am doing out for so long he answers them appropriately m5 rnd 02 it seems that demonstrating her communication and negotiation skills within the family and sharing her achievements as a mentor has given her parents confidence in her ability to deal with situations outside this opening for dialogue with the trust it inspired gave mentors the capability to negotiate mobility beyond her parivartan duties to pursue education but also for leisure time prior to parivartan mobility restrictions had caused three mentors to drop out of mainstream education yet with increased confidence and parental trust m1 and m5 began attending night school outside the community this required them to access public transport and travel back home in the dark on their own mentors m8 and m9 negotiated leisure time with their friends going beyond the slum boundary taking pride in commuting independently something inconceivable before the programme they navigated this change partly by first obtaining permission to spend leisure time with the mentor group an intermediary step that made it easier to gain permission from parents fears and failures mentors recounted their agency in effectively enrolling parents support for their duties as mentors and beyond yet there was hesitation too they did not take their current freedoms for granted and fears of falling back were prevalent with mobility seen as conditional on not making mistakes sharing their opinion with parents demanding justice or asking to be involved in any decision that concerns her was still seen as a potential step too far i am scared that if i say something or ask for some permission she mother could say no there is no need for you to go out of the house anymore i fear that she will stop me from doing this as well she will say you dont go out at all and i will have to be in the house all the more and that day she got angry with me and said dont go to school and dont go anywhere… just dont get out of the house there is no need for you to go out she was saying this once mentors had started moving independently they became frustrated when they needed a valid reason to go out or when only permitted out if escorted by a male relative ready and willing to negotiate they clearly needed to be cautious and strategic in pushing boundaries gradually even when mentors felt they could appropriately respond to neighbours who might question their mobility they still feared neighbours power to influence their parents suspicion about sexual chastity and its impact on family honour could easily raise its head and undo the hardwon trust they had built there was also concern about incidents in the community reawakening doubts about how unsafe the environment really is and how others may incite parents to reinstate normative restrictions mentor 2 an orphan who lived with her grandmother saw her freedom reigned in when her uncle who is her guardian returned from the middle east where he had been exposed to more orthodox religious ideas having described her relative freedom in the first round of interview in the second she describes how his views had changed … he is come for the past one month and now everything in the house has changed i have to be careful about the time i spend out of the house the cloths i wear… he is insisting on every woman and girl in the house wearing a burkha … he was not like this before when grandmother spoke to him about me joining the programme he readily agreed and never had a problem with my clothing but now since he is back he is behaving as if he has lost his mind for m2 increased restrictions on clothing and the amount of time spent outside the house had become reality during the first round of interviews all mentors had spoken of their wish and resolve to postpone marriage until after the end of the parivartan programme by the second round 6 months later two mentors had dropped out because of marriage or engagement the decision to quit had been imposed by the families they were getting married into before their engagement they achieved freedoms equal to those of other mentors as the group of mentors had become a new important reference group they were acutely aware of what they had come to see as a right now being revoked the failure of their attempts to negotiate which had been effective with parents previously left them clearly exasperated he rules they have i am unable to follow them and also to understand why they are saying this… they often say thats why i say girls should not go out so much… when they get outside air then they dont like to stay at home her personal history is important to consider both during and before the programme mentor 6 was the one who disobeyed her elder brother about attending the residential training initially she and her parents had faced a lot of questions from neighbours about her movements yet everyone had become more supportive of her duties serving younger girls in parivartan this ultimately brought more respect to mentor 6 and her family with neighbours now approaching her for advice on education and schooling in the first round of interview mentor 6s level of agency was impressive the start of marriage negotiations had actually predated parivartan she had already broken off one engagement as it meant moving back to her village which she refused she narrated how she had successfully negotiated with her new fiancé to postpone her marriage until after parivartan as he lived about 20 km away which would preclude her continuation unfortunately her fiancés mother became ill and insisted that her son get married at the earliest this was a shock to the mentor and again she negotiated with her fiancé to travel home every weekend in order to continue her association with the programme but once she got married and went to live with her inlaws she was not allowed out and she was required to wear a burkha even in front of her male inlaws her husband assured her that everything would be fine later but patience was called for in these early days of marriage as opposing his mothers wishes would send the wrong message she never did get permission to go back home on weekends and thus quit as a mentor she reported enjoying the times she had on her own with her husband trusting him and understanding the pressure he is under from his family for mentor 4 the renewed restrictions were imposed in her own home her story illustrates how her parents seemed pressured to do a uturn and start conforming back to normative expectations of confining women to household chores and away from public visibility m4 described the changes in her mother and fiancés behavior towards her after her future motherinlaw had come to stay with her family and had been unimpressed with the freedom she was afforded her fiancé started exerting control on her while she was still leading kabaddi sessions as a mentor checking her whereabouts by phoning both her and her mother on sundays i used to go late roam around and then go to the market but he would call me often and start yelling at me how much time are you taking so much time is being spent at work in half an hour you should be at home and you are roaming around till late and mother is working alone at home then they coax my mother too so when i would return home my mother would also yell at me what is it about you go early come back early otherwise i will not let you go if you are going then come back early mentor 4 had perceived her father struggling with the apparent demands and attitudes of her future inlaws she observed him expressing doubts to his wife who rebuked him with everything is new let it go now and see what happens later her father had become quiet and her mother seemingly tried to create a conducive environment in preparation for marriage again personal history seems important in illuminating her parents conflicted situation as they had concerns about her mental fragility and health impacting on her marriageability she was once kissed by a male childhood friend which upset her to the extent she took pills to end her life the risk of breaking off an engagement and the gossip it would create in the community further decreases the prospects of marriage receiving no support and only silence from her parents the mentor finally gave into the demands of the inlaws and her fiancé to discontinue with the programme once she quit she was confined to the house and lost all contact with the other mentors discussion this qualitative case study situated in a mumbai slum demonstrates how a carefully structured sports mentoring programme conceptualized to contest restrictive visibility norms for girls and women in public spaces allowed mentors to effectively negotiate a respectable presence outside the home for themselves and the participating girls the parivartan programme relied heavily on the mobility and visibility of mentors for its success and charted out a comprehensive strategy that supported their collective and individual agency and promoted proactive family engagement not compromising on the womens ability to negotiate their own movements and reputation proved instrumental in the transformative nature of this intervention the mentors themselves negotiated freedoms both in and outside their homes they changed the nature of key daytoday social interactions whether it was with mothers fathers and brothers neighbours parents of their groups of athletes or men on the streets we must reiterate that mentors were purposively selected as positive deviants educated and still unmarried in their early 20s from families previously involved in development initiatives or selfhelp groups with apnalaya a respected organisation in the community since social norms set limits to bargaining and to what can be bargained over 15 opportunities for shifts in gender relations were maximized by involving families supportive of their daughters aspirations our data suggests that elevated levels of aspirations on the part of mentors and their mothers was a strong driver of the bargaining in favour of mobility within and beyond the family contesting restricted norms involved gradual negotiation initially drawing on valid reasons to gain permission to perform necessary tasks or duties as mentors careful bargaining was needed to navigate the complex shift from an identity constructed around predominately domestic duties towards a new identity of a mobile young woman working towards a cause visible to neighbours and community the bargaining power to change gender dynamics at home and in the community are linked 15 the most critical enablers at home were the mothers with whom mentors shared discussion topics on gender inequality and gender justice always strategic about what and when to share this process was characterised by both cooperation and conflict the more mentors questioned and challenged issues of inequality the less they were willing to accept constraints on their mobility and freedom in line with traditional gender conduct mothers initially negotiated on their behalf with the male members of the family yet mentors also started communicating directly with elder brothers and fathers this demonstration of individual agency in itself seems to have contributed to the mentor winning parental trust in her ability to be safe in public spaces the family was thus enrolled in the coproduction of a new identity 16 as a respectable young woman doing good work with younger members of the community parents were active players by not giving into social sanctions of neighbours and relatives as the programme unfolded the mentors developed into a strong support group for each other influencing and inspiring each other to stretch boundaries gaining confidence each time they witnessed each others successes the programme created opportunities for collective action increasing mentors ability to think and relate in a collectivized manner they formed a new reference group for each other in terms of what was possible and acceptable our data corroborate the finding that collective bargaining and action are central to both questioning and contesting gender relations 15 mentors contested mobility restrictions taking risks as a group with collective agency an important step towards greater individual agency in daytoday social interactions 11 first they sensibly used strategies for protection moving in groups taking inside alleys to avoid crowds of men on the main streets when going on their own in other words they modified their behaviour to avoid unwanted male attention in order to resist exclusion from public space while this strategy risked reproducing the norms that reduce their claim to safe access 17 the skills gained from the gender training enabled them to go further mentors rebuked men and boys on the street and came to no harm they managed gradually to achieve the right to take risks and put their right to access public spaces above their desire for protection diminishing the perpetuation of patriarchal power 6 most mentors went beyond negotiating mobility for performing duties and achieved more leisure time away from home notable in our data was how conversations steered away from reputational risks the discourse of sexual safety was side stepped in both the narratives and in the intervention in fact the mentors presence in public spaces became desexualised instead of losing respectability by being visible in the community they gained social standing through their new identity as mentor performing a valued community service in association with a reputable and trusted social development organisation this observation may have important implications for other interventions that aim to increase education and delay marriage by dwelling too much on marriageability programmes may unwittingly reinforce concerns about sexual safety rather than defusing them all mentors expressed anxiety about potential curtailment of their freedom and insecurity about what will happen once the programme ends importantly bargaining power to leave the home all but evaporated for the two mentors who dropped out confronted with more genderretrogressive inlaws their parents support also waned while they seemed to come from less progressive families in the first place we cannot tell how the other mentors will fare once the marriage process starts mobility restrictions did increase again for the mentor whose uncle and guardian migrated back from the middle east identity and cultural politics appeared to take center stage at the cost of women and girls symbolically representing cultural exclusiveness limitations to this study include a potential desirability bias in mentors accounts even when they felt free to express concerns about their future we also cannot know how the mentors income increased their bargaining power within the family and what will happen when it falls away but we will explore this once the third round of data collected a year after the end of the programme are available we cannot disregard influences from secular change and other development initiatives indeed previous efforts addressing gender inequality no doubt contributed to the mentor families readiness for change in the same way this sports programme inspires and prepares other families for future change opportunities the ultimate target of parivartan are the girls participating in the sessions and documenting the changes among them was beyond the scope of this paper however a first step was establishing that mentors drawn from within the slum community were able to implement the programme and provide new role models despite visible change in these young womens presence in public spaces it seems too early to claim that these mentors have set a new standard by having adopted new roles and responsibilities 12 yet the symbolic aspects of performing gender came under strong scrutiny and the positive reception so far gives hope for greater participation of young women as citizens in times of ongoing social and economic change conclusion in a mumbai slum where fear and social control significantly limit young womens access to public space the daytoday social interactions of mentors implementing a sportsbased programme changed in significant ways the mentor role created opportunities for collective action increasing mentors ability to think and relate in a collectivized manner and taking risks free from overbearing paternalistic protection this paper makes a significant contribution because gender norms continue to act as structural barriers to many public health programs and rob generations of young women to participate as citizens in society it provides important insights into addressing embedded social norms that perpetuate gender discriminatory practices and the social patterning of health inequalities abbreviations icrw international center for research on women iips international institute of population sciences ngo nongovernment organisation authors contributions rvk lh and md made substantial contributions to conception and design of the programme rvk lh md and mc contributed to the research methodology sb collected the data sb mc and md analysed and interpreted the data bc gave detailed input on social norms sb and mc drafted the manuscript all authors critically reviewed and approved the final manuscript competing interests the authors declare no competing interests

background harmful gender norms are known structural barriers to many public health and development interventions involving adolescent girls in india restrictions on girls liberty to move freely in public spaces contribute to school dropout and early marriage and negatively affect girls health and wellbeing from adolescence into adulthood we report on mechanisms of change among female mentors 18 to 24 years old who contested discriminatory norms while implementing a sportsbased programme for adolescent girls in a mumbai slum methods we adopted a prospective qualitative research design our analysis is based on case studies derived from two rounds of face to face in depth interviews with 10 young women recruited to serve as mentors for the projects young female athletes we combined both thematic and narrative analysis results the programme created opportunities for collective action increasing mentors ability to think and relate in a collectivized manner and challenged the traditional female identity constructed for young women which centres on domestic duties the mentors themselves negotiated freedoms both in and outside their homes which required careful and strategic bargaining they changed the nature of key daytoday social interactions with parents and brothers as well as with neighbours parents of their groups of athletes and men on the streets they formed a new reference group for each other in terms of what was possible and acceptable demonstrating greater negotiation skills within the family helped win parents trust in the mentors ability to be safe in public spaces parents became active supporters by not giving into social sanctions of neighbours and relatives thus coproducing a new identity for their daughters as respectable young women doing good work they effectively side stepped reputational risk with their presence in public spaces becoming desexualised conclusions mentors contested mobility restrictions by taking risks as a group first with collective agency an important step towards greater individual agency this research provides important insights into addressing embedded social norms that perpetuate gender discriminatory practices and the social patterning of health inequalities

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introduction the australian population is ageing fast with a predicted increase in the old age dependency ratio from 21 per cent in 2011 to 3842 per cent in 2050 1 the rapid population ageing in australia will lead to shortages of labour force as well as increases in government expenditure on age pensions health and aged care services as stated in the australian governments intergenerational report 2010 23 maintaining labour force participation at mature ages is considered to be the most constructive strategy for addressing all the challenges of an ageing society as working longer can not only increase productivity and tax revenue but also assist individuals to build resources for their own retirement income as well as reduce the governments potential liability 24 however mature age workers aged 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 in australia were found to leave employment well before pension age and have relatively lower level of workforce participation when compared to both domestic younger working age groups and same age groups in other countries of the organization for economic cooperation and development oecd 56 though the labour force participation among mature age australians has increased substantially from 67 per cent in 2001 to 74 per cent in 2012 mainly due to the increase in females participation in part time jobs according to oecd statistics 5 it was still lower than that in the united states and canada and much lower than that in new zealand australian matureage men saw a downward trend in participation rates that dropped from 85 in the 1960s to a low of 60 in the 1980s and 1990s before recovering to 72 in 2011 6 mature age workers were also found to be disproportionately represented among the longterm and very long term unemployed in australia 578 the increasing health life expectancies in last two or three decades makes labour force participation at late life more feasible especially for those working in less physically demanding jobs further understanding of how ageing impacted on sustainable work ability and why workers left their paid work at later life early before the age pension age are extremely important for workforce planning and ageing well in an ageing society the literature review shows that labour force participation and early retirement are complex and multidimensional 9 10 11 12 13 extensive attention in previous studies has been paid to individual factors from labour supply side such as the impacts of ill health 14 financial consideration 15 joint labour supply and family care needs 16 as well as institutional factors such as universal medical insurance eligibility for superannuation age pensions and income tax system 17 etc while less studies focus on factors from labour demand side such as employment history work conditions and job satisfaction 151819 gender difference is also cognizant in literature for instance men are more likely to consider financial aspects while women are more likely to consider worklife balance such as the work and caring responsibilities and the joint retirement decision with their spouses 20 first of all poor health chonic diseases caring responsibilities workplace inflexibility age discrimination without nonschool qualifications and lack of trainings are found to be the major barriers to the continuous employment or reemployment of mature age workers 81416 secondly older people working in manual occupations are more likely to get injured or disabled or have difficulty to meet high physical requirement when age arise hence they are more likely to be retrenched at mature age while less likely to be reemployed in other occupations 821 thirdly job dissatisfaction and long term unemployment are found to have strong discouraging effects on labour force participation at mature age 2223 lastly the australian system including the more favourable access to superannuation and agedisability pensions as well as the universal health insurance is characterised by incentives to retire early which might contribute to the relatively younger expected ages of retirement in australia when compared to united states though both countries have comparable life expectancies and healthy life expectancies 17 as there is no longer a mandatory retirement age in australia and some other developed countries retirement can be either voluntary or involuntary aligned with factors influencing leaving there are several studies in australia looking at the individual characteristics associated with voluntary and involuntary not working 524 significant difference was found among the voluntarily and involuntarily not working groups in terms of individualhousehold characteristics labour market experiences and wellbeing at mature ages 5 in addition involuntary retirement is associated with a marked decline across of economic wellbeing measured by financial hardship and life dissatisfaction while there is no decline in economic welfare at anticipated early retirement 42526 nevertheless to our best knowledge there is no study in australia so far looking into the common and different factors predicting voluntary and involuntary workforce transitions at mature ages this study aims to fill in this research gap by using the nationally representative longitudinal data drawn from the household incomes and labour dynamics in australia survey 20022011 for australians aged 4564 the results can serve as evidence to inform researchers policy makers and industrial actions to promote workforce longevity hence to better prepare for an ageing society one theory and two conceptual approaches are adapted for our study to provide a useful framework to guide us to select important factors which might predict voluntary and involuntary workforce transitions at mature ages the theory of cumulative advantage suggests that inequalities across the life course underlie the increasing gulf between the welloff and the disadvantages in later life 2728 consequently preventing people from accumulating lifelong disadvantages in health education and employment since their earlier life stages could help to delay the onset of chronic diseases and reduce involuntary workforce transitions at mature age 29 the ecological model of aging 30 focuses on the fit between individuals changing capacities demands and preferences with consequences for staying or leaving their current living environment we modified this fit approach from living environment to working decision a flexible and ageing friendly workplace could help the mature age workers to meet their changing health financial status and preferences hence stayed at work longer the second conceptual approach is the elderly migration model 31 in which push pull and contextual factors are utilized to predict older peoples decision concerning their life arrangements the push and pull factor analysis has also been used for workforce transitions by shultz et al 11 in which push factors are perceived as negative considerations while pull factors as positive considerations for early retirement the aims of this study are to explore how lifelong advantages and disadvantages could influence voluntary and involuntary workforce transitions at mature ages how the changing health capacity and changing preference to work more or less hours could influence voluntary and involuntary workforce transitions at mature ages how the pull and push factors could influence voluntary and involuntary workforce transitions at mature ages materials and methods data this study utilizes the nationally representative household income and labour dynamics in australia survey data of waves 2 to 11 the hilda follows the same individuals yearly since 2011 and collect comprehensive information by asking respondents questions on sociodemographics labour force participation employment history current working conditions job satisfaction income housing and wellbeing etc 3233 key measures we follow the same way in gong and mcnamara 5 and gong and kendig 4 to define voluntary and involuntary workforce transitions mature ages are defined as aged 45 to 64 years given that relatively few people remain in the workforce beyond age 64 working includes both part time and full time paid work not working includes being unemployed or not in labour force during the week before the survey those selfemployed are excluded from this study as they have been found in literature to be very different from other workers in terms of working conditions and behaviours 34 voluntarily or involuntarily not working at each year was defined according to individuals responses to four questions whether people want a job if wanting a job whether they are looking for a job if not looking for a job what are the main reasons and what are the main activities when they are not working voluntarily not working is defined when people report that they are not in the labour force and do not want a job not in the labour force and might want a job but they are not looking for one because of does not need to workno timeprefers to look after childrennot interested or not in the labour force do not report whether or not they want a job and their main activity is one of retiredvoluntarily inactivestudytravelholidayleisuredoing voluntary job involuntarily not working includes people who report that they are unemployed not in the labour force but want a job not in the labour force and want a job but they are not looking for one because of own illness injury or disabilitychildcare reasonhealth of someone elsetoo young or too old or not in the labour force and do not report whether they want a job and their main activity is one of home dutieschildcareown illness injury or disabilitycaring for ill or disabled person we then define voluntary and involuntary workforce transitions as from working in one year to voluntarily or involuntarily not working in the subsequent year we have also identified whether people had ever returned to paid work after the transitions until the last recorded hilda wave used for this study methodology the logistic and multinominal logistic models are utilized to investigate what factors jointly predicting not working voluntary or involuntary workforce transitions among australians aged 4564 3536 the dependent variables in the regression models are transitions from working at one year to not working voluntarily or involuntarily not working when compared to those staying at work at the subsequent year our methodology recognizes that people at mature ages could leave the workforce for a time and then returned to paid work we count each transition from working in one year to not working in the subsequent year as an independent transition while the change from one job to another is counted as no transition group stayed at work for example if an individual worked in one year left work in the subsequent year and returned to work before or until the last wave we counted as one transition if an individual worked in one year left work returned to work and left work again before or until the last wave we counted as two transitions the preliminary data check on hilda survey 20022011 indicates that among 1241 workforce transitions in 10 years 942 occurred on different respondents in different years with one transition per person 260 occurred on 130 respondents with two transitions per person and 39 happened on 13 respondents with three transitions per person around two thirds of these transitions were associated with not returning to paid work while the other one third was associated with returning to paid work before last wave as each individual might have zero one two or three transitions over ten years there might be concern on the autocorrelation and dependence of the residuals in our regression model due to the use of pooled data of same participants from the longitudinal survey we have implemented ways to decrease this potential bias firstly every transition is treated as an independent one in our regression model with changing age family structure financial situation and work conditions though gender and education might be stable over time secondly we use the survey data as crosssectional one by restricting all workers aged 4564 in each of the 10 years so that the respondents aged 45 were different in different years thirdly we use the crosssectional weights in hilda survey which were adjusted yearly to make sure the survey data to be nationally representative in each of the years lastly we have controlled for as much as the individual characteristics and taken into account the reasons for leaving paid work and main activities after workforce transitions in defining voluntary and involuntary work force transitions consequently we expect the impact of the autocorrelation and dependence of the residuals on our modelling estimations to be small nonetheless we estimate predictors and advise caution in any attempt to interpret our results in terms of causality 4 as there is no large crosssectional survey data in australia with information on workforce transitions for older workers aged 4564 our strategy of using pooled data drawn from different waves of existing longitudinal data could increase the number of transitions and hence be able to estimate the transition models that would not be possible by using any single year data with small sample size this approach is not only feasible timeand costefficient but also permits the study of transitions occurred in a longer period than was assessed within any single investigation all the analyses are conducted by stata 151 selected predictors according to the theory of cumulative advantage ecological model of aging and the elderly migration model as discussed above we use the proportion of paid and unemployed years tenure in current occupation and the highest educational attainment from hilda survey data to reflect lifelong advantages and disadvantage whether paying mortgage or whether having a child or dependent student to reflect financial status aging and long term health conditions to reflect changing health capacity and preference to more or less work hours to reflect changing preferences long term health conditions job dissatisfaction fixed term and casual contracts high local unemployment rate working as labourers as push factors while no mortgage partnership partners working status and income working as professional staff or in public sector as pull factors part time work can be push or pull factor depending on individuals the multiple factors associated with work force participation at later life found in the empirical studies include physical and mental health educational attainment taxtransfer expected retirement income and health insurance systems social and employers attitudes to ageing caring responsibility work flexibility access to retraining and support services occupations and other job characteristics 7 12 13 14 15 16 17 2223 the predictors controlled for in our final regression models are individual and household characteristics including age age square term gender partnership number of children under age 15 number of dependent students aged 1524 lifelong advantagesdisadvantages including educational attainment tenure in current occupation ratios of paid and unemployed years after graduation financial factors including whether paying mortgage or not partners working status and income work conditions including working in public or private sector employment type occupations contract type changing capacity and preference including long term health conditions preference of work hours job dissatisfaction on various job aspects and state average unemployment rate at the same year when workforce transitions occurred job satisfactiondissatisfaction is measured by a group of questions in hilda asking individuals how satisfied are you with your job on a scale of 0 to 10 in this study we used the job dissatisfaction with four job aspects we generate a dummy variable each aspect of job satisfaction dissatisfied if with a response from 0 to 5 and satisfied if with a response from 6 to 10 the scale is used as a threshold for being satisfied or not in this study as 60 out of score 100 is socially perceived as a threshold of being satisfied or not during school evaluation in addition the distribution of job satisfaction shows that the proportion of respondents with a satisfaction level lower than score 6 was ranging from 10 to 20 in hilda 2011 which is more close to the proportion of leaving paid work when compared to the proportion with a satisfaction level lower than the mean or the median long term health condition is measured by asking respondents does anyone here have any longterm health condition disability or impairment as shown in the showcard any disfigurement or deformity any mental illness which requires help or supervision shortness of breath or difficulty breathing chronic or recurring pain long term effects as a result of a head injury stroke or other brain damage a longterm condition or ailment which is still restrictive even though it is being treated any other longterm condition such as arthritis asthma heart disease alzheimers dementia etc for comparison purpose we have adjusted income data into 2009 price by indexing them using the average of monthly australia national consumer price index for each year the annual unemployment rate by state was generated by the average of abs monthly unemployment rates 37 we use whether people are still paying their mortgage as a proxy for their financial status as wealth data is only available in every four years in hilda results incidence of workforce transitions as shown in the first part of table 1 the tenyear pooled data yields approximately 1241 work force transitions from working at one year to not working in the subsequent year voluntarily not working or involuntarily not working when compared to staying at work as shown in the second part of table 2 there are 490 voluntary transitions without returning back to work till last wave 136 voluntary transitions returning back to work until last wave 282 involuntary transitions without returning back to work till last wave and 274 involuntary transitions returning back to work until last wave after voluntary not working only one fifth returned back to work while after involuntarily not working around half returned back to work this is mainly due to financial pressure after leaving their jobs 438 figure 1 provides the age profiles of voluntary and involuntary workforce transitions from one year to the subsequent year occurred within the survey period of 20022011 it shows that at age 45 people start to exit their jobs slowly and gradually either voluntarily or involuntarily with a relatively higher proportion of involuntary workforce transitions than that of voluntary workforce transitions since age 53 the voluntary workforce transitions increase much more rapidly while the proportion of involuntary workforce transitions are relatively constant and voluntary workforce transitions starts to overwhelm involuntary workforce transitions for instance the proportions of voluntary and involuntary workforce transitions are 1 27 figure 1 provides the age profiles of voluntary and involuntary workforce transitions from one year to the subsequent year occurred within the survey period of 20022011 it shows that at age 45 people start to exit their jobs slowly and gradually either voluntarily or involuntarily with a relatively higher proportion of involuntary workforce transitions than that of voluntary workforce transitions since age 53 the voluntary workforce transitions increase much more rapidly while the proportion of involuntary workforce transitions are relatively constant and voluntary workforce transitions starts to overwhelm involuntary workforce transitions for instance the proportions of voluntary and involuntary workforce transitions are 127 per cent and 231 per cent at age 45 years 313 per cent and 271 per cent at age 53 years and 1884 per cent and 531 per cent at age 64 years individual characteristics and work conditions individual characteristics and work conditions table 2 presents the individual characteristics and work conditions associated with workforce transitions which are used in the final regression model it shows that the total number of workforce transitions from working to not working is 16811 in which 15701 were staying at work 563 voluntarily not working 492 involuntarily not working 55 were not working but unable to be determined as voluntary or involuntary one when transitions occurred the average age of workers in our study was 5223 years about 51 per cent of them were males 76 per cent currently had a partner while 24 per cent did not have a partner on average there were 031 children and 034 dependent students per household about 38 per cent of mature age workers had a degreediploma 25 per cent with a certificate 10 per cent with year 12 completion and 27 per cent finishing year 11 or below the proportion with any longterm health condition was about 21 per cent regarding working or not at mature ages the most important financial concerns are whether still paying mortgage eligibility to superannuation whether partner is working or not and by how much income 3940 in our study 44 per cent of mature age workers were still paying their mortgages 32 percent of them were eligible for superannuation and only 031 percent of mature age workers did not have any superannuation among those with a partner 80 per cent of their partners were working and the average annual income of working partners was au 74 230 at 2009 price when transitions occurred the average tenure in current occupation was 1437 years after graduation on average 87 per cent of years after graduation were paid years and 2 per cent were unemployed years 35 percent of respondents were working in public sector and more than two thirds were working full time and 27 per cent working part time about 38 per cent were managers and professionals 11 per cent were technicians 34 per cent were workers sales clericals or administrative staff and 17 per cent were operatorsdriverslabourers the majority had a permanent or ongoing contract 9 per cent had fixed term contract 15 per cent were working on a casual base and very few were on other contract types more than half of people preferred to work the same hours as they currently did about one third would like to work less hours and only one tenth preferred to work more hours about one fifth of workers were dissatisfied with their jobs in which 19 per cent 13 per cent 11 per cent and 18 per cent were dissatisfied with their job payment job security work itself and working hours respectively the state average unemployment rate is 52 per cent across all years we use whether paying mortgage to represent financial status as we found that there is no significant difference among outright owners and renters regarding their probability of workforce transitions the owners have home ownership and relatively higher wealth but the renters are more likely to receive government rent allowance once they are not working regression results we have run three multivariate regression models model 1 is the logistic model on the transitions from working to not working model 2 is the multinominal logistic model on the transitions from working to voluntarily or involuntarily not working and model 3 on the transitions from working to voluntarily not working till last wave voluntarily not working and back to work involuntarily not working till last wave or involuntarily not working and back to work the three models all used workers staying at work from one year to the subsequent year as their reference group the estimated coefficients and significant levels of all predictors from the three models are reported in table 3 for comparison the first column of numbers reports estimated coefficients from model 1 the second and fifth columns present estimates from model 2 and other columns from model 3 table 3 shows that age squared term significantly predicts voluntarily not working and not going back to work while it is associated with less likelihood to voluntarily leave paid work and going back to work age is insignificant to involuntarily not working males are more likely to voluntarily not working and going back to work currently without a partner decreased voluntarily not working but it increased involuntarily not working and going back to work the number of dependent students decreased voluntarily not working and not going back to work as well as decreased involuntarily not working and going back to work education is insignificant to all the work force transitions longterm health conditions significantly increased both voluntarily and involuntarily not working besides health finance is also a very important factor in explaining work force transitions at later life we found that still paying mortgage decreased voluntarily not working but it was insignificant to involuntary not working having a partner who is working decreased voluntarily not working and it decreased involuntarily not working and not going back to work partners income only slightly increased voluntary not working and also slightly increased involuntarily leaving paid work and going back to work both work conditions and job dissatisfaction predicted voluntary and involuntary not working at later life but in different ways tenure as defined as years in current occupation increased voluntary not working while decreased involuntary not working proportion of paid years decreased both voluntary and involuntary not working while proportion of unemployed years significantly increased involuntarily not working working in public sector significantly decreased involuntary not working working part time increased voluntary not working as well as increased involuntarily not working and not going back to work workerssalesclericalsadministrative staffdriverslabours were more likely to voluntarily not working and not going back to work while less likely to voluntarily leave paid work and going back to work fixed term contract significantly predicts involuntary not working while casual work predicts both voluntary and involuntary not working preference to work less hours significantly predicts voluntary not working and increased involuntary not working and going back to work while preference to work more hours predicts less voluntary not working while increased involuntarily not working and going back to work dissatisfaction on job security and work itself predicts involuntary not working while dissatisfaction on work hours predicts voluntary not working and not going back to work in order to better understand how different factors could drive voluntary and involuntary work exits at later life we compared the signs of estimated coefficients of predictors from the regression model 2 it demonstrates that the factors driving voluntary and involuntary workforce transitions at mature ages are very different in australia excepting that both long term health conditions and preference to work less hours increased while having a working partner and proportion of paid years decreased both voluntary and involuntary work force transitions besides these four common factors the voluntary workforce transitions were jointly driven by individual and household characteristics financial concern employment history and current work conditions while involuntary workforce transitions were mainly driven by vulnerable employment history and current work conditions discussion summary of findings findings in our study indicate that the working proportion decreases slightly since age 45 and then goes down rapidly after age 50 especially after age 55 the majority of mature age workers moved from working to voluntarily not working and only a few to involuntarily not working before age 53 the proportion of involuntary workforce transitions is slightly higher than that of voluntary workforce transitions while after age 53 voluntary workforce transitions increase rapidly and start to overwhelm involuntary workforce transitions the positive age effect on voluntary workforce transitions especially after age 53 years is likely to be associated with the rising opportunities to be eligible to use income from superannuation or receive a disability pension 41 once other factors have been controlled for the age effect is insignificant for involuntary workforce transitions indicating that the observed slight increase in involuntary workforce transitions with age in figure 1 is unlikely to relate to age itself it is found that there are four common factors which had significant impacts on both voluntary and involuntary work force transitions in which proportion of paid years played the most important role followed by long term health conditions having a partner who is working and prefer to work less both historical and current employment statuses have significant impacts on workforce transitions and this is consistent to the accumulated lifelong advantage and disadvantage theory used for labour market 2742 the longer the tenure in current occupations the less likelihood to exit paid work involuntarily while the higher probability to exit paid work voluntarily the higher the proportion of paid years after graduation the lower likelihood of not working either voluntarily or involuntarily at later life while the higher the proportion of unemployed years the higher probability of involuntary not working at later life having long term health conditions has a similar and strong power in predicting both voluntary and involuntary workforce transitions this reflects the fact that long term health condition is a major reason for mature age workers to leave paid work as well as a barrier for them to go back to work this could be explained that mature age workers with long term health conditions might value their free time more and are more likely to be eligible for government disability pension hence have a higher probability to leave their paid work voluntarily on the other hand workers with long term health conditions are less demanded by their employers hence their probability of involuntarily not working is higher family structure partnership and paying mortgage also have significant impacts on workforce transitions at mature ages unsurprisingly home buyers still paying mortgage are less likely to exit paid work voluntarily workers currently without a partner are less likely to exit paid work voluntarily and are more likely to go back to work after involuntary workforce transitions reflecting their high independence in both time and finance workers with a partner who is working are less likely to voluntarily exit paid work reflecting the complementarities of joint arrangement of work and leisure time between partners at later life partners income had a significant positive but small impact on voluntary workforce transitions workers with dependent students are less likely to exit paid work voluntarily but once they exit their paid work involuntarily they are less likely to come back to work reflecting that they have strong incentives to stay at work to support their dependent students but face strong barriers to go back to work at mature ages there were also strong incentives among mature age workers to adjust their working hours when age arises and there is room to improve workforce participation by hours for those who were under employed when compared to those who prefer to work same hours prefer to work less hours significantly predicts both voluntary and involuntary not working dissatisfaction on working hours increased voluntary not working while prefer to work more decreased voluntary not working part time casual work and prefer to work less hours might be a signal for a pathway to retirement for those workers who were financially prepared 43 while for workers with an overwhelming workload work hours need to be adjusted down according to their changing health capacity and preference the estimated coefficients of other predictors are mostly under our expectations and in line with existing literature for instance workers who were dissatisfied with their job security or work itself working under fixed term or casual contracts were more likely to leave paid work involuntarily while working in public sectors predicts a lower probability of involuntary workforce transitions nonprofessional staff had a lower likelihood to go back to work after voluntary not working the general insignificance of education levels on workforce transitions at mature ages might simply reflect the combination of income and substitution effects as mentioned by human capital theory on the one hand the income effect predicts that higher educated people with higher earnings are more likely to be able to afford to enjoy free time by exiting their paid work earlier before the age pension age on the other hand the substitution effect states that higher educated people might stay in paid work longer due to a higher opportunity cost driven by their higher wages or better employment conditions 844 policy implications in order to remove the barriers that many older workers are facing to carry on working the oced called on the australian authorities to take further actions to enhance the public awareness and effectiveness of age discrimination legislation to prevent social securities as incentives to early retirement and to strengthen older workers employability 6 it is found that in new zealand from 1992 to 2001 increasing age pensions age from 60 to 65 for both men and women and allowing people to stay at paid work while receiving age pensions have effectively increased labour force participation at mature and older ages 6 the oecd has concerns that in australia the possibilities to draw superannuation benefits unconditionally as a lumpsum at an early age to use disability pension as a pathway to early retirement and to reduce income from age pensions while receiving income from paid work might contribute to the decrease of labour force participation at mature ages which have not been well examined the existing policies and current efforts to increase workforce participation at later life in australia include improving education and training assisting attachment to labour market enhancing long term campaign with age stereotypes and age discrimination financially encouraging employers to hire workers aged 50 and plus providing substantial superannuation tax incentives after age 60 as well as to increase progressively the preservation age for superannuation from 55 to 60 and age pension eligible age from 65 now to 67 and further to 70 22145 the current policies aiming to increase age eligibility for superannuation and age pensions are expected to delay some voluntarily not working with financial consideration but not for others without financial consideration the implications of our findings suggest that in order to facilitate longer workforce participation and enhance productivity and wellbeing at later life different government policies and employment practices should be engaged to address the major causes of voluntary and involuntary workforce transitions at mature ages promoting mature age workers health employability work flexibility and friendly work environment as well as providing rational and secure pathways before full retirement could help older workers to meet their changing health and family needs hence stay in paid work longer 4 46 47 48 a central and new challenge for an ageing society is to enable continued workforce participation at later life by preventing or ameliorating chronic diseases or disabilities when age arises for workers in their 50s or 60s 49 the health first and fitness approaches and lifelong accumulative disadvantage theory should be taken in consideration in making further policies to tackle the healthrelated or vulnerable worklessness for mature aged workers in australia for voluntarily not working at later life the health first and fitness approaches suggest that the fundamental policies and employment practices are health promotion over life span agefriendly workplaces work flexibility to meet changing preference etc the health first approach targets the root cause of worklessness through preventing improving and managing chronic diseases at mature ages hence refining workers health capacity and employability 50 health promotion can reduce both local worklessness and health inequalities but need joint efforts among clinical groups work program providers work organizations and local authorities 451 in europe where some of countries have already taken important steps to tackle the challenge of ageing population health promotion activities in workplace for ageing workers have recently been promoted as a new approach to improve occupational and populational health 51 besides the historic approach that takes into account occupational risks technical and medical expertise and ergonomic adaptions in the work environment this new approach promotes healthy habits which may delay the onset of diseases or help to manage the chronic diseases a great effort has been made to increase the motivation of older workers to move to healthier habits as older workers are more reluctant to make changes than younger workers the existing health interventions in australia have mainly occurred in communities for promoting physical activities and in primary care centers for disease prevention as well as in health and aged care institutions for managing disabilities and chronic diseases the health promotion activities in workplace are still inadequate australia shares the same obstacle for health promotion programs as in europe on how to ensure continuity of funding and effectiveness after the end of the intervention programs with the extended life expectancy many people in their 50s and 60s are expected to work with some form of mild chronic diseases or disabilities it has been found that working longer hours than what is feasible is harmful to health indicating that the standard full time work might no longer be the best fit for many older people with long term health conditions 495253 the fitness approach encourages the employers and employees to discuss and negotiate work hours hourly wage and other work arrangement after reaching certain ages according to the changes in both labour supply and demand sides hence to achieve a new agreement which could be beneficial to both employers and employees our analysis supports this by evidence that almost one third of mature age workers had indicated their willingness to reduce working hours at later life the alternative options could be secured part time or casual employment as a pathway to full retirement when health and energy declined at mature ages for involuntarily not working at later life the life course approach suggests the implementation of policies in equalizing lifelong opportunities for health education training retraining employment assistance can help to promote lifelong health work capacities and continuous labour force participation for those with vulnerabilities such as those without nonschool qualifications or trainings job insecurity is the most emerging issue to be addressed for those involuntarily not working in last two or three decades there has been continuous shift away from secure to insecure jobs and from standard full time contracts to nonstandard arrangements in australia and many other developed countries 2949 these changes are mainly driven by the economic restructure and technical change resulting a shift of economy from manufacturing sectors to service sectors 2949 it has been found that during this shift older workers are often forced into precarious employment with the consequent cycle of fewer job opportunities little training and lack of income security exposure to discrimination harassment and workplace bullying nonportability of leave entitlements as well as a reduced capacity to exercise autonomy in how the work is done resulting damage to health and wellbeing 294954 the new policy making will also need to take into account the changes in role model and work culture during the new economy as these changes are likely to increase the demand for secure part time jobs at mature ages on the labour force supply side our analysis shows that the current generation of mature age workers are baby boomers who are still working under the male breadwinner female caregiver model pursuing the norm of good jobs as secure and full time jobs working as long as possible except for married females who participated in labour force flexibly to balance work and care needs 2949 55 56 57 while for the new generations the working model is changing significantly where people spend more years on formal education and trainings in early life in order to better survive in the new knowledgebased economy with males working mostly full time but spending more time with children and reducing work effort in response to health change in later life while females reducing working hours instead of fully withdrawing from work force for caring responsibilities 49 on the labour force demand side the employer and recruiter perspectives are also changing in terms of what they want from mature age workers for instance the notion of employability has changed from reliability punctuality and the ability to accept direction to resourcefulness adaptability and flexibility the requirement for formal qualification has grown the lowskilled jobs have been reduced and casualization of the workforce is increasing in an uncertain economy 29 current efforts in australia to increase job security of part time or casual work include extra loading in earnings wage subsidy and protection against unfair dismissal etc 49 further investigation needs to be done on how to increase the options of more secure parttime fixtermed or casual employment and other forms of more tenuous engagement in a new economy of services retraining programs with focus on broader skills and employability for workers who have lower level of qualifications and fewer training opportunities in a declining industry or occupation could assist transition from one industry to another hence to ensure lifelong continuous labour force participation 8 as discussed the strategy of using pooled data drawn from different waves of existing longitudinal data allows us to estimate the workforce transitions at mature ages that would not be possible by using any single year data with small sample size nonetheless we estimate predictors and advise caution in any attempt to interpret our results in terms of causality 4 other limitations of this study include the utilization of onedigit occupational group to identify whether the work is physically demanding and the use of job dissatisfaction to identify potential psychosocial risk factors in the workplace for future research more detailed occupational categories in hilda can be used to identify possible impacts of hazardous work and impairing work on work force transitions in addition workrelated stress 58 and workplace psychological harassment 59 are recognized worldwide as major challenges to workers mental health problems and other stressrelated disorders which are known to be among the leading causes of early retirement from work high absence rates overall health impairment 5859 larger crosssectional and longitudinal survey for mature age and older workers are necessary for further estimations conclusions encouraging mature age workers to work as long as possible is a longterm strategy in australia and many other countries to address the policy challenges associated with ageing population the issue in the current labour market is that mature age workers are facing longterm unemployment or underemployment while employers increasingly claim labour force shortages 29 this calls for a deep understanding of what mature age workers need and face what policies can address informed by a lifecourse perspective and a move away from the focus on individuals to the attitudes of society and employers to older people including job security promotion of healthy life styles ageing friendly workplace and work flexibility 8294951 our research indicates that many mature age australians want to work longer and continuous paid employment could help older workers to work longer at later life but how to best facilitate the retirement transitions when health deteriorates and how to keep older workers to work decently safely and appropriately will be the challenges for government industry and society as a whole to overcome

the fast population ageing has generated and will continue to generate large social economic and health challenges in the 21th century in australia and many other developed and developing countries population ageing is projected to lead to workforce shortages welfare dependency fiscal unsustainability and a higher burden of chronic diseases on health care system promoting health and sustainable work capacity among mature age and older workers hence becomes the most important and critical way to address all these challenges this paper used the pooled data from the longitudinal household incomes and labour dynamics in australia hilda survey 20022011 data to investigate common and different factors predicting voluntary or involuntary workforce transitions among workers aged 45 to 64 long term health conditions and preference to work less hours increased while having a working partner and proportion of paid years decreased both voluntary and involuntary work force transitions besides these four common factors the voluntary and involuntary workforce transitions had very different underlying mechanisms our findings suggest that government policies aimed at promoting workforce participation at later life should be directed specifically to lifelong health promotion and continuous employment as well as different factors driving voluntary and involuntary workforce transitions such as lifelong training healthy lifestyles work flexibility ageing friendly workplace and job security

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introduction childhood obesity rates are particularly alarming in europe however the problem varies across regions with higher prevalence in southern countries such as portugal a plateau or decreased in overall prevalence of childhood obesity has been suggested in many developed countries a surveillance study carried on portuguese children reported a decreased in overweight and obesity rates between 2008 and 2019 unfortunately this optimistic picture may not be true for all children in the usa skinner et al found that the obesity rates did not decreased for any age group and continued upward among socioeconomically disadvantage subgroups between 1999 and 2016 in highincome or industrialized populations obesity tends to be more frequent among those classified with a low socioeconomic position the inverse is true in lowand middleincome countries also lowsep children may experience a greater increase in overweight risk during macroeconomic downturns resulting in widening inequalities by social disadvantage in the face of economic crises the latest economic recession that started in 2008 and affected many european countries has hit hard portugal however few studies have looked for the impact of the economic crisis in the childhood obesity rates and inequalities currently the portuguese economy is suffering with the impact of the covid19 pandemic which is exerting a radical and abrupt effect on the countrys gross domestic product and unemployment rates this context reinforces the need to have up to date information on levels and trends of overweightobesity to quantify its health effects and to prompt decisionmakers to prioritize action and evaluate where progress is or is not being made the present study aimed to describe the prevalence of childhood obesity in coimbra between 2002 and 2016 and observe how childhood overweight and obesity was associated with sep in each observation period methods sample population and methodology the present study uses populationbased data from multiple projects of the research centre for anthropology and health of the university of coimbra portugal cias has focused on the study of childhood obesity and related determinants and has carried a number of national surveys and crosssectional studies in schools during the last two decades data from the district of coimbra primary schools were randomly selected from the list of public and private schools in the district and all the children were invited to participate questionnaires were delivered in the schools sent home with the child and completed by the childrens caregivers the basis of the instrument was similar for all the studies and details can be found elsewhere the protocol for all studies was in accordance with the international ethical guidelines involving human subjects and was approved by the portuguese data protection authority and the portuguese ministry of education parents were fully informed about all study procedures informed written consent was obtained from the parents childrens consent was obtained prior to the anthropometric measurements children were included in this study if they were between 6 to 10 years old had complete information on height and weight and were given parental consent anthropometry height and weight were measured in schools by researchers who had been trained in standard anthropometric methods and using calibrated equipment where possible the same anthropometric equipment was used in all the studies body mass index was calculated and the cutoff points from the international obesity task force were used to classify childrens nutritional status socioeconomic position sep a proxy variable of the socioeconomic inequalities was defined by the parents education level which considered the highest level of education from mother or father in monoparental families the parental education was based on the childrens principal guardian the variable was scored based upon the portuguese educational system and grouped into three categories low medium and high this has been done in previous studies in the portuguese context since the country does not have an official measure for sep sport activity and television viewing parents reported their childrens physical activity and television viewing the same question was used in 5 studies does your child practice any regular and organized physical activity outside school hours if yes how many minutes per weekdays saturdays and sundays the total minutes per week were calculated by adding the answers for all days of the week parents also reported the time their children spent watching tv during saturdays and the total minutesday were classified as a categorical variable according to the recommendations of the american academy of pediatrics such as less than 2 hoursday and 2 or more hoursday data from 2011 were excluded since the criteria used to define active children and the time watching tv was not the same as in the other studies statistical analysis the prevalence of overweight and obesity among 6 to 10 years old children from coimbra was examined in five different time periods 2002 2009 2011 2013 and 2016 the percentage and confidence interval for overweight obesity and overweight was calculated separately for boys and girls a chisquare test was run to test the differences between sample characteristics across the years the data was divided according to the sep and the percentage of overweight was calculated for the five time periods in order to observe the socioeconomic impact on childrens nutritional status finally a logistic regression was used to examine the association between sep and childrens overweight and obesity in the different time periods odds ratio 95 confidence interval and pvalues were reported all analyses were conducted using spss v23 statistical significance was set at 5 results the mean age of the 7192 children analyzed was 814 and 3610 were girls childrens sep pa and tv viewing were statistically different across time periods overall between 2002 and 2016 there was an increase in the adoption of pa behaviors and more children spent 2 or more hoursday watching tv on saturdays independently of the sex most children were from a highersep particularly from 2009 onwards prevalence of both overweight and obesity was higher among girls than among boys among girls the prevalence of obesity was higher in 2002 and lower in 2009 in boys the lowest prevalence of obesity was found in 2011 and the highest was registered in 2002 the lowest prevalence of morbid obesity in boys was found in 2009 from 2002 to 2016 the decline in overweight and obesity was higher among girls than boys figure 2 shows that the prevalence of overweight including obesity between 2002 and 2016 was continuously higher among children of lowerand mediumsep and lower among highsep children a pattern of decline was observed across the years in children from highersep but the inverse was found for mediumand lowsep children the differences in childrens overweight including obesity between sep groups increased from 59 in 2002 to 147 in 2016 table 3 shows crude and adjusted associations between parental sep and childrens overweight and obesity lowsep was associated with increased odds of overweight and obesity but the association was attenuated after adjustment for childrens sex pa and tv viewing the association between sep and childhood obesity was weaker in this can be considered a positive change and may reflect a trend also reported in other developed countries the literature has supported the notion that in countries facing the childhood obesity epidemic over several years the plateau can be partly attributed to the initiated public health programs focused on the lifestyle of children in the last years the portuguese government implemented several actions including the creation of a sugar tax on sweetened beverages that led to an 11 reduction of total energy intake through sweetened beverages consumption by the population results from the present study are in line with those reported in other portuguese studies and in others countries such as greece reflecting a trend for decrease prevalence of childhood obesity during the economic crisis from 2009 to 2012 temporary economic slowdowns may lead to an increase in parental engagement in health promoting activities when working hours decrease or a decrease in total caloric intake when households face extreme hardship however increasing levels of childhood obesity were observed in times of economic slowdowns in countries such as ireland these discrepancies indicate that changes might differ for overweight and obese children according to their age and the context they live in and the role of cultural characteristics in each country moreover the suggested decrease may not be shared equally across all the socioeconomic groups we found that while the prevalence of overweight and obesity is declining among children from highersep the inverse is seen for their counterparts of lowersep between 2002 and 2016 socioeconomically disadvantaged children were more overweight or obese than their counterparts of highersep and the magnitude of that inequality grew within those years which is in line with previous studies growing disparities in socioeconomic health inequalities during the last years were reported for english schoolaged children and preschool children from the usa while the peak of the recession is over financial situation have not returned to the levels seen prior to the crisis potentially contributing to the continue widening socioeconomic disparities found in the present study the 2008 economic recession due to deterioration of socioeconomic and living conditions had a major contribution to the widening of inequalities in childhood obesity according to sep from 2011 to 2013 portugal lost approximately 7 of the gdp and the recession period was characterized by rising deficits and high unemployment rate since 2008 the percentage of households with children that have been unable to buy meat or fish every second day has more than doubled during the economic crisis in countries such as estonia greece italy and portugal and data from the portuguese national health surveys revealed that the consumption of soup fish and meat significantly decreased between 2005 and 2014 the economic crisis may have reinforced the socioeconomic disparities in obesity related behaviors previously reported for portuguese children namely that children from lowersep had higher odds of consuming saturated and fat diets and less probability of participating in extracurricular sport activities this study has several strengths first to our knowledge it is the first to examine changes in the prevalence of overweight and obesity in portuguese children according to the sep throughout the last decade including the years of the economic crisis second the measures were objectively collected using trained researchers and standardized methods thus reducing the risk of misclassification of weight status and third the studys large sample size provided robust data to study different socioeconomic levels however these were crosssectional studies based on different independent samples which does not allow to suggest the causality and period effects could not be rule out furthermore while the socioeconomic disparities in obesity widened over the time period that included the recession it is not possible to conclude that the recession caused this tendency more studies are needed regarding the direct impact of the recession on individuals households in the abovementioned period and also in the post covid19 era in conclusion childhood obesity remains a challenge for public health and there is a need to promote more daily pa and less sedentary time since we showed that those behaviors may attenuate the association between sep and overweight or obesity reducing inequalities may require a proportionate universal approach where the receipt of an intervention is proportionate to the degree of disadvantage such that more children in deprived groups would receive programs to prevent obesity author disclosure statement the authors declare that there are no competing financial interests

aim to observe the trends of overweight and obesity among portuguese children from 2002 to 2016 before and during the years of the economic crisis and compare these trends according to familys socioeconomic position sep methods prevalence rates were calculated using data from six studies providing comparable estimates from 2002 2009 2011 2013 and 2016 for children aged 610years living in the portuguese midlands n7192 502 girls height and weight were objectively measured children and family characteristics were collected by standard questionnaires a logistic regression was used to test the association between variables results between 2002 and 2016 there was a decrease in the prevalence of overweight and obesity which reached a statistical significance for girls the prevalence of overweight including obesity was high lowsep305 highsep205 and a widening of socioeconomic inequalities was found socioeconomically disadvantaged children had more than 2 times the odds of having obesity than children from highersep even after adjusting for sex physical activity and screentime conclusion while a decrease in overall rates of overweight and obesity was observed from 2002 to 2016 the social inequalities have been widened which suggest the need for public efforts to promote healthy weight at a population level especially in lower socioeconomic classes

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background transgender women in san francisco carry a large populationspecific burden of hiv with almost half estimated to be living with hiv as of 2020 1 trans women in san francisco have lower engagement in hiv care than other groups despite the availability of genderaffirming trans health clinics hiv care experts and universal health care access 2 3 4 trends in san francisco are mirrored throughout the us in a study of trans women receiving hiv care services throughout the country fewer trans women had durable viral suppression than other populations living with hiv 3 viral suppression among trans women is 10 lower than in people living with hiv in san francisco overall covid19 has likely affected trans womens viral suppression and hiv care engagement as of march 2021 viral load tests which are a marker of hiv care engagement were down by 6 in san francisco 2 hiv care engagement and viral suppression are lower among trans women due to a myriad of factors rooted open access correspondence 1 san francisco department of public health san francisco usa full list of author information is available at the end of the article in discrimination toward trans women that leads to disproportionately high housing instability food insecurity criminalization and violence 245 stressors from these experiences are associated with elevated mental distress and substance use which impact hiv care engagement and outcomes 67 many trans women living with hiv have trauma due to healthcare discrimination and may have high levels of anxiety mistrust of providers and fear of retraumatization which present barriers to initiating mental health and substance use services 8 9 10 11 one of the many reasons for high rates of substance use among trans women is to cope with the effects of physical assault and intimate partner violence which is a known barrier to adherence for those living with hiv 1213 there is a considerable unmet need for substance use and mental health services for trans women living with hiv who access care in the public system 14 and yet there is little data that exists on the barriers to substance use services and mental health support for trans women living with hiv our team conducted a qualitative study of the barriers to mhsu services among trans women living with hiv we aimed to engage providers and trans women to assess determinants that could be addressed in an intervention to improve mental health and substance use linkage for trans women living with hiv methods the study included a convenience sample of providers and trans women living with hiv we recruited providers for trans women living with hiv from eight organizations in san francisco health care providers included a cisgender physician and cisgender nurses who specialized in hiv and genderaffirming care cisgender is a term used to describe people whose gender identity aligns with their assigned sex at birth mental health care providers consisted of licensed clinical social workers social service providers were trans and nontrans identified substance use program managers case managers and outreach workers we also recruited trans women living with hiv who were not providers we hosted one focus group of staff from a genderaffirming hiv care clinic and conducted indepth interviews with trans and nontransidentified providers and trans women living with hiv focus groups and indepth interviews were conducted from february 2021 through may 2021 using semistructured interview guides examples of focus group questions centered on exploration for trans women living with hiv examples of the interview questions centered on access interviews were conducted over zoom due to covid safety protocols all interviews were recorded and transcribed verbatim participants provided verbal informed consent all methods were carried out in accordance with relevant guidelines and regulations the study was approved by the institutional review board at university of california san francisco data analysis to identify analyze and report themes found in the data we used an iterative approach in which thematic analysis was employed 15 due to the scarcity of studies regarding mhsu services for trans women we used an inductive approach in which we derived categories and themes directly from the data coding was conducted in dedoose with one coauthor and senior author once coding was completed we held weekly meetings which were attended by all authors we began the process with data reduction identified themes deliberated on the conclusions chose illustrative quotes and wrote and edited the manuscript any concerns or conflicts were discussed on an iterative basis and consensus was reached among the authors results a total of 15 participants were interviewed professional roles and job titles are listed in table 1 we found two main themes and three subthemes barriers and facilitators to accessing mhsu services for trans women were discussed main theme lost trust in the system a main theme identified was that patients and providers had lost trust in the systems ability to best meet trans womens needs for mhsu services providers explained that access to publicly available mhsu services was mostly facilitated through referrals from primary medical care providers although trans women could initiate engagement in services on their own most trans women living with hiv were linked to mhsu services via their hiv specialist and genderaffirming primary care providers mhsu service barriers were linked to barriers to medical care and medical care was a key access point to obtaining publicly available mhsu services for trans women living with hiv in san francisco subtheme suboptimal engagement to mhsu services due to the referral system a recurring system barrier was the referral system for mhsu services participants explained that mhsu referrals were primarily facilitated by medical providers in their genderaffirming primary medical care setting trans women reported that it took multiple medical clinic visits to receive an mhsu referral when referrals were made the onus of followup to initiate a new service was the responsibility of trans women living with hiv lack of followup put the responsibility of initiating mhsu services on the patient which lowered the chance of followthrough to initiation providers reported that service initiation was a laborious process as there were multiple steps in the intake process before people would see a counselor i do think there actually is a wide disparity in terms of how intake is done and this is another problem actually because primary care clinics need to be aware of how each clinic might operate a little bit differently which is kind of a crazy thing to ask them to know additionally providers at the medical clinic were not aware of what intake processes were in place so they did not prepare nor support patients through the intake process subtheme suboptimal engagement to mhsu services due to structural barriers providers and trans women living with hiv described structural barriers to medical substance and mental health care safety clinic reputation language clinic hours and lack of transspecific clinics and trainings may have impacted visit engagement and access to mhsu services providers discussed that some medical and social services had relocated to unsafe neighborhoods in san francisco clinic location was especially important for those who were in recovery or struggling with substance use social service provider d stated its right there in a druginfested area…… people are harassed because when i used to go there id come out of the doctors office you got these kind of pills or those kind of pills its like sweetie come on leave me alone visit attendance among those in recovery and struggling with reducing substance use may have been impacted by having to access medical care in locations where active drug selling was regularly occurring providers also speculated that a clinics reputation may determine if and where trans women would seek treatment providers reported that when it is known that a clinic provided poor health care to the trans community it impacted engagement with the mhsu services structural barriers related to language capacity and hours in which services were offered were also important barriers some providers discussed that there were not enough spanish speakers in mhsu services which created access barriers for monolingual latina trans community members other providers discussed that there were no afterhours mhsu services known to them furthermore some clinics and programs that offered mhsu services struggled with providing transcompetent care providers also said they did not receive medical mental health or substance use training on how to provide genderaffirming services and learned about the needs of trans women living with hiv on the job providers mentioned that even when they were trained on the job many other people in the clinic from security to benefits specialists did not have training on genderaffirming care this was a concern as providers reported that there is no routine oversight or monitoring of the quality of services trans people in the system receive subtheme suboptimal engagement to mhsu services due to constant changes within the existing system another important subtheme was that constant changes in what was offered in the public system created distrust and barriers to engaging in services one participant reported that a side effect of innovations in services and changing city priorities was a lack of consistency that left some key populations including trans women behind social service provider a stated the truth is in san francisco a lot of people have lost trust in the system because weve had so many different programs and weve been so innovative in trying to find the right fit for the community that a lot of people got stepped on and left out in the process constant changes in treatment programs had a negative impact on community members interest in mhsu services changes at the clinic level created instability that reduced patient satisfaction it is worth noting that some substance use services struggled to meet the needs of trans women living with hiv providers discussed that other barriers were shortened treatment times in substance use programs from 6months of detox and inpatient rehabilitation to 30 60 and 90 days decreasing the days of treatment was seen as less efficacious for substance use recovery abstinence outcomes and may impact posttreatment care of their patients people who completed their treatment in 3 months often returned to the same neighborhood …then the panic comes in when the treatment is over of where am i going im going right back to the same neighborhood where i was at its like nothings going to change … something needs to happen where you start making a way for people to not live in that area if possible … maybe they need more housing programs providers reported that trans women recovering from substance use needed longterm stable housing to increase their chances of recovery main theme antitrans and mental health stigma participants reported that they observed and experienced antitrans discrimination in the san francisco public healthcare system social service transidentified provider c recalled a waiting room in a clinic where the provider overheard a staff member deadnaming a trans client she was calling the patient by their male name and then when i was talking to her the patient was like i dont care but i know they care i know in the back of their head they care they just dont have the energy to fight every single day because of the tether between medical care and other services via the referral system healthcare avoidance from discrimination had a direct impact on mhsu access the vicarious trauma providers experienced from serving the trans community may also lessen trans providers interest in pushing for referrals an important barrier to engaging in mental health services specifically was the stigma associated with engaging in therapy one trans woman living with hiv said i think people have this notion that if you say oh i see a therapist that means youre cray cray mental health provider a said related to that is i think theres the issue of stigma at a mental health clinic and seeking out mental health services as a trans person that is just really…i think its a really big barrier the issue of mental health stigma hinders engagement to mhsu service among a community already burdened with multiple stigmas due to their gender identity and or race facilitators and recommendations providers recommended that a peer navigator could be hired to facilitate access to mhsu services through the fractured public health system and help rebuild trust in the system furthermore a support group may reduce the heightened social isolation trans women experience due to covid19 providers suggested that peer support groups would be helpful for people in recovery from addiction i think it would be good to have a group with maybe i would think maybe once or twice a month to have guest speakers that share their experience of how life was for them trans health care needs such as any genderaffirming procedures were seen as a facilitator in seeking mental health services in san francisco residents genderaffirming procedures are covered if they are eligible for medical or healthy san francisco the citys health access program i think that theres a way in which i think the surgery thing and the mental substance use actually runs very much in parallel and that could be an incentive for someone to agree to uptake a navigator because this is a person whos going to help you meet the requirements that you need to get your electrolysis to get your surgery while other providers agreed there was discussion of the impact on the clients comfort level and the necessity of overcoming that discomfort in order to engage in genderaffirming surgeries finally our providers highlighted the importance of making connections between life stressors mental health and substance use as knowledge that could promote interest and engagement in mhsu services one hiv care specialist stated i think that one of the things i see as a need is that for the particularly trans women clients that we have the amount of substance use is really high and not surprisingly we see people who are socioeconomically disadvantaged traumatized etc so a lot more people are going to use to cope lack of knowledge about the root causes of their mental distress or substance use may influence their engagement or lack of engagement to mhsu services increasing this knowledge through peer navigation support groups and selfadvocacy may potentially increase mhsu engagement discussion we found substantial structural and systems barriers that may contribute to unmet mhsu needs for trans women living with hiv in our city our medical services are intricately connected to mhsu services through the referral system thus barriers that impact the medical services in turn impact access to mhsu services one of the most common findings was that linkages between referrals and services were broken participants reported that referrals for mhsu services were often made without followup to ensure services were initiated providers in the medical setting neither had the time nor the resources to ensure referrals converted to services initiation this is consistent with another study finding that lack of followup on referrals in addition to complex referral systems and compartmentalization of specialty services were barriers to health care utilization among trans women living with hiv in canada 16 another system barrier was the availability of ancillary services that were needed to support recovery from substance use and promote mental health for example even after trans women were linked to substance use treatment services and completed a program many faced unstable housing that often resulted in relapse as a way to cope with unmet basic needs stable housing has been identified as a crucial pillar to recovery 17 the need for services to provide access to housing opportunities for jobs and safety are likely needed before trans women living with hiv can be expected to initiate and use mhsu services barriers to services also existed because of the constant changes in the system of services participants described how innovations in services relocation of clinics staff changes and other clinic operation changes resulted in confusion about what services were currently available consistent with past literature safety concerns related to their medical clinics location and the clinics patient population were a deterrent to accessing care 18 the lack of knowledge and misinformation underscores the need for better communication between different clinics and providers in the public health system past studies indicate that organizational changes such as staff turnover and management reorganization were associated with poor patient outcomes and a decrease in the effectiveness of treatment among patients with personality disorders 19 however when health providers are involved in these changes and these changes are communicated successful organizational change can occur and continuity of care for patients can be achieved 2021 we also identified barriers that may impact trans womens willingness motivation and readiness to participate in mhsu services providers discussed how poor mental health hindered their clients ability to engage in their mhsu services trans women living with hiv may lack knowledge about the root causes of their mental distress or substance use and the services offered to address these issues other studies support that people may lack insight into how daily stressors can impact their mental health and their need to engage in mental health services 2223 antitrans stigma within the system and fear of mental health stigma were also important barriers to mhsu service fear of discrimination due to gender identity and hiv stigma have led to delays in health and health care among trans women 9 mental health stigma another stigma that trans women living with hiv in our study expressed is a main barrier to seeking mental health services among trans people 24 several limitations of this study should be noted this study was conducted with trans women transidentified providers and cisgender providers in the public health systems however there were only a small number of trans women interviewed this study relies primarily on the views of transidentified and cisgender providers providers from a private health system or those in acute care settings may provide different perspectives and experiences in the referral process for trans women living with hiv furthermore as san francisco offers universal health care these findings may not apply to other geographical areas we also note that due to isolation uncertainty and in the context of the pandemic an increase in poor mental health puts a strain on an already loaded mental health system 25 barriers may likely have increased and new barriers may result from a shortage of staff and other resources recommendations interventions are needed to mitigate the systems stigma and structural barriers trans women living with hiv face in initiating and engaging in mhsu services perhaps the most important intervention needed is the development of a coordinated mhsu linkage system that helps address concerns and facilitates access for trans women living with hiv to engage in mental health and substance use services participants reported that peer navigation may help facilitate linkages and help address barriers navigation services have been successful in engaging trans women in hiv care 26 navigation services and particularly peer navigators who identify as trans and work in the public health system have been shown to improve hiv care engagement and outcomes and may provide the needed bridge for trans women to link to mhsu services through the fostering of trust the similarities in background between peer and participant and accessibility of peer navigators 26 27 28 29 not only can peer navigators offer support through referrals to ancillary support programs but they can educate provide feedback and motivational interventions to teach about the connection between social and daily stressors with mental health and substance use and may create motivation to engage in mhsu services 2829 peer navigators need institutional support in which genderaffirming trainings for staff are tracked and supervised and a professional support system that has a process to discuss opportunities to decrease stigma and discrimination in the workplace and with the trans community monitoring to ensure quality services are being offered may be supportive of the work of navigators having peer navigators and more staff and health care providers who are from the trans community may help address quality concerns and mitigate antitrans stigma still existing in the public health system while empowering trans women living with hiv and providing the impetus to engage in mhsu services increasing the number of transidentified health care providers needs a substantial increase in education and employment opportunities for the trans community we recommend that additional funds and resources be allocated to increase the number of trans people in the public health workforce conclusions health care providers identified several barriers to mental health and substance use service for trans women living with hiv in san francisco the referral system location of clinic clinic hours clinic reputation lack of transspecific clinics and programs changes within the public health system and antitrans and mental health stigma these findings suggest that there is a need on multiple fronts to help trans women utilize mental health and substance use services a peer navigator may help trans women navigate the health care system and link them to mental health and substance use services competing interests the authors report no real or perceived vested interest related to this article that could be construed as a conflict of interest

background little is known about the barriers to mental health and substance use services for trans women living with hiv we conducted a qualitative study with trans women living with hiv and providers to explore barriers to mental health and substance use services in san franciscowe conducted focus group discussions and key informant interviews with a total of 15 medical mental health substance use and social service providers and trans women living with hiv we identified analyzed and reported themes using thematic analysis and derived themes directly from the data results our study participants identified two main themes and three subthemes one main theme is that trans women and providers have lost trust in the system due to a lack of a linkage system between referrals and services b structural barriers such as service location language capacity clinic hours and c constant changes in services available another main theme is antitrans and mental health stigmainterventions to coordinate linkage from medical to mental health and substance use mhsu services are urgently needed to facilitate the utilization of mhsu services other interventions to improve quality monitoring and system improvement and to address multiple stigmas broadly in society are needed to improve unmet mhsu service needs among trans women living with hiv in san francisco

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introduction every individual must pass through the stages of development in the span of his life the stages of development of human life start from childhood adolescence early adulthood to old age at each stage of development individuals have their developmental tasks that should be passed well according to their age early adult individuals are expected to be able to adapt to new patterns of life development and are also expected to be able to play new roles desires attitudes and values in early adulthood individuals have great opportunities to explore themselves but on the other hand they will also face great challenges hurlock explains that early adulthood starts from the age of 18 to 40 years however according to arnett this exploratory phase is experienced by early adult individuals with an age range of 1829 years which is known as emerging adulthood things that are explored by early adult individuals and usually become problems are related to careerwork peer relations education and life partners the amount of exploration that individuals do in early adulthood causes instability in themselves there are so many changes that they want to make and feel when exploring themselves the various changes experienced by individuals in early adulthood are not all positive there are various kinds of negative feelings that also often arise in their minds not all individuals can go through and overcome the changes and challenges that occur in this phase of emerging adulthood arnett says that this phase of emerging adulthood is a phase filled with a lot of instability the forms of crises that commonly occur in emerging adulthood include feelings of anxiety doubts about their abilities isolation not understanding what their desires and goals are in life confusion about making the right decisions and fear of failure in the future the crisis phenomenon that occurs in individuals in the emerging adulthood phase is often known as the quarterlife crisis the quarterlife crisis was first coined by robbins and wilner as a crisis that occurs due to an individuals unpreparedness to transition from adolescence to adulthood there are 7 dimensions of the quarterlife crisis according to hassler namely feelings of doubt and doubt in making a decision feeling hopeless because they always find failure to achieve an achievement having a negative selfassessment for things that happen that are not in line with expectations feeling trapped in a difficult situation because they have to carry out what has already been chosen feeling anxious about things that will happen in the future feeling depressed when faced with the fact that they have to live independently feeling worried about interpersonal relationships because they have not been able to meet expectations demands and standards in the surrounding environment these negative feelings if not handled properly will result in emotional crises ranging from stress depression to other psychological disorders some individuals experiencing a quarterlife crisis tend to feel panicked insecure depressed and useless many questions and demands arise because of the prevailing norms and culture for example indonesia with a collectivistic culture that tends to demand to get married and continue their offspring have a career or job and have good social relations the survey conducted by robinson and wrig on 1023 early adult individuals in the united kingdom showed that as many as 70 of individuals aged 30 years experienced many crises when they were in their 20s the same thing was also found in which showed that around 86 of individuals experienced a quarterlife crisis in a situation where the individual is experiencing a quarterlife crisis phase in his life the worlds current condition is being hit by the covid19 pandemic a disaster that in an instant changed the situation and condition of the entire world where there are many emergency rules and policies issued by the government to limit the activities and movement of all human beings this situation certainly has a considerable impact on each group in various ways individuals who usually interact and communicate by meeting physically are no longer a priority during the covid19 pandemic then the impact of the covid19 pandemic for early adults is increasing unemployment because fewer job vacancies are opened this is reinforced by the big data analysis presented by the central statistics agency which explains that job vacancies have decreased as a result of the covid19 pandemic unemployment is not limited to individuals who have not worked or are looking for work individuals who work but are less productive can also be included in the unemployment category the economic impact also makes many companies unable to operate normally increasing the number of unemployed this can be seen from the statement from the minister of national development planning head of bappenas suharso monoarfa who explained that the number of unemployed in indonesia had increased to 37 million people due to the covid19 pandemic these economic problems cause considerable pressure for individuals stress due to a mismatch between expectations and reality in work and social relations is often found as the thing that triggers the emergence of a quarterlife crisis in early adulthood the pandemic has impacted the mental health of young adults given the many changes experienced by early adulthood individuals and coupled with the covid19 pandemic social support from those closest to them becomes very important social support can be defined as practical emotional and informational assistance from significant others such as family members friends or coworkers or people who are always there when needed in the current state of the covid19 pandemic with everything mostly done from home individuals will be more intense in meeting their families who live under the same roof family is the closest person to each individual where the nuclear family consists of parents and children or husband and wife meanwhile the extended family consists of a wider network namely there are several generations in it such as grandmothers grandfathers uncles aunts and cousins family functioning is an interaction between family members to achieve functions and goals in a family goleman states that a family that functions optimally has closeness and openness between each of its members research by retnowati et al shows that the closeness of each family member is one of the factors supporting understanding and expressing emotions in individuals therefore this study aims to see the correlation between family functioning and the quarterlife crisis in early adulthood during the covid19 pandemic research method the subjects involved in this study were 123 individuals the sampling technique used in this research is purposive sampling in the form of accidental sampling where subjects who can be involved in research are those who fit the criteria set by the researcher the population in this study were early adult individuals ranging in age from 18 to 29 years adjusted to the criteria for early adulthood who tend to experience a quarterlife crisis this study uses a correlational quantitative approach correlational quantitative research is a measurement of the correlation between 2 or more variables there are two variables studied in this study namely family functioning and a quarterlife crisis this research instrument uses the mcmaster family assessment device scale and the quarter life crisis quiz scale with a likert scale model containing 5 alternative answers the likert scale is a scale that puts response categories at points along a psychological continuum the mcmaster family assessment device scale proposed by epstein bishop and levin contains 38 items adapted and modified with aspects that exist on the scale namely problem solving communication roles ability to react affective involvement and behavior control the quarterlife crisis scale developed by hassler which was later adapted and modified by agustin amounted to 25 items with aspects of indecision in making decisions hopelessness negative selfassessment trapped in difficult situations feelings of anxiety depression to feelings of worry about interpersonal relationships that are being and will be built this questionnaire contains statements about how individuals perceive the uncertainty of the situation around them including the emotions they feel from themselves namely career achievement interpersonal relationships education and financial stability the research instrument was prepared using a google form and distributed through social media data collection was carried out for approximately 2 weeks starting from october 4 2021 the data that has been collected is then scored and analyzed descriptively from each variable before carrying out the correlation test a normality test and linearity test were carried out using the statistical analysis program jeffreyss amazing statistics program version 141 based on the results of the validity test of adaptation and modification of the family functioning scale and quarterlife crisis the different power values for each item on a scale are greater than 01 without any item being dropped while the results of the reliability test of the family functioning scale show the reliability value of the alpha value of 0963 which indicates the reliability of this scale is very high the quarterlife crisis scale has an alpha reliability value of 0967 which is also very high the data analysis technique in this study uses nonparametric statistics namely the spearmanrho correlation test because the data is not normally distributed result and discussion result the results of the assumption test for normality showed that the distribution of the data was not normally distributed at 0001 while the linearity test showed a significance value of 0066 which means it can be said to be linear the results of the spearman rho correlation test show a value of 0012 with a correlation coefficient of 0226 which means that there is a significant correlation in a negative direction between family functioning and the quarterlife crisis in early adulthood during the covid19 pandemic where if the functioning of the family is high then the quarterlife crisis in early adulthood is low on the other hand if the functioning of the family is low the quarterlife crisis in early adulthood is low this is in line with the research of cheung et al which explains that good family functioning can improve individual wellbeing and reduce early adult individual anxiety related to social relations the results of score categorization on the family functioning variable showed that there were 2 subjects in the high category 120 subjects in the medium category and 1 subject in the low category while the categorization of scores on the quarterlife crisis variable shows 37 subjects are in the high category 59 subjects are in the medium category and 27 people are in the low category based on the analysis of demographic data the distribution of subjects based on gender was obtained as follows table 3 shows that the number of female subjects was more than male subjects namely 86 subjects and 37 people demographic data based on marital status can be explained as follows details of the level of family functioning and quarterlife crisis based on categorization can be seen further in table 2 table 4 shows 109 subjects are not yet married and 14 subjects are married demographic data based on employment status can be explained as follows table 6 shows that 87 subjects lived with their parentsfamily 11 subjects lived with their partners 4 subjects lived with siblings and 21 subjects lives alone discussion the results of this study showed that more than 70 of the subjects involved in the study were in a moderate to high quarterlife crisis phase this condition is considered a bad thing because the impact experienced and felt by early adult individuals when they were unable to get through the crisis they experienced was quite severe early adult individuals who are caught in the crisis will feel useless increasingly doubting their abilities fearing failure to face the future and not being confident in their life plans and goals in line with the research demographic data dickerson states that women tend to experience more quarterlife crises than men because the demands on women are not only about getting married and taking care of the family but also being able to work and have good financial conditions stable and build social relations women in asia especially indonesia are still required to get married before the age of 30 because of the collectivistic culture in this study more subjects were unmarried than married this is related to the quarterlife crisis which states that two things are usually the focus of individuals when entering early adulthood the first is a career and the second is related to love employmentrelated demographic data is that more early adult individuals in this study were unemployed than employed this can be one of the factors that cause individuals to experience a quarterlife crisis research from basis found that one aspect that can improve the quality of life of early adult individuals is work early adult individuals usually desire to have a career before marriage or to continue their education to a higher level however sometimes in reality there are still many early adult individuals who do not have the desired job or that is by their educational background in addition dissatisfaction with the work being undertaken can also cause individuals to experience a quarterlife crisis in addition based on demographic data regarding residence status more early adult individuals are living with their parents or family than those living with their spouses siblings or living alone ideally early adult individuals are more independent and no longer dependent on their parents on the other hand early adult individuals have the perception that they want to no longer burden their parents this feeling of being trapped in a difficult situation is known to trigger a quarterlife crisis in early adulthood in the time of the covid19 pandemic it is increasingly making each individual have limited space for movement the reality is that early adulthood individuals need social support to help them deal with crises in their lives andayani found that social support provided for individuals will be able to help them carry out good coping strategies to overcome the crisis they are facing in this study it is explained that the family is the closest support system for early adult individuals especially during this covid19 pandemic because early adult individuals also need good family functioning to help them face the crisis interaction between family members is one way of managing crises and adjusting to the circumstances that occur good individual interpersonal relationships and the high social support received by early adult individuals can help reduce the quarterlife crisis experienced conclusion based on the research data it can be concluded that there is a significant correlation between family functioning and the quarterlife crisis this shows that the family which is the closest person to each individual has a role in getting through the crisis faced by individuals in early adulthood this study shows that the family does not only play a role in the developmental stages of children and adolescents but even into early adulthood the family still plays a role this research is an initial study related to the role of family functioning in the quarterlife crisis in early adulthood especially during the covid19 pandemic therefore the researcher hopes that this research can be further developed by adding other variables that can play a role in overcoming the quarterlife crisis in early adulthood in addition it is hoped that future researchers will set more specific subject criteria so that data comparisons can be carried out

this study aims to determine the relationship between family functioning and the quarterlife crisis in early adulthood during the covid19 pandemic the subjects in this study were early adult individuals aged 1829 years with a total of 123 subjects data collection was done by the purposive sampling method this research instrument uses the family assessment device fad scale and the quarter life crisis quiz data were analyzed by the nonparametric statistical analysis technique spearman rho the results of data processing obtained a correlation coefficient p of 0226 with a significance value of 0012 p 005 which means that there is a negative relationship between family functioning and quarterlife crisis in early adulthood where if the functioning of the family is good then the quarterlife crisis is low and vice versa if the functioning of the family is bad then the quarterlife crisis is high

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introduction rethinking the concept of privacy in the digital age inevitably entangles the descriptive and the normative dimensions of this concept theoretically these two dimensions of privacy can be distinguished one dimension can describe the degree of privacy people enjoy without taking a normative stance about the desirable degree of privacy in normative discussions the focus is on the reasons why privacy is important for leading a fulfilling life this distinction should not distract us from the fact that privacy is not a completely neutral concept instead it has a positive connotation for example an invasion of privacy is a violation of or intrusion into something valuable that should be protected discussion of the concept however brings into question why privacy should be cherished and protected in the digital age the normative dimension is the object of intense discussion existing dangers to privacybecause of big data applications cloud computing and profilingare widely recognized but feelings of resignation and why should we bother lie dormant defenders of privacy are regularly faced with scepticism which is fueled by schmidts innocent people have nothing to hide and zuckerbergs having two identities for yourself is a lack of integrity traditionally in defences of privacy the focus has been on the individual privacy was defined in terms of an individuals space which was seen as necessary for meeting the individuals vital interests in the last decade however we have seen a shift in the emphasis a view of privacy as the norm that regulates and structures social life has gained importance in both law and philosophical literature for instance the european court of human rights previously stressed that data protection was an individuals right not to be interfered with however more and more the court is focusing on individuals privacy as protection of their relationships with other human beings in philosophical literature on privacy many scholars have explicitly distanced themselves from the individual approach and instead study the social dimensions of privacy helen nissenbaum is by far the most important spokesperson for the social approach she has introduced the notion of contextual integrity as an alternative to what she describes as too much focus on individuals rights based notions of privacy nissenbaum criticizes the socalled interestbased approach which defines conflicts in terms of interests of the parties involved for instance uncontroversial acceptance of healthcare monitoring systems can be explained by pointing to the roughly even service to the interest of patients hospitals healthcare professionals and so on the problem with this approach according to nissenbaum is that it sooner or later leads to hard fought interest brawls which more often than not are settled to the advantage of the more powerful parties it is necessary to create a justificatory platform to reason in moral terms as a rightsbased approach is not satisfactory she proposes a normative approach that does more justice to the social dimension the distinction between a focus on the individual and privacy as social value is not only of academic importance for policies on privacy this makes quite a difference on the one hand the emphasis can be on an individuals right to decide about personal interests and transparency for empowering the individual as for instance the european data protection supervisor asserts on the other hand the emphasis can also be on institutional arrangements that protect social relationships the fact that good privacy policies require measures should not be a reason to overlook their fundamental differences in this paper we compare individualbased justifications of privacy with the social approach we open with a discussion of the strengths of the individualfocused approach by relating privacy to a concept that has a strong normative sense and is most closely associated with individualbased privacy conceptions autonomy as we will see a defence of privacy along these lines is both possible and necessary in our discussion of the social approach we focus on helen nissenbaums model a critical discussion of the normative dimension will lead to suggestions for strengthening this model the individual approach the importance of privacy autonomy the history of justifications of privacy starts with warren and brandeiss legal definition of privacy as the right to be left alone this classic definition is completely in line with the literal meaning of privacy the word is a negativum of public the right to privacy is essentially the right of individuals to have their own domain separated from the public the basic way to describe this right to be left alone is in terms of access to a person in classic articles gavison and reiman characterize privacy as the degree of access that others have to you through information attendance and proximity discussion about the importance of privacy for the individual intensified in the second half of the twentieth century as patterns of living in societies became more and more individualistic privacy became linked to the valued notion of autonomy and the underlying idea of individual freedom in both literature on privacy and judicial statements this connection between privacy and autonomy has been a topic of intense discussion sometimes the two concepts were even blended together even though they should remain distinct a sharp distinction between privacy and autonomy is necessary to get to grips with the normative dimension of privacy the concept autonomy is derived from the ancient greek words autos and nomos especially within the kantian framework the concept is explicated in terms of a rational individual who reflecting independently takes his own decisions being autonomous was thus understood mainly as having control over ones own life in many domains of professional ethics autonomy is a key concept in defining how human beings should be treated the right of individuals to control their own life should always be respected the patient the consumer and the research participant each must be able to make his or her own choices physicians are supposed to fully inform patients advertisers who are caught lying are censured and informed consent is a standard requirement of research ethics in each of these cases persons should not be forced tempted or seduced into performing actions they do not want to do when privacy and autonomy are connected privacy is described as a way of controlling ones own personal environment an invasion of privacy disturbs control over ones personal sphere this notion of privacy is closely related to secrecy a person who deliberately gains access to information that the other person wants to keep secret is violating the other persons autonomy through information control we see the emphasis on privacy as control over information in for instance marmors description of privacy as grounded in peoples interest in having a reasonable measure of control over the ways in which they can present themselves to others autonomy however does not entail an exhaustive description of privacy it is possible that someone could have the ability to control yet he or she lacks privacy for instance a woman who frequently absentmindedly forgets to close the curtains before she undresses enables her neighbour to watch her if the neighbour does so we can speak about a loss of the womans privacy nevertheless the woman still has the ability to control at any moment she could choose to close the curtains thus privacy requires more than just autonomy the distinction between privacy and autonomy becomes clearer in judith jarvis thompsons classic thought experiment imagine that my neighbour invented some elaborate xray device that enabled him to look through the walls i would thereby lose control over who can look at me but my privacy would not be violated until my neighbour actually started to look through the walls it is the actual looking that violates privacy not the acquisition of the power to look if my neighbour starts observing through the walls but im not aware of it and believe that i am carrying out my duties in the privacy of my own home my autonomy would not be directly undermined not only in thought experiments but also in literature and everyday life we witness the difference between autonomy and privacy taylor refers to scrooge in dickens a christmas carol who is present as a ghost at family parties his covert observation of the intimate christmas dinner party implies a breach of privacy although he does not influence the behaviour of the other people in everyday life we do not experience an inadvertent breach of privacy as loss of autonomy these examples make it clear that there is a difference between autonomy which is about control and privacy which is about knowledge and access to information the most natural way to connect the two concepts is to consider privacy as a tool that fosters and encourages autonomy privacy thus understood contributes to demarcation of a personal sphere which makes it easier for a person to make decisions independently of other people but a loss of privacy does not automatically imply loss of autonomy a violation of privacy will result in autonomy being undermined only when at least one additional condition is met the observing person is in one way or another influencing the other person such a violation of privacy can take various forms for instance the person involved might feel pressure to alter her behaviour just because she knows she is being observed or a person who is not aware of being observed is being manipulated this in fact occurs more than ever before in the digital age loss of autonomy in the digital age in the more than 100 years following warren and brandeis publication of their definition privacy was mainly considered to be a spatial notion for example the right to be left alone was the right to have ones own space in a territorial sense eg at home behind closed curtains where other people were not allowed an important topic in discussions of privacy was the embarrassment experienced when someone else entered the private spatial domain consider for example public figures whose privacy is invaded by obtrusive photographers or people who feel invaded when someone unexpectedly enters their home the digital age is characterized by the omnipresence of hidden cameras and other surveillance devices this kind of observation and the corresponding embarrassment that it can cause have changed our ideas about privacy the main concern is not the intrusive eye of another person but the constant observation which can lead to the panopticon experience of the interiorized gaze of the other it is selfevident that the additional conditions are now being met viz the persons autonomy is threatened in situations in which the observed person feels impeded to follow his impulses the loss of privacy leads to diminished autonomy the loss of autonomy resulting from persistent surveillance becomes even more striking when we take into consideration the unprecedented collection and storage of nonvisual information collecting data on individuals such as through the activity of profiling offers commercial parties and other institutions endless possibilities for approaching people in ways that meet the institutions own interests driven by invisible algorithms these institutions temp nudge seduce and convince individuals to participate for reasons that are advantageous to the institution the widespread application of algorithms in decisionmaking processes intensifies the problem of loss of autonomy in at least two respects first when algorithms are used to track peoples behaviour there is no observer in the strict sense of the word no human actually ever checks the individuals search profile nevertheless the invisibility of the watchful entity does not diminish the precision with which the behaviour is being tracked in fact it is quite the opposite second in the digital age mere awareness of the possibility that surveillance techniques exist has an impact on human behaviour independently of whether there is actually an observing entity more than ever before foucaults addition to benthams panopticon model is relevant the gaze of the other person is internalized this brings us to the conclusion that despite the fact that a loss of privacy does not necessarily involve a loss of autonomy in the digital age when privacy is under threat the independence of individual decisions is typically also compromised these observations are striking when we consider that western societies in particular focus on the individual person whose autonomy is esteemed very highly we can contrast the selfimage and ego vocabulary that prevail in everyday life with online situations where an individuals autonomy is lost there are two examples of this from domains where autonomy has traditionally been considered to be very important and where it has come under threat advertising in consumer and advertising ethics the consumers free choice is the moral cornerstone in the online world this ethical value is scarcely met digitalisation facilitates customised advertising which originally was presented as a service for the individual tailored information was supposed to strengthen a persons capacities to make choices to his own advantage but now the procedure has become degenerated people are placed into a filter bubble based on algorithms and corporate policies that are unknown to the target persons individuals control and knowledge about the flow of information are lost as we all are keenly aware requiring people to agree with terms and conditions does nothing to solve the problem in the first place very few people even read them this kind of autonomy is apparently too demanding for most people to exercise secondly the terms and conditions do not themselves say anything about the algorithms todays consumer finds himself in a grey area where he struggles between exercising autonomy and being influenced by others of course it is an empirical question as to what degree the algorithms influence customers behaviour the least we can say is that the wide application of algorithms suggests that they must have a substantial effect following the critical study of sunstein in which he warns that the political landscape might become fragmented much research has been undertaken on the influence of algorithms on political opinions this has resulted in a nuanced view of the widespread existence of confirmation bias for instance it has been shown that the need for information that confirms ones opinion differs from other kinds of information and that it is stronger in those people who have more extreme political opinions furthermore there turns out to be a major difference between how often individuals actively search for opinions similar to their own and how often they consciously avoid noticing opinions that differ from their own people surfing the internet often encounter news they were not consciously looking for but which they nevertheless take seriously this is called inadvertent attention for news the question how online networks influence exposure to perspectives that cut across ideological lines received a lot of attention after the brexit referendum and trump election using data of 101 million facebook users bakshy et al confirm that digital technologies have the potential to limit exposure to attitudechallenging information the authors observed substantial polarization among hard content shared by users with the most frequently shared links clearly aligned with largely liberal or conservative populations but onesided algorithms are not always of decisive importance the flow of information on facebook is structured by how individuals are connected in the network how much crosscutting content an individual encounters depends on who his friends are and what information those friends share according to bakshy et al on average more than 20 of an individuals facebook friends who report an ideological affiliation are from the opposing party leaving substantial room for exposure to opposing viewpoints dubois and blank using a nationally representative survey of adult internet users in the uk found that individuals do tend to expose themselves to information and ideas they agree with but they do not tend to avoid information and ideas that are conflicting particularly those who are interested in politics and those with diverse media diets tend to avoid echo chambers dubois blank observe that many studies are single platform studies whereas most individuals use a variety of media in their news and political information seeking practices measuring exposure to conflicting ideas on one platform does not account for the ways in with individuals collect information across the entire media environment even individuals who have a strong partisan affiliation report using both general newssites which are largely nonpartisan and include a variety of issues these findings are consistent with other studies that indicate that only a subset of americans have heavily skewed media consumption patterns research ethics corporations such as google and facebook as well as data brokers use peoples personal information in their research activities one disturbing example is the research that facebook conducted in 2014 the corporation experimented on hundreds of thousands of unwitting users attempting to induce an emotional state in them by selectively showing either positive or negative stories in their news feeds acquiring information by manipulating people without their informed consent and without debriefing them is a gross violation of the ethical standards that established research institutions must follow such violations of peoples autonomy indicate a striking contrast between the offline ideals of most users and their online practices whereas in the offline world we typically take autonomy as a moral cornerstone on the internet this ideal is not upheld how to deal with this discrepancy in values upheld in the real world and on the internet is one of the central challenges in discussions about privacy when we do not strive for more clarity and transparency in the flow of information we relinquish autonomy a value that is deeply embedded in western cultures the social approach we might be tempted to associate the emergence of the social approach in discussions about privacy with the digital age as if only in these times of rapid information flow reflection on the social dimension of privacy is justified this however would be a false suggestion during the twentieth century an important undercurrent in discussions of privacy was an emphasis on the importance of privacy for social relationships privacy was seen as a component of a wellfunctioning society in that it plays an important role in what is described as a differentiated society privacy guarantees social boundaries that help to maintain the variety of social environments because privacy provides contexts for people to develop in different kinds of relationships respect for privacy enriches social life privacy also facilitates interactions among people along generally agreed patterns as the poet robert frost remarked in mending wall good fences make good neighbors this characteristic of privacy is important not only at an institutional level in peoples private lives the creation and maintenance of different kinds of relationships is possible only when subtle differences in patterns of social behaviour and social expectations are recognized remarkably this subtlety becomes clearest in examples of intrusions of privacy in unoccupied public places consider someone who deliberately attempts to sit beside lovers who are sitting together on a park bench or intrusive bystanders at the scene of a car accident in both cases the intrusions of the privacy of the persons involved are very important the most trivial words and gestures can reflect a deep dedication and intense relationship between two people in one of the first descriptions of the core of privacy the english jurist and philosopher stephens depicted it as an observation which is sympathetic sympathetic is derived from the greek word sympathein which means being involved with the same indeed in private situations different people experience the same things as important a small clearly distinguished domain is created and the events should be shared only by those who directly participate in them the persons involved are tied together by having undergone common experiences they have an immediate relationship to what is at stake and in this relationship they are deeply engrossed an outside observer who has not participated in the common experience is viewed as invading their privacy he cannot share the meaning of what is going on because he has not been directly involved when understood this way the concept of privacy is helpful in explaining the difference between occasionally being noticed and being eavesdropped upon in cases involving eavesdropping someone participates in an indirect and corrupt way in what is going on the participation is indirect because the person acquires knowledge without participating directly the things that are at stake should not concern him the participation is corrupt because the indirect participant is not genuinely interested in what is going on he sees the others involved not primarily as people with their own sensibilities goals and aspirations but as the objects of his own curiosity when the other people become aware that they are being observed they begin to see themselves through the eyes of the observing person and they thereby lose spontaneity their direct involvement in the meaning of what is at stake is lost in cases like these neither the content of the action nor the secrecy surrounding it qualifies the actions as belonging to the private sphere the content might be very trivial but it would be offensive to the lovers sitting on the park bench to suggest that what they are expressing to each other could be made public the most commonplace of actionsfor instance walking with ones children down the streetcan be private note the indignation of people in the public eye about obtrusive photographers who take photographs of public figures while they are doing ordinary things like we all do the essence of secrecy is intentional concealment but the private situations that we discuss here concern behaviour inward emotions and convictions that can be shown and experienced in various places that are accessible to everyone as for instance in the case of the young couple we saw sitting in the park this characteristic of privacy in social relationships cannot be captured by the concept of autonomy in the sense of an individual independently and deliberately making his or her own choices what is at stake in situations like these is not a lack of transparency there is no question about the autonomy of an independent individual the person would be deeply engrossed in precarious and delicate situations involving social relationships an intrusion on this persons privacy would mean that he feels inhibited in being immersed in the social interaction and share the meaning at stake in order to do justice to this notion of privacy other strategies for protecting privacy are required it is not primarily an individuals mastery that must be protected rather it is the possibility for the individual to be properly embedded in social relationships to answer the question of how this concept of privacy manifests itself in the digital age we turn to helen nissenbaums contextual integrity model which is an elaboration of socially embedded privacy in the digital age helen nissenbaums contextual integrity model after having conducted several preliminary studies helen nissenbaum published privacy in context a book that became very influential in philosophical and political debates on privacy it inspired the obama administration in the united states to focus on the principle of respect for context as an important notion in a document on the privacy of consumer data the core idea of nissenbaums model is presented in the opening pages of her book what people care most about is not simply restricting the flow of information but ensuring that it flows appropriately in nissenbaums view the notion appropriate can be understood to mean that normative standards are not determined by an abstract theoretically developed default the criteria for peoples actions and the expectations of the actions of other people are developed in the context of social structures that have evolved over time and which are experienced in daily life as examples of contexts nissenbaum mentions health care education religion and family the storage monitoring and tracking of data are allowed insofar as they serve the goals of the context privacy rules are characterized by an emphasis on data security and confidentiality in order to ensure that the flow of information is limited only to the people directly involved the key players in the context have the responsibility to prevent the data from falling into the wrong hands nissenbaums model is wellsuited for the information age it describes privacy in terms of the flow of information and the model is easy to apply to institutional gatekeepers who deal with data streams at the same time the contextual approach deviates from the classical view of autonomy the personal control of information loses ground and shared responsibility that is expressed through broader principles becomes more important nissenbaum considers it a serious disadvantage of the autonomy approach that it is usually associated with notions of privacy that are based on individuals rights in the articulation of justificatory frameworks in policymaking and the legal arena we often see major conflicts among parties who insist that their rights and interests should be protected she also distances herself from the connection between privacy and secrecy privacy is not forfeited by the fact that someone knows something about another person within contexts information about persons might flow relatively freely in line with this nissenbaum puts into perspective the classic distinction between the private and the public realm contexts might transgress borders between the public and the private for instance professionals in social healthcare work with information that comes from intimate spheres as professionals they are however part of the public domain it is their professional responsibility to deal properly with the flow of information within the realm of their own activities normative weakness and the threat of conservatism nissenbaums rejection of autonomy as the basis for privacy raises questions about the normative strength of her model does she indeed deliver the justificatory platform or framework to reason in moral terms she asserts that her model does do so when she claims that the context procures a clear orientation which can guide policies on privacy this claim suggests that it is completely clear what a context is as is the way in which it delivers a normative framework in this respect nissenbaums work has some flaws in her description of context as a structured social setting that guides behaviour nissenbaum refers to a wide array of scholars from social theory and philosophy nissenbaum for instance reviews bourdieus field theory schatzkis notion of practice in which activities are structured teleologically and walzers spheres of justice there are however major differences among these authors schatzki focuses on action theory and the way in which people develop meaningful activities walzer describes the plural distribution of social goods in different spheres of human activity and bourdieu focuses on power relationships when searching for a normative framework it matters which of these approaches is being taken as the starting point the theories also differ in their emphasis on a descriptive versus a normative analysis this vagueness about the normative framework is a serious problem because protection of privacy in the digital age requires systemic criteria to measure new developments against established customs nissenbaum assumes at the start that online technologies change the way in which information flows but they do not change the principles that guide the flow of information the principles by which digital information flows must be derived from the institutions as they function in the offline world ie the background social institutions consider online banking as an example in the digital age contacts between costumers and banks have completely changed impressive buildings in which people previously made financial transactions have been partly replaced by the digital flow of information but the core principles regarding the actions of the actors have not changed this implies that people working within the context are familiar with the sensible issues and 1 3 they have the final say the only thing that must be done is to translate the principles to the new situation in case the novel practice results in a departure from entrenched norms as nissenbaum says the novel practice is flagged as a breach and we have prima facie evidence that contextual integrity has been violated indeed nissenbaum admits that this starting point is inherently conservative and she flags departures from entrenched practice as problematic she leaves open the possibility that completely new developments can lead to a revision of existing standards and she gives ample guidelines about how to implement such a revision nissenbaums emphasis on existing practices must be understood in the context of a nonphilosophical and nonsociological source eg the notion of reasonable expectation which plays an important role in united states jurisprudence on privacy in the conclusion of her book nissenbaum describes privacy as a right to live in a world in which our expectations about the flow of personal information are for the most part met reasonable expectation was the core notion in the famous case of katz versus united states which laid the foundation for privacy discussions in the united states before katz it had already been recognized that within ones own home there was a justified expectation of privacy katz dealt with the kind of privacy situations in the public sphere that was described in the preceding paragraph in this case a phone call had been made from a public phone booth while enforcement agents used an external listening device to listen to the conversation the court considered this to be unjustified the fourth amendment to the united states constitution protects people but not places therefore the actions of the enforcement agents constituted an intrusion regardless of location oral statements are protected if there is a reasonable expectation of privacy this extension of privacy was a revolutionary development and the notion of reasonable expectation turned out to work well for instance in cases where the distinction between hardtoobtain information and information that is in plain view plays an important role in many cases however just because information is in plain view does not mean there is a reasonable expectation of privacy consider the situation where the police accidentally uncover illegal drugs concealed in an automobile in cases like this an appeal to privacy to protect criminals cannot be justified however the normative strength of the notion reasonable expectation is weak the notion refers to existing practices reasonable is what in a society counts as reasonable in many cases this might work out well we usually do not need polls to make it clear what reasonable means eavesdropping is despised yet video surveillance in a taxi is generally accepted police arbitrarily invading a house is not justified however police actively working to find concealed drugs are justified in times of rapid development referring to existing practices to find ultimate normative justification is not a good strategy for at least two reasons first the danger of rigid conservatism might be just around the corner this danger was already present in nissenbaums idea that standards for online intrusions of privacy must be derived from the offline world in times of technological developments new problems make their appearance and new technologies change the effects of existing rules particularly in the digital age practices and normative conceptions are under pressure existing frameworks cannot be used unequivocally in the times of katz the distinction between hardtoobtain information and information in plain view was based on how easy it was to access the information irrespective of the type of information this distinction is outofdate in the digital age the revolution in techniques of surveillance makes almost all information that is in plain view information any development in surveillance or monitoring if communicated well might be placed under the umbrella of reasonable expectation suppose a government takes highly questionably measures and is completely honest about doing so the government does not want to surprise its citizens so it duly informs the public that this is how things are being done anyone who makes a phone call has the expectation that her data will be stored we all know this is not simply a hypothetical example the same pattern can be distinguished in the way google and facebook justify their practices thanks to mark zuckerbergs and eric schmidts statements facebook and google users do not have expectations about privacy ironically the insistence on transparency which is so often heard in debates on privacy takes the sting out of the idea of reasonable expectation transparency implies that data streams can flow in all directions as long as the responsible persons are open and honest about it some would suggest that the word reasonable has a certain normative strength the word refers to standards that have a certain degree of plausibility and are widely shared again however in order to guarantee protection of privacy we need more guidance about what these standards mean for the concept itself does not provide this guidance the matter is turned upside down when we search for normative strengths simply by referring to current practices the threat of conservatism in the digital age and the failure of the notion reasonable expectation lead us to the conclusion that strong anchors which meet certain criteria are needed this is first of all apparent in the conservativeprogressive dimension the standards must be related to existing frameworks alienation from these hampers acceptance on the other hand they shouldnt be so rigid that promising new developments are impeded second it is apparent in the generalspecific dimension to motivate people they must be so general that a wide range of applications is possible nevertheless they should not be too vague they must be specific enough to contain guidelines for action a variety of notions that describe normative standards accompany nissenbaums reference to various philosophical and sociological sources as far as the dimension conservativeprogressive is concerned she switches on the one hand between internal logic of and settled rationale for social systems and she pleads on the other hand for the moral superiority of new practices nissenbaum also speaks about ultimate criteria as delivered by the purposes and ends of the context this description is too concrete in times of rapid technological developments todays targets become outmoded tomorrow some more general notion is required in a recent refinement of her model nissenbaum provides more clarity for example she mentions a few domains of cooperative activities that need not count as context per se the business model for instance does not count as context because in business the core value is earning money when everything is for sale it is impossible to develop independent substantive landmarks she also makes it clear that a describing context as a technological system is highly problematic it leads to technological determinism and therefore is a petitio principi normative standards about how to deal with technological problems are derived from technological developments a proper context can count as what she describes as a social domain remarkably she hardly considers this notion the search for independent substantive landmarks might be guided by the expression norms and values which nissenbaum uses in her book norms are fixed standards usually they are concrete descriptions of particular things that must be realised or derived norms are necessary for guiding actions but in times of fast changes they are too rigid values on the other hand are very general even though they are not vague values such as justice responsibility and efficiency are used in a wide variety of contexts this is especially true for the group of values that is concerned with the way in which we treat other people these values surpass the context they are important in society as a whole they are therefore too general to deliver a normative orientation for actions within a context one way to solve this problem would be to rewrite the values in a contextspecific sense this requires orientation points that refer to characteristics of the contexts at the end of her book nissenbaum admits that her description of context is deficient she acknowledges that further research on the concept is necessary we suggest following a suggestion that nissenbaum herself made in a short paragraph in privacy in context she refers to michael walzers conception of goods as constitutive for contexts it is the only notion to which she devotes a full paragraph intriguingly however she does not elaborate on this concept in her later work this notion could be very useful for making more explicit the underlying normativeness in contexts the concept of substantial goods in his famous spheres of justice walzer stresses that he does not include material objects of transaction in his definition of goods instead he uses a broader and more abstract notion of goods they are immaterial qualities that people conceive and create in the course of their actions in his book he comments on goods such as security education health kinship and life while performing an action people are oriented towards goods such as these the goods come into peoples minds before they come into their hands goods are moreover crucial for social relationships the development of goods takes place in social contexts for people to be able to live together they must have more or less shared conceptions about the meaning of vital goods the main goal of walzers book is to show that different spheres of actions are characterized by different conceptions of goods and subsequently different distributions of principles the book turned out to be a very important expression of an idea that became very influential in determining standards for professional conduct when human beings closely share an orientation on good actions with other human beings this leads to a proper professional life only when goods are determined is it possible to adjust the standards without going into detail we can point to two lines of thought that have contributed to elucidation and specification of the notion good both charles taylor and bernard williams have distinguished goods from objects of impulsive desires and wishes by explaining that goods have an impact on a deep level of motivation goods are judged as belonging to qualitatively different modes of living they are the fulfilment of deeper commitments and engagements not the intensity of the desire but the sense of worth that makes life meaningful is characteristic of human attitudes towards goods attachment to and engagement with goods extend over a longer period and lead to a deeper fulfilment when satisfied goods give meaning to professional life for professional ethics alisdair macintyres contributions have been of great importance he elaborated on a distinctive characteristic of the concept good which professionals have very often used in dealing with moral dilemmas in socially established cooperative activitiesmacintyre mentions various examples of these such as chess portraitpainting and educationpeople are guided by internal goods which are defined as abstract qualities that are realised in the course of an active life macintyre distinguishes between internal goods and external goods such as money power and prestige external goods are necessary only for maintaining organizations and institutions so that the kernel for a practice exists in realising internal goods the distinction between internal and external goods can be made along two lines first external goods are called external as they also can be acquired through activities that are not restricted to the practice this is true in the sense that in activities outside the practices money power and prestige play a role but it is also true in the sense that within practices it is possible to acquire money power and prestige through dishonest means in opposition to this internal goods can be acquired only by excelling in activities that belong to the practice secondly external goods are always in some individuals possession the more someone has of them the less there is for other people they are always objects for competition internal goods on the other hand are not in short supply their achievement is good for the whole community whose members participate in the practice they can be shared in the full sense of the word many people can be orientated towards acquiring them without being in conflict with one another in fact a common orientation strengthens the motivation of each member of the community the differences among these authors do not invalidate their common focus the distinctions they make are insightful for understanding how certain kinds of activities contribute to a meaningful life we describe them under the heading substantial goods which furnish us with a normative framework that can be used to evaluate activities during recent decades this line of thought has played an important role in public administration journalism business healthcare and science it has been particularly helpful to distinguish between qualities that are related to the content of a work and institutional and external pressures for instance the appropriate task for a variety of professions that stress quantitative performance measures can be elucidated using the emphasis on substantial goods they include journalists working in a democracy scientists working in academic institutions and public administrators who must answer to higherlevel management the ultimate goal of their actions does not lie in complying with external standards but in realising goods that are themselves recognized as being of substantive importance substantial goods in helen nissenbaums model in the application of this line of thought to helen nissenbaums model we make explicit the goods that are at stake in a context and we take them as the starting point for decisions about the flow of information this strategy can contribute to the solution of several problems that currently stand in the way of further applying nissenbaums model a more explicit articulation of the goods at stake will be helpful in solving the problem of conservatism we have discussed how the notion of reasonable expectation and nissenbaums model might evoke the reproach of someone with a conservative orientation to fixed standards that do not do justice to new developments the notion of substantial goods enables us to describe activities under a normative perspective without being restricted to certain activities the meaning of goods can be translated in various activities new developments lead to new interpretations of the goods involved which in turn facilitate innovation take for instance education under the umbrella of having a good education a wide variety of patterns of education can be developed and new trends can be incorporated another advantage of elaboration of the notion of goods is that it contributes to a sharper contextspecific meaning of broad general values such as justice respect and integrity these values are very important throughout society as a whole but the price they have to pay for the overall appreciation is that they are vague and abstract a more precise meaning requires them to be applied in concrete contexts this is exactly what michael walzer does with the value justice in spheres of justice he shows that the criteria for distribution are dependent on standards that differ from one context to another likewise a precise description of the meaning of the notion respect in education differs from respect as understood in healthcare knowledge of the substantial goods at stake is helpful when it comes to concretizing these broad notions and this is not simply a superfluous luxury in the digital age for instance in healthcare explicit awareness of the meaning of respect for the patient helps to determine the appropriate flow of information that benefits the patients health it is therefore helpful in protecting the interests of the patient from institutional pressures or pressures from special interest groups in addition to these merits an articulation of the substantial goods delivers a welcomed intervention in an otherwise awkward debate about the different roles that privacy can play privacy is not exclusively positive it can for instance be used to conceal poor practices hiding information is a central feature of deception for instance feminists have stated that privacy is the enemy of equality… placing ordinary people at the mercy of powerful people for criminals privacy is a coverup for their activities relating privacy to the substantial goods it serves is helpful in these debates in which privacy seems to be a doubleedged sword when it is clear which kinds of goods privacy serves a contextspecific discussion on the value of privacy is possible finally the notion of goods importantly contains a normative orientation which is distinguished from for instance economic imperatives after all commercial interests are increasingly hampering privacy a stronger awareness of the substantial goods at stake strengthens arguments against commodification this is even more important as privacy is increasingly encroached upon in terms of tradeoffs people are being seduced to choose between for instance more privacy versus more customized offers from corporations or more privacy versus paying a lower insurance premium in such tradeoffs privacy is described as a luxury that only wealthy people can afford how far can we go without spoiling what is vital for leading a good life a strong articulation of substantive goods will be helpful placing a barrier between commercial pressures and leading a good life conclusions during the past decade we have witnessed the emergence of the socalled social approach to privacy this approach must be clearly distinguished from an autonomy approach these two approaches rely on different normative frameworks and different justification strategies both of them have their merit in the digital age changing technologies threaten autonomy and autonomy is indispensable for making clear what is at stake in discussions of privacy neglecting autonomy and the processes that threaten to undermine it is harmful for individuals the social approach which has been an undercurrent for decades gains importance in the digital age when privacy is defined in terms of control over flows of information an approach is required that surpasses the perspective of the individual the right to privacy provides protection in relationships with other human beings and with institutions where the fulfilment and development of ones personal identity can be realised the normative strength of this approach can be improved by a more explicit elaboration of the goods that are at stake open access this article is distributed under the terms of the creative commons attribution 40 international license which permits unrestricted use distribution and reproduction in any medium provided you give appropriate credit to the original author and the source provide a link to the creative commons license and indicate if changes were made publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

this paper takes as a starting point a recent development in privacydebates the emphasis on social and institutional environments in the definition and the defence of privacy recognizing the merits of this approach i supplement it in two respects first an analysis of the relation between privacy and autonomy teaches that in the digital age more than ever individual autonomy is threatened the striking contrast between on the one hand offline vocabulary where autonomy and individual decision making prevail and on the other online practices is a challenge that cannot be met in a social approach secondly i elucidate the background of the social approach its importance is not exclusively related to the digital age in public life we regularly face privacymoments when in a small distinguished social domain few people are commonly involved in common experiences in the digital age the contextual integrity model of helen nissenbaum has become very influential however this model has some problems nissenbaum refers to a variety of sources and uses several terms to explain the normativity in her model the notion context is not specific and faces the reproach of conservatism we elaborate on the most promising suggestion an elaboration on the notion goods as it can be found in the works of michael walzer and alisdair macintyre developing criteria for defining a normative framework requires making explicit the substantive goods that are at stake in a context and take them as the starting point for decisions about the flow of information doing so delivers stronger and more specific orientations that are indispensible in discussions about digital privacy

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introduction promotion of cognitive health has been a public health priority in rapidly aging societies considering its impact not only on older adults quality of life but also on their families health care system and economy 1 vietnam is one of the countries with fastest rate of aging in the world 2 the number of people aged ≥65 years in vietnam was 74 million in 2019 accounting for 77 of population 3 which is expected to increase to 181 by 2049 4 hearing loss the most prevalent sensory deficit affecting about one in three adults aged over 65 years 5 has not been a priority in cognitive impairment risk management for long 6 however cohort studies have recently showed that even mild levels of hearing loss increase the longerterm risk of cognitive decline 78 however reported results on the association between cognitive impairment and hearing loss are conflicting 910 and the underlying mechanism to clearly explain these two associations is not yet established hearing loss leads to difficulties in communication and creates barriers in interaction 1112 social isolation defined as having a small social network or a lack of close relationships or sources of social support 13 is one of the factors that relate both with cognitive impairment and hearing loss 1415 the development of information technology has diverted ways of communication from simple telephone calling to video calls or text messaging application which allows declined visual and hearing function to be mutually complemented 16 easytouse options including modulating pitch and amplitude on communication devices enable older adults to compensate peripheral functional deficit of age related hearing loss 17 in addition communication device usage makes up for facetoface communication limitation due to changes in family structure and lifestyles 18 considering the interrelationships of cognitive impairment hearing loss and interpersonal communication the question emerges how usage of communication tools may affect the association between cognitive impairment and hearing loss in vietnam with the rapid development of information and communication technology telephone and internet access have become more accessible and affordable the percentage of internet users per 100 inhabitants in vietnam exceeds 50 and the number of mobile cellular telephone subscribers is equal to the size of the vietnamese population 319 in 2019 917 of households owned phone or mobile phone or tablet 320 in addition communication applying these technologies into usage of smartphones or social media has been penetrated even among older adults in communities where face to face communication with their children relatives and close friends is limited due to changes in family structure and lifestyles 21 to date there were few primary studies in vietnam focused on the cognitive impairment of older adults these studies mainly investigated epidemiological aspects of cognitive impairment the previous vietnam reports showed the prevalence of cognitive impairment ranged from 29 to 48 22 23 24 however a lack of study included mild cognitive impairment an early stage of dementia moreover though much research has documented that hearing loss was associated with cognitive impairment in highincome countries a minimal number of studies have been done in lowand middleincome countries including vietnam and few have focused on the role of communication patterns a better understanding of communication patterns role in the association between hearing loss and cognitive impairment would provide valuable insights into potential approaches in preventing or delaying cognitive decline progress this study was performed to estimate the prevalence of cognitive impairment among older adults in central vietnam and explore the effects of the use of communication devices on the association between hearing loss and cognitive impairment methods measurements the study participants attended a facetoface interview with interviewers who were public health specialists with psychiatric knowledge questions designed in english were converted to vietnamese by a forward and back translation process sociodemographic and types of interaction in addition to age and sex level of education was categorized into elementary school or lower secondary or high school and university or higher living area was categorized as rural or urban living with spouse and children were categorized as yes or no financial strain was categorized as no when participants had enough money for their daily needs over the past month or yes if they lacked money for daily needs interaction using communication devices was defined as the use of tools of telephone email or social media to communicate with family and others interaction not using communication devices was defined as facetoface direct interactions with family and others at social gatherings such as going out together or visiting each others homes both interactions using and not using communication devices were classified as frequent or infrequent health status and lifestyles cognitive function cognitive function was evaluated using the mmse 25 a paperbased test that is a commonly used standard instrument for detection of cognitive impairment 2627 the mmse includes two parts the first of which requires vocal responses and covers orientation to time and place word repetition and recall and attention while the second part tests the ability to name objects follow verbal and written commands write sentences and copy complex polygons the mmse total score ranges from 0 to 30 with higher scores indicating better cognitive function cognitive function evaluated by mmse was divided into three categories mmse 023 mmse 2427 and mmse 2830 based on cutoff points of 2324 and 2728 reported to distinguish different older adults cognition 27 28 29 sensory function a short questionnaire to assess selfperceived hearing and vision loss was administered at the interviews in community surveys to cover a large population this method is widely used and several studies have shown that selfrated hearing impairment is correlated with audiometric measures in older adults 3031 participants were asked to rate their hearing and vision ability as no difficulty difficult or very difficult participants with hearing or vision ability classified as difficult or very difficult were categorized as having hearing or vision loss instrumental activities of daily living eight items of the lawton instrumental activities of daily living ie using a telephone shopping food preparation housekeeping doing laundry using transportation taking medications and financial behavior were used to assess the ability of older adults participants to perform daily tasks 32 difficulty with iadl was defined as the inability to perform at least one of the above items independently 33 presence of chronic disease the presence of chronic disease was categorized as no one and more than one chronic disease based on selfreporting of clinical diagnosis history smoking current smoking status was categorized as yes or no statistical analysis the frequencies of demographic and socioeconomic characteristics interaction types cognitive function health status living arrangement and lifestyles of participants were calculated the chisquare test was used to compare the levels of cognitive impairment according to the frequencies of interaction types sociodemographic characteristics health status and lifestyles of participants ordinal logistic regression analysis was performed to quantify the associations between hearing loss and cognitive function outcomes according to the frequencies of interaction types with adjustments for sociodemographic characteristics health status living arrangement and lifestyle ordinal logistic regression is the best fit when the dependent variable is ordinal and can be ordered in a natural way 34 odds ratio 1 indicates exposure associated with higher odds of decreased cognitive function statistical analyses were performed using ibm spss statistics version 250 in all analyses p 005 was taken to indicate statistical significance results the characteristics of participants are shown in table 1 the total number of study participants included in the statistical analysis was 644 literate adults aged 60 years and above nearly half of whom were aged 6069 years old the majority were women and more than a half had elementary school or lower educational level most subjects lived with a spouse orand children selfrated hearing loss was documented in 219 of participants there was no significant difference in the characteristics of participants between the original sample size and the sample of only literate participants table 2 presents the levels of cognitive function according to the type of interactions and the characteristics of the participants overall 124 participants were categorized as having severe cognitive impairment 152 had mild cognitive impairment and 368 had normal cognitive function the prevalence rates of mmse group scores were significantly different between participants with different frequencies of interaction types and hearing function table 3 shows the results of multivariable ordinal regression analysis of the association between hearing loss and cognitive function stratified according to the frequencies of interaction using and not using communication devices in the all combined model cognitive impairment was associated with hearing loss vision loss being female age over 80 lower education current smoking and difficulty with iadl model 2 showed association of hearing loss with cognitive impairment in participants with infrequent interactions using devices however association between hearing loss and cognitive impairment was attenuated in model 3 and this relationship was not significant in participants with frequent interactions using communication devices in models 4 and 5 selfrated hearing loss showed a significant association with cognitive impairment in participants with both infrequent and frequent interactions not using communication devices furthermore vision loss current smoker and iadl difficulty showed significant associations with cognitive impairment regardless the frequencies of the interaction types discussion severe and mild cognitive impairment had prevalence rates of 193 and 236 respectively in our study population the results presented here also suggested that the association hearing loss and cognitive function varied according to the frequencies and ways of communication in particular hearing loss was associated with decreased cognitive function among participants with infrequent interactions using devices and among those who had facetoface interaction without devices regardless of the frequency in contrast frequent interactions using communication devices attenuated the association between hearing loss and cognitive impairment prevalence of mild and severe cognitive impairment in the present study the combined prevalence of mild and severe cognitive impairment was 429 highlighting the public health impacts of these conditions and the need for national strategies to prevent cognitive impairment in older adults 35 based on 10 studies in eight countries the cohort studies of memory in an international consortium showed that the prevalence of mci ranged from 21 to 207 36 the cosmic used the same criterion for mci as in the present study but participants were people aged ≥ 65 years and participants with dementia were excluded with regard to the prevalence of severe cognitive impairment mmse score 023 was used as the criterion to detect dementia and had sensitivity of 089 and specificity of 089 26 using the same criterion of mmse 023 but with some differences in methodologies and study populations other studies in vietnam reported severe cognitive impairment prevalence rates of 2948 2224 furthermore in our study the combined prevalence of mild and severe cognitive impairment at 429 highlighted the public health impact of these conditions and the urgency for conducting national strategies to prevent or delay cognitive impairment in older adults 35 diverse association of hearing loss and cognitive function according to interactions types the results of the present study showed cognitive impairment was more prevalent among older adults with hearing loss hearing loss has been recently recognized as a risk factor for dementia 63738 hearing loss may be causally associated with cognitive impairment via increased cognitive load changes in brain structure and function and increased social isolation 14 our results showed that frequent interactions with family and others at social gatherings using communication devices attenuated the association between hearing loss and cognitive impairment this may be explained by the attenuating effects of frequent interactions with communication supportive devices on social isolation in older adults with hearing loss while the infrequent interactions or both frequent and infrequent interactions without using communication devices showed no such effect direct interactions with family and others at social gatherings such as going out together or visiting each others homes not applying any communication device are traditional ways to provide or receive social support however the direct interactions could bring challenges for older adults sometimes frequent interactions and dense social networks sometimes result in intrusive support overwhelming advice and interference and may exacerbate stress 3940 in particular older adults may perceive wellintentioned support efforts from family or friends as control although such wellintentioned support can have beneficial effects on health outcomes it can potentially lead to the development of interpersonal conflict and stress 3941 these aspects of the direct interactions without communication technology support may become more severe in older adults with hearing loss with partly limited communication ability in contrast interactions involving the use of communication devices such as telephone email or social media can somewhat offset the limitations of the direct interactions communication using devices are much easier to connect to a selected person regardless of time and geographical barriers thus allowing older adults to gain access to the support that they need in addition with high rates of urbanization older adults may have limited choice of living with a significant family member or others indirect interactions with use of indirect means of communication allow older adults to choose the people with whom they connect although these selected individuals cannot provide as much instrumental support as the people who live with older adults but they have the advantage of potentially providing better emotional support 42 in addition having the ability to use indirect means of communication such as telephone is beneficial for the selfefficacy of older adults 43 in vietnam with the rapid development of information and communication technology telephone and internet access have become more accessible and affordable the percentage of internet users per 100 inhabitants in vietnam exceeds 50 and the number of mobile cellular telephone subscribers is equal to the size of the vietnamese population 319 in the present study 83 of older adults had the ability to use the telephone at different levels these observations highlight the significant advantages of public health intervention programs based on interaction using communication devices noteworthy communication means should be particularly designed for older adults who may have cognitive and functional limitations keeping in mind that even though some older adults do not have their own communication devices or face difficulties in learning how to use them their housemates can operate communication devices for them the major strengths of this study included the use of populationbased representative data facetoface interview and standard data collection tools ordinal logistic regression allowed us to examine three levels of cognitive function as a dependent variable including mci which is an early stage of cognitive decline that may have potential benefits for early preventive interventions the results of this study revealed the critical role of interaction using communication devices including telephone mail and online social networks in modifying the association between hearing impairment and cognitive function this study had several limitations first due to its crosssectional design the results of associations of variables could not determine causal relationships further longitudinal studies are required to make causal inferences second our results may have been subject to recall bias if necessary demographic information was doublechecked with family members of the older adults included in the study third the study relied on a selfreported measure of hearing loss our results were interpreted on the basis of understanding that selfrated hearing impairment is correlated with audiometric measures in older adults 31 however this correlation is still a matter of debate for cases of mild hearing impairment fourth validity of mmse in vietnamese version to evaluate cognition of the vietnamese population would be carefully examined in a future study in addition as mmse includes two questions that evaluate reading and writing ability illiterate participants were excluded from the analytical statistics to reduce misclassification of cognitive impairment by mmse this exclusion was helpful in analyzing the frequency of use of interaction using communication devices that require reading and writing ability such as email and social media therefore our results should be interpreted in the context of the exclusion of illiterate participants further longitudinal studies are required to elucidate the benefit of communication using devices on the association between hearing loss and cognitive impairment both quantitative and qualitative study designs are recommended for example a quantitative study could measure the impact of the specific means of communication on cognitive function in the specific context a qualitative study could measure the advantages and disadvantages of using different means of communication from either perspective of older adults or their caregivers conclusions the association between cognitive impairment and hearing loss of older adults varied according to frequencies and ways of communication results of a study conducted in one of the worlds fastest aging societies vietnam showed that frequent communication using devices attenuated the association between hearing loss and cognitive impairment these results suggested that fitted communication methods for older adults whose sensory functions declined with aging is vital to maintain their cognitive function data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available due to them containing information that could compromise the privacyconsent of research participants author contributions conceptualization tdth and kn methodology tdth and kn software tdth and kn validation kn formal analysis tdth and kn investigation vnhd and tvv resources kn and tvv data curation tdth writingoriginal draft preparation tdth and kn writingreview and editing tdth kn ks vnhd and tvv visualization tdth kn and ks supervision kn project administration kn and tvv funding acquisition kn and tvv all authors have read and agreed to the published version of the manuscript institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki approved by the institutional ethics committee of hue university of medicine and pharmacy vietnam informed consent statement informed consent was obtained from all subjects involved in the study

this study examined the prevalence of cognitive impairment among older adults in central vietnam and the roles of communication with or without communication devices in the association between cognitive impairment and hearing loss this crosssectional study was performed on 725 randomly selected communitydwelling older adults aged ≥60 years from thua thien hue province vietnam participants attended a facetoface survey sociodemographic characteristics social interaction with or without communication devices health status and cognitive function using the minimental state examination were reported ordinal logistic regression analysis was performed to quantify the association between hearing loss and cognitive function by frequency of communication with and without devices mild and severe cognitive impairment had prevalence rates of 236 and 193 respectively cognitive impairment was more prevalent among older adults with hearingloss vision loss and difficulties with instrumental activities of daily living iadl the association between hearing loss and cognitive impairment was not significant when older adults had frequent communication with others using devices this study presented the relatively high prevalence of cognitive impairment in communitydwelling older adults in vietnam frequent communication using devices attenuated the association between hearing loss and cognitive impairment

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introduction research into learning analytics has garnered much attention for its potential impact upon a number of central issues in education for instance the identification of learning strategies the prediction of academic success and the provision of personalized feedback at scale to name a few while this field of research promises much the spectre of validity looms large and many of the most frequently relied upon measures have not been subjected to robust validation a pertinent example of this is timeontask the estimation of which was rarely discussed in the literature instead researchers would often opt for a heuristic approach such as limiting session activity to a defined time period however there was little consideration of the consequences such estimation heuristics had on the results of the final predictive model to address this oversight kovanović et al investigated how different timeontask estimation methods affected predictive models of learner outcomes across diverse learning contexts the authors found that estimation methods play an important role in shaping the final study results concerns regarding validity ultimately relate to the extent to which a metric actually measures what it purports to measure this is known as construct validity and is highly relevant to learning analytics methods particularly in the context of this study on social network analysis sna has been one of the most commonly applied methods within learning analytics while sna can offer insight into the types of relationships and interactions that occur between individuals groups and communities little research has considered the validity of findings derived from common sna methods for instance although batool and niazi assessed the construct validity of centrality metrics in complex networks studies such as this are the exception rather than the rule existing research has paid little attention to the validity of a number of common sna constructs and in particular the impact of various tie definitions on these constructs remains largely overlooked following messick validity may be deconstructed into a number of different aspects including structural validity or the fidelity of the scoring structure to the structure of the construct itself generalizability or extent to which score properties generalize to and across populations and settings and external validity such as supportive or dissuasive evidence arising from related constructs the present study investigates the construct validity of a number of social tie definitions in the context of online discussion forums these definitions seek to represent the relationships formed between individuals on the basis of interactions and mutual participation within threads that is we assess how variations in tie definition result in different characterizations of these relationships in doing so we investigate three aspects of construct validity structural validity is assessed by comparing tie definitions on the basis of the structural features of the derived networks and by using statistical models to compare the statistical properties of these networks external validity is evaluated by investigating how measures of network centrality are associated with academic performance and generalizability is assessed by pursuing the foregoing analysis in two distinct learning settings literature review sna and discussion forums the analysis of discussion forums particularly massive open online course discussion forums has received considerable attention in recent years in this body of research sna has proven to be a powerful tool in extracting patterns of connections between learners exploring their relationship with learning and generating understanding about the underlying relational structure of a community across a variety of contexts in particular the emergence of moocs has provided ample opportunity for the application of sna methods given the increasing number of students enrolling in moocs sna has become an increasingly adopted tool for visualizing and extracting interaction patterns from social learning activities as well as for investigating the association of network centrality with constructs such as academic performance sense of community social presence and creative potential there is considerable heterogeneity in how learners interact with the discussion forum gillani and colleagues for example analyzed forum users on the basis of coparticipation in the same threads and found that the coherence of the network mainly depends on a small set of central users rather than a closeknit community forum users may be more accurately characterized as a loosely connected crowd poquet and dawson explicitly analyzed different user groups and found that regular users form a denser more centralized network as they have more opportunities to establish connections further work by boroujeni hecking hoppe and dillenbourg confirmed that membership of these groups remains stable over time however there is more to discussion forums than structure alone wise and cui distinguished between discussions that were related to course material and those that were not they found that students who made both content and noncontent related posts had a higher passing rate than those who only contributed to one type furthermore those who contributed to contentrelated threads performed slightly better than those who did not the results of these analyses however have not always been consistent for instance joksimović et al investigated the factors that influence social connections in two instances of a mooc offered in english and spanish that taught students how to program ties were extracted on the basis of direct reply from an online discussion forum in examining the association between centrality degree closeness betweenness and academic performance the authors found weighted degree was significantly associated only in the english offering while the effects of betweenness and closeness were only found in the spanish offering furthermore the authors found evidence of performancebased homophily indicating that learners tend to talk to those in the same performance group as themselves another study by jiang et al also investigated the associations between social centrality and academic performance their study was conducted on two moocs in algebra and finance and ties were extracted via copresence in a thread that is on the basis of shared activity and participation in the discussion while degree and betweenness were positively correlated with academic performance in the algebra course no significant correlation was found between any centrality measure and academic performance in the finance course in further contradiction of joksimovićs findings the authors found that students tend to talk to those in different performance groups than themselves the findings of these two studies are largely inconsistent a discrepancy which may in part be attributed to methodological differences for instance joksimović et al hypothesize that the association between academic assessment and network centrality measures was moderated by the presence of simmelian ties in lieu of such a hypothesis jiang and colleagues methodology did not consider the presence of a simmelian influence in this case and others researchers have used different methods to extract social ties yet the effects on those extractions are rarely studied while in the case of these two studies the effects of tie extraction methods are studied in connection with the association between network centrality and academic performance the same methodological oversight may be found regarding other constructs and hypotheses moreover not all research into networked learning has relied upon moocs and in investigating how social tie extraction methods impact upon the structures and statistical properties of networks there is scope for a comparison between networks extracted from moocs and other more formal educational contexts network processes and exponential random graph models studies that apply sna methods rely upon mathematical models to describe relationships between variables to reveal important characteristics and to identify processes within the social network for instance descriptive models enable us to identify whether or not reciprocity exists within a given network however to understand whether or not such processes occur more often than expected if ties were generated randomly we must rely on statistical models one commonly proposed method is the exponential random graph model introduced by frank and strauss and wasserman and pattison ergms belong to a family of probability models that allow for generalizable inferences over the structural foundations of social behavioural patterns within networks ergms treat network ties as random variables and model the overall network structure through a set of local network processes such as triadic closure mutuality or transitivity the model assumes each tie within these processes is conditionally dependent indicating that empirical network ties do not form at random but they selforganize into various patterns arising from underlying social processes though ergms have long been successfully applied in other fields their application to the structural analysis of forum networks is relatively novel in general these results have revealed a reciprocal tie effect within networks and a lack of network centralization beyond a few influential nodes for instance kellogg et al used ergms to provide a more comprehensive understanding of the dynamic processes underpinning peer support learning in moocs the authors used both descriptive and statistical methods and found a strong and significant reciprocity effect indicating that students are more likely to aid their peers when there is prior evidence of reciprocity in a more recent study joksimović et al utilized ergms to determine whether network social dynamics such as simmelian ties have an impact on the predictive power of network positions the study found that incorporating both descriptive and statistical models allowed for more nuanced and contextually salient inferences about learning within a network poquet dawson dowell found that different facilitation or pedagogical approaches mediated the extent of reciprocity that is while direct reciprocal ties were characteristic of nonfacilitated forums triadic reciprocal ties were more prominent in forums with a high degree of facilitation while statistical models such as ergms have facilitated much valuable research and provided considerable insight into network processes the literature has neglected research into whether and if so to what extent network processes and statistical properties are influenced by variations in the tie definitions that underpin them social tie definitions research into sna and in particular sna studies of moocs have relied upon a variety of definitions to construct social ties while some authors defined ties on the basis of direct replies others have relied on copresence as the basis of any sna analysis tie definition is crucial and each definition carries with it a set of assumptions about the nature of social interactions in the literature this theoretical oversight remains largely unaddressed and studies often establish a tie definition with no explanation or rationale even when one is provided each decision often carries its own shortcomings for instance gruzd haythornthwaite consider three potential tie definitions and note that each makes specific assumptions about the nature of social interactions that may not hold in a study of mooc forums wise cui and jin investigated the impact of different tie definitions on social network structures and the resultant characteristics at the network community and individual node level while their study found that network properties were characterized by a limited sensitivity to differences in tie definitions their analysis was limited to descriptive statistics and did not consider the statistical properties of networks such as the propensity for reciprocity or homophilic ties accordingly there is scope for an investigation into how different tie definitions relate to differences in the statistical properties of networks and the interpretation of such social networks social tie definitions can typically be classified into two distinct types those that interpret a tie as created when an individual speaks to another and those that extract ties on the basis of coparticipation within a discussion perhaps the most prevalent and straightforward of the former is direct reply under this rubric a tie is constructed when there is a reply relationship between two nodes in the same thread for instance between the starter of a thread and the author of a reply post addressed to it or between the author of a reply post and the author of a reply to that reply while this definition has been widely used there is no guarantee that users will opt for the correct location and level of post nor that the platform itself will support a sufficiently rich reply structure for instance in one popular platform for online discussions piazza only three levels of post are supported post reply and reply to a reply if a poster wishes to reply to a reply to a reply post it is logged as another reply to a reply post in building a network a direct reply tie definition would link this new post to the reply post rather than the reply to a reply post to which it was originally intended to address accordingly the extent to which the reply structure thus derived reflects the actual relations among learners is open to question to address such concerns zhu and colleagues proposed the star reply tie definition while direct reply considers multiple levels of replies and defines ties as connections across levels star reply does away with reply structures and considers all posts within a thread as tied to the thread starter the justification for this is that even if a reply post does not directly address the thread starter it was made in the context of the discussion originated by the thread starter while star reply emphasizes the thread starter it fails to distinguish between different levels of replies and does not consider connections formed between posters within the same thread to address this direct star amalgamates the two and defines ties across different levels within a reply structure on the basis of direct reply while also linking posts within a discussion back to the thread starter however the methods thus far identified strictly emphasize the act of speaking to another individual within a thread a prospective poster may read much of the existing discussion before penning their own reply accordingly defining ties on the basis of speaking contact alone overlooks the interactions between individuals who do not speak directly but share an interest and an awareness of each other within the same thread tie definitions of the second typethose based on coparticipation within a discussionseek to address this issue by creating a network of copresence across nodes within such a network a tie is defined as being present in the same part of the discussion there is no necessity for direct interaction ties are thus created without regard for the reply structure present in a discussion connections are formed both between a parent node and its children and between the children themselves accordingly this type of tie definition represents online discussions not as strict hierarchies but as collective conversations within this type of tie definition a common approach is that of total copresence where any two nodes in the same thread are connected regardless of post type while this is often used to map interaction in the case of large threads it can prove problematic in the case of small threads linking all individuals as part of a collective discussion might be reasonable however this assumption becomes implausible when the number of replies is very large one way to address this problem proposed by wise and colleagues is to set a cap on the reasonable number of posts in the same thread to create a measure of limited copresence beyond this threshold all posts within subthreads are connected to all other posts within that subthread and the thread starter an alternative method of assessing coparticipation that has been largely unexplored is that of viewing ties as contained within a moving window within a large thread a prospective poster may only attend to recent posts in framing their reply and so the collective conversation of which they are part is defined as some subset of the overall thread a moving window defined as some number of posts moves sequentially over a thread and at every step all posts within the window are connected this approach ignores the hierarchical structure of a discussion and instead emphasizes each post as being part of a temporally defined collective discussion however there is no a priori rationale for choosing one window size over another and different sizes may lead to a variety of different conclusions while each tie definition carries with it a set of assumptions about the nature of social interaction in the literature little heed was paid to this and extraction methods may instead be chosen on the basis of expediency such as whichever structure is readily permitted by the discussion platform furthermore there has been little research into the impact that variations in tie definitions have both on the statistical properties of networks and on the association between network centrality metrics and academic performance study framing in this study we examine the effects that different social tie definitions have on the structural and statistical properties of the derived networks these range from networklevel properties such as reciprocity to individual properties such as the association between metrics of centrality and academic performance to validate our results our analysis is applied in two separate contexts a blended learning environment and a mooc the importance of doing so is twofold on the one hand it provides a glimpse into how differences in learning contexts may impact upon social interaction on the other the two contexts allow us to assess the construct validity of tie definitions by measuring their impact on the structural and statistical properties of the resultant networks the paucity of existing research into whether network construction choices determine network properties motivates our two research questions rq1 do differences in tie formation mechanisms determine the statistical properties of networks across different learning contexts rq2 do differences in tie formation mechanisms affect the association between social centrality and academic performance across different learning contexts method data sources this study analyzed forum discussions from two separate courses the first dataset comes from a flipped classroom firstyear engineering course at an australian higher education institution offered in 2016 the course called introduction to computer systems lasted 13 weeks and of a total enrollment of 477 students 227 students participated in the discussion forum the flipped classroom design was composed of two elements a set of online resources intended to be completed in preparation for the plenary session and the reframing of the plenary session to embrace an active learning design requiring student preparation and participation in collaborative problemsolving tasks the second dataset comes from a course called code yourself which was delivered on the coursera platform in 2015 the mooc was designed to introduce teenagers to computer programming while covering basic topics in software engineering and computational thinking the course lasted five weeks and of a total enrollment of 59900 students discussion forum data was available for 1421 students the content consisted of lecture videos quizzes and peerassessed programming projects if students scored at least 50 in their coursework they were deemed to have passed while a distinction was awarded to students receiving a score of 75 or more participation in the discussion forum was not required in either course forum activity in ics consisted of 536 threads comprised of 1115 posts activity in cy by contrast consisted of 774 threads comprised of 5950 posts summary statistics of the two forums are provided in table 1 the courses were selected to provide two disparate learning contexts for assessing the construct validity of typical sna methods in particular the two courses exhibit drastic differences regarding structure while ics is a blended learning environment where the students are likely to have offline connections not captured by the discussion forum cy is a mooc where students are likely to interact solely through the discussion forum this difference is particularly salient since ics involves offline collaborative problem solving furthermore ics is considerably longer lasting 13 weeks compared to just five for cy pedagogy also differs in ics instructors mediate and interact with students in the forum with the intention of prompting indepth discussion of the relevant concepts by contrast no such mediation exists in cy these differences and others frame two different contexts and are essential for understanding and interpreting the different social relationships that arise within them tie extraction ties were extracted using the six tie definitions selfties were excluded in all cases direct reply ties the author of each post was connected with the author of its parent post concretely for each thread in the discussion forum and each post within each thread if a post was either an instructor answer a student answer or a leveltwo post a tie was created from the leveltwo poster to the thread starter however if a post was classified as a levelthree post a tie was created from the levelthree poster to the author of the parent leveltwo post star reply ties the author of each leveltwo and levelthree post was connected with the author of the thread starting post to be more concrete for each thread in the discussion forum the thread starter was identified and for each post in the thread a tie was created from the poster to the thread starter direct reply star ties ties defined in both direct reply and star reply were included but the same tie was never counted more than once specifically for each thread in the discussion forum and each post within each thread if the post was an instructor answer a student answer or a leveltwo post a tie was created from the poster to the thread starter in the case of levelthree post a tie was created from the levelthree poster to the leveltwo poster and if they were not one and the same person the thread starter too total copresence all authors in the same thread were connected with each other in this case ties are considered to be undirected limited copresence all users in small threads were connected to each other with undirected ties in larger threads users were connected to all other users in their subthread and the thread starter only for threads of five or more posts if a post was a leveltwo post the leveltwo poster was connected to the thread starter however if levelthree posts exist then each levelthree post was linked to each other the leveltwo post and the thread starter for each thread in the discussion forum if the number of posts within a thread was less than n then a tie was created between each post otherwise starting from the first post the first n posts are selected and an undirected tie was created between each post then the window moved to the second post and the next n posts were selected and ties created this process repeated until the window reached the end of the thread in this study we investigated windows of sizes two through five given our definitions each type of social tie resulted in the number of connections as show in table 2 analysis social network analysis to address our research questions networks were extracted for the two courses in accordance with the six tie definitions social network analysis was then conducted across all networks in two complementary phases structural and statistical network analysis our analysis of the networks structural features relied on some of the most commonly used nodelevel sna metrics to characterize centrality including degree closeness betweenness and eigenvector centrality degree centrality captures the local structure surrounding the node and indicates the number of connections a node has for this reason degree is often considered a measure of popularity closeness centrality measures the distance of a given node to all other nodes in a network and so can be viewed as a measure of each nodes potential to connect with other nodes betweenness measures the number of shortest paths between all other nodes that a given node lies on and so can be viewed as a metric of brokerage or the extent to which a node bridges distinct parts of the network finally eigenvector centrality gives greater prominence to a node the more it is connected to other highly prominent nodes accordingly it can be viewed as a ranked metric of influence additionally we investigated structural features at the networklevel including density diameter and average path length within a network density measures the proportion of actual connections between nodes to all possible connections and so can be viewed as a measure of the extent to which all members of a network are connected to each other diameter measures the maximum eccentricity of any node in a network that is the maximum distance between any two nodes finally average path length measures the average number of steps along the shortest paths for all possible pairs of network nodes for the statistical analysis of networks ergms were used to reveal a variety of network statistics and investigate network formation processes in particular we aimed to investigate the effects of reciprocity popularity and transitivity as a network statistic reciprocity represents the tendency of students to form mutual ties and group together in the context of our datasets and tie definitions this would indicate whether or not students tend to continue interaction with their peers who replied to their posts as this metric represents directed loops of length two it only applies in the case of replybased networks popularity was modelled by the geometrically weighted degree distribution gwidegree is a statistic that geometrically discounts the value of incoming ties when the indegrees are summed in the statistic or more intuitively captures a popularity effect gwodegree considers the number of ties an individual sends in the network and captures structures that result from highly active nodes transitivity refers to the extent to which the relation that ties two connected nodes in a network is transitive that is the extent to which the friend of my friend is also my friend this statistic is represented by the geometrically weighted edgewise shared partner distribution for each of the networks we consider a variety of models in the case of replybased networks we examined a model for each of our statistics of interest similarly for coparticipationbased networks we examined a model for each of our statistics of interest models were then analyzed on the basis of goodnessoffit statistics networks were extracted using the ergm 380 r package regression analysis to examine the association between academic performance and our nodelevel measures of centrality and so answer our second research question we conducted a regression analysis in the case of replybased networks we examined six metrics and in the case of coparticipationbased networks which do not distinguish between inand outgoing ties we examined four since our dependent variable the course outcome was measured differently in our two datasets two distinct approaches were required in the case of ics the dependent variable was continuous so a linear regression model was fitted by contrast the cy course outcome was categorical accordingly multinomial logistic regression a method that explains the association between a categorical dependent variable and one or more continuous independent variables was adopted to investigate this association four models were fitted for each dataset each model included the dependent variable one of the centrality measures and in order to control for an activity effect a variable representing an individuals forum post count multinomial logistic regressions were performed using the mlogit 024 r package in the case of ics the dependent variable was heavily skewed and all independent variables across both courses appeared to following a power law distribution they were therefore log transformed results networks formed by six tie definitions descriptive statistics for both datasets reveal clear distinctions between replybased tie definitions and those based on coparticipation network centrality metrics were calculated by averaging over the nodelevel values for each network and centrality type except for eigenvector centrality being more akin to a ranking measure this network metric was calculated as the sum of differences between each nodes eigenvector centrality and the maximum eigenvector centrality divided by the maximum possible such value replybased definitions produced networks of striking similarity regarding centrality metrics at both node and network level regarding coparticipationbased definitions the range of moving windows investigated exhibit clear trends across all centrality and network level metrics as the window size decreased the number of connections to each was on average attenuated as was the overall density of the network furthermore the distribution of influence across the networks as measured by eigenvector centrality increased compared to the other coparticipationbased tie definitions total copresence produced dramatically distinct networks in both datasets by contrast limited copresence resulted in very similar networks to the moving window 3 definition across both courses statistical network properties in both courses under investigation the three replybased tie definitions produced networks with largely consistent statistical properties estimated coefficients are presented in table 5 across all replybased definitions and datasets gwesp was insignificant indicating an absence of transitive ties this consistency across two disparate learning environments is surprising in the case of ics students interact in both the discussion forum and the facetoface plenary sessions and accordingly one might expect the derived networks to resemble those emerging from social media where transitive ties are a sine qua non regarding replybased networks the effect of reciprocity was significant in all networks across both courses except for star reply in ics across all tie definitions and courses the effects of popularity and activity as measured by gwidegree and gwodegree were strong negative and highly significant indicating an absence network structures characterized by highly popular or active agents in the case of coparticipationbased networks results across both courses were consistent in that all of the investigated network processes were predominantly absent and the baseline model provided the best fit the only exception to this pattern was for moving window 5 and moving window 4 in the cy course here the derived networks exhibited evidence of transitive ties in future research it is worth investigating to what extent this transitivity is induced by selective mixing as increasing the likelihood of within category ties provides opportunities for completed triangles within categories especially when groups are small as the low density in table 4 indicates centrality and academic achievement assessing the association between nodelevel centrality measures forum activity and academic outcomes revealed further differences between the tie definitions in the case of replybased networks in the ics dataset no centrality metrics exhibited any significant association with course performance however for all centrality metrics except for indegree activity was significantly and positively associated with course performance in the case of coparticipationbased networks in the ics dataset no centrality metrics except closeness and eigenvector were significant however for all tie definitions except for limited copresence and moving windows 4 3 and 2 activity was significantly and positively associated with course performance in the case of total copresence closeness centrality was significantly and negatively associated with course performance indicating that as the mean distance between nodes decreased academic outcomes suffered however it should also be noted that these assessments across centrality measures effectively constitute multiple comparisons that have not been controlled for given the number of estimated parameters the occurrence of some significant parameters at the 5 level is likely even under the null hypothesis for the cy dataset in the case of replybased networks indegree centrality was significantly associated with obtaining a certificate of distinction 17918 p 0001 star χ 2 21343 p 0001 direct star χ 2 17877 p 0001 but it did not have a significant impact upon the likelihood of obtaining a normal certificate by contrast for direct reply and direct star reply outdegree centrality increased the likelihood of obtaining a normal certificate 16885 p 0001 direct star χ 2 19282 p 0001 but not a certificate of distinction betweenness centrality was significantly and negatively associated with course performance across all replybased networks 109820 p 0001 star χ 2 58401 p 0001 direct star χ 2 101050 p 0001 specifically increases in betweenness significantly reduced the likelihood of obtaining a certificate with distinction in the case of coparticipationbased networks in the cy dataset nodes ranked higher by eigenvector centrality were significantly less likely to obtain either certificate in the cases of total and limited copresence 195320 p 0001 limited copresence χ 2 2265 p 0001 but were significantly more likely to obtain either certificate across all other definitions 273770 p0078 moving window 4 χ 2 273800 p0125 moving window 3 χ 2 275080 p0173 moving window 2 χ 2 267930 p0167 increases in activity significantly increased the likelihood of obtaining both a distinction and a normal certificate for all metrics except for eigenvector centrality where influence was only significantly associated with a normal certificate for moving windows 4 and 3 discussion structural network properties descriptive statistics for both datasets clearly partitioned social ties according to replybased and coparticipationbased definitions while these two tie types produced distinct network structures there remained some notable intratype variations in particular total copresence produced dramatically different networks with high values of degree centrality this finding in keeping with wise et al suggests that total copresence should be used with caution due to the disproportionate influence it assigns to large threads by contrast in both datasets limited copresence produced networks comparable to moving window in particular moving window 3 there are a number of possible explanations for this similarity such as the predominance of short threads and associated subthreads in both datasets statistical network properties in addressing our first research question there is evidence that across different learning contexts and pedagogies variations in social tie formation mechanisms may produce different statistical properties in the derived networks in the case of replybased networks we investigated the propensity of networks to form directed loops of length two a popularity and activity effect and the extent to which the friend of my friend is also my friend across all tie definitions the results were broadly consistent for our statistics of interest except for star reply in the ics course where reciprocal ties were notably absent in the case of coparticipationbased networks we investigated the propensity of networks to exhibit a popularity effect and the propensity for transitive ties to form the coparticipationbased tie definitions we investigated produce a number of transitive triangles within each thread and subthread however a transitive effect is only identified in the case of moving window 5 and 4 the predominance of na values in tables 6a and6b is the result of model degeneracy the absence of reciprocal ties in star reply may in part be explained by both the definition itself whereby all ties are from responders to a thread starter and the relatively low student count and thread count of the ics dataset compared to the cy dataset since reciprocal ties are not created within star reply threads a larger student and thread count provides greater opportunity for reciprocity to manifest itself beyond this exception the estimated coefficients are broadly consistent on an intracourse basis while the estimates in cy are quite high these are in line with those found in existing studies as lusher et al have argued it appears that a strong reciprocal effect may be seen as a defining characteristic of interaction in online social networks in general furthermore lusher et al identified such networks as selfdisclosing characterized by strong relations between nodes in these networks students selfdisclose themselves to establish social presence creating comfortable learning and knowledge sharing environments however the low network level cohesion evidenced by low density indicates that students commonly interact with smaller groups across all replybased tie definitions and courses the effects of popularity and activity were strong negative and significant such an effect could indicate that within the network the distribution of popularity and activity were largely homogeneous rather than being centralized on inor outdegree regarding popularity this result is consistent with existing studies in the case of replybased cy definitions where reciprocity and a negative popularity effect were particularly strong the interpretation is quite intuitive rather than be concentrated in a few individuals the high propensity of students to engage with each other on a reciprocal basis distributes the effects of popularity over the population centrality and academic achievement regarding our second research question our results indicate that the choice of tie definition can affect the observed association between centrality and academic performance for instance for all replybased networks in the cy dataset indegree centrality significantly improved the likelihood of obtaining a certificate of distinction however for the very same networks betweenness centrality significantly decreased the likelihood of obtaining a certificate of distinction given these findings it is important to assess the underlying assumptions that give rise to such inconsistencies for instance while indegree centrality was significantly and positively associated with obtaining a distinction in all cy replybased networks the relation was reverted in the case of total copresence this may be because the construct being measured differs between the two definitions in the case of replybased networks indegree centrality indicates the extent of social prominence however in the case of total copresence degree centrality measures the extent of shared interest while shared interest increases with thread size social prominence is diluted which could account for the contrary associations similarly in the cy dataset eigenvector centrality rank across all tie definitions was significantly associated with obtaining a distinction but the direction of the association depends upon the tie definition while this association was positive for most definitions it was negative for total and limited copresence this may be because replybased and to a limited extent moving window definitions represent the purposeful direct exchange of information total and limited copresence by contrast dilute this effect place inflated importance on large threads and so provide limited information for assessing influence these findings give cause to reiterate the warning provided by wise et al that total copresence and to a lesser extent limited copresence should be used with caution while our results indicate that the choice of tie definitions can affect observed associations it is important to emphasize that these comparisons have been made at the overall network level not for specific individuals it remains unclear to what extent individual centrality metrics are consistent across definitions this is an interesting avenue of future research and is an essential consideration when seeking to identify individuals with certain social status learning and pedagogical context while inconsistent associations between centrality metrics and performance may be in part explained by tie definition they may also be attributable to differences in learning and pedagogical context regarding such contextual factors the two courses analyzed exhibit important differences for instance while ics is a blended learning environment where students interact both inside and outside the discussion forum cy is a mooc where the forum is students only point of contact this could result in mooc interactions being characterized more by q a than indepth discussions while a content analysis would have to be conducted to ascertain this in our dataset the literature provides some evidence in favour of such a hypothesis for instance gillani eynon found that forums harbour crowds not communities of learners networks were fragmented and became increasingly so over the duration of the course furthermore although instructor mediation existed in ics no such mediation occurred in cy poquet et al found that different facilitation strategies mediated a reciprocal effect whereby nonfacilitated forums were characterized by direct reciprocal ties our findings replicate this result a reciprocal effect was present across all replybased tie definitions but was almost three times stronger in the case of cy pedagogy may also have impacted student behaviour for instance ics involved a collaborative problemsolving exercise in the plenary session which could have led learners to participate differently in the discussion forum participation may also be affected by contextual factors for instance while students created far more posts in the cy forum students on average posted a similar number of times in each course however a small proportion of mooc users even participated in the forum let alone consistently not only did a far greater proportion of ics participate but they also had offline connections formed over a far longer course period while our research questions did not directly address the impact of pedagogy and learning context such factors likely played an important role and should be explicitly addressed before any conclusions or comparisons can be made between courses however our results also point to the importance of selecting an appropriate tie definition for a given research goal for instance replybased tie definitions emphasize the purposeful directed exchange of information between individuals and the derived networks may be useful for identifying roles or influence within a group coparticipationbased definitions such as total and limited copresence instead treat all ties within a thread as homogenous and focus on identifying shared interest our more novel tie definition moving window has a number of appropriate applications depending on the course context and window size for instance it may be useful within a collaborative learning context where posts within a thread are strongly related to recent posts within the same thread however such a structure is highly idealized not only do learners not always read discussions chronologically but in an asynchronous manytomany discussion forum messages may refer to several others appearing far earlier in the chain that said the moving window definition emphasizes the temporal structure of threads a potentially important aspect overlooked by more conventional tie definitions implications this study investigated the construct validity of a number of social tie definitions such ties purport to characterize the relationships formed between individuals on the basis of interactions within an online discussion forum structural validity was assessed by comparing the definitions on the basis of the structural and statistical properties of the networks they induced from our datasets our tie definitions could be categorized into two types and while we found broadly consistent structural and statistical properties within these two categories across category comparisons revealed striking differences external validity was assessed by investigating how measures of network centrality were associated with academic performance while we found that increased social centrality was predominantly associated with opportunities and improved academic outcomes for students there were some notable exceptions including significant negative associations this would indicate that external validity cannot be assured and that the choice of tie definition does matter we also assessed the extent to which our findings generalized by conducting our analyses in two distinct learning settings regarding the structural properties of networks we found replybased tie definitions produced strikingly similar nodelevel centrality measures even in spite of the considerable differences in course context and scale this was not reflected in the case of coparticipationbased networks although in both contexts total copresence produced vastly inflated figures crosscontext similarities were also found within the networks statistical properties for replybased tie definitions both courses exhibited a significant negative popularity effect counterbalanced by a significant positive reciprocal effect regarding the association between centrality and academic performance most metrics enjoyed consistent associations however there were deviations particularly total copresence which compared to other definitions in some cases exhibited the opposite association though in many cases our results generalized across the definitions under study the departures from this consistency indicate that the validity of sna methods cannot be assured and researchers should proceed with caution our results lend support to the argument that researchers should be transparent in their choice of tie definition and moreover provide justification for their choice given the impact that tie definitions can have it is advised that researchers try a number of different methods to ascertain the extent to which such methodological choices can bias their results on the basis of this study we recommend future sna researchers pursue an exploratory comparison of total copresence with a replybased definition as this could produce contrasting results and provide clarity on the internal validity of their chosen methods declaration of conflicting interest the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article

the widespread adoption of digital elearning environments and other learning technology has provided researchers with ready access to large quantities of data much of this data comes from discussion forums and has been studied with analytical methods drawn from social network analysis however within this large body of research there exists considerable variation in the definition of what constitutes a social tie and the consequences of this choice are rarely described or examined this paper presents findings from two distinct learning environments regarding different social tie extraction methods and their influence on the structural and statistical properties of the induced networks and the association between measures of centrality and academic performance our findings indicate that social tie definitions play an important role in shaping the results of our analyses the primary purpose of this paper is to raise awareness of the consequences that such methodological choices may have and to promote transparency in future research• social network analysis has been one of the most commonly applied methods within learning analytics however many of the common constructs and tools these methodologies employ have not been subjected to robust validation such concerns pertain to construct validity namely does a metric actually measure what it purports to measure • in this study we find that different social tie extraction methods influence the structural and statistical properties of the induced networks as well as the associations between centrality measures and academic performance • our results emphasize not only the importance of transparency in the choice of tie definition but also the importance of providing a justification for that choice given the impact that tie definitions may have we advise that practitioners investigate a number of options to ascertain the extent to which such methodological choices can bias their results

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background childhood obesity childhood obesity remains prevalent across the world presenting one of the most challenging public health problems of this century 1 once established obesity and related comorbid chronic conditions often persist into adolescence and adulthood 2 the persistent nature of this condition may result from the establishment of obesityrelated behaviors in early childhood including poor diet obesogenic eating behaviors and physical inactivity which often track through adulthood 3 therefore infancy and toddlerhood may be critical periods for obesity prevention efforts health behavior patterns underlying the development of childhood obesity are influenced by a complex ecology of factors 4 thus interventions designed to change obesityrelated behaviors require multilevel approaches with multiple components 5 currently no compelling evidence advocates for one program or method for preventing childhood obesity however comprehensive approaches addressing both behavioral risk factors and psychosocial support within relevant contexts tend to offer more promising outcomes 67 for young children family homes are ideal settings for the implementation of childhood obesity preventions strategies 8 9 10 11 as the family home represents a microsystem of processes by which child functioning is shaped 12 however more research is needed to understand how features of family homes may influence such efforts chaos and childhood obesity chaos is one feature of family home environments that may be consequential for earlychildhood weight development but evidence is mixed for example crosssectional studies investigating direct associations between chaos and weight status among preschoolaged children report null findings 1314 one prospective study of caregiverreported chaos measured twice over a sixmonth period indicated higher levels of chaos were associated with higher body mass index zscore in among infants 15 other studies propose chaos may operate through mediators such as cortisol patterns child eating behaviors and sleep duration to contribute to poorer child weight outcomes 1416 chaotic environments are often described as noisy crowded and lacking organization 17 furthermore both structural and temporal instability in the form of frequent changes in adults romantic partners residential mobility loss of family income and disrupted family routines and rituals may also contribute to chaos 18 chaos is more likely to occur among households with fewer socioeconomic resources 17 however transdisciplinary research consistently demonstrates the detrimental effects of chaos on child health and development above and beyond the influence of socioeconomic status 17 18 19 even among samples that are homogeneous with regards to ses 20 moreover it has been proposed that chaos may act as the mechanism by which ses affects child health and development 20 21 22 within the context of the family home chaos may undermine essential processes that facilitate healthy weight development 23 for example the elevated stimulation and unpredictability associated with higher levels of chaos may be stressful for young children 14 additionally caregivers living in more chaotic households may exhibit less warmth and responsiveness towards their children 2425 it has been proposed that the ways in which caregivers respond to their children during moments of heightened stress may impact the organization of emerging stress physiology in early life 26 the mechanisms responsible for physiological responses to stress are closely related to the processes governing mood and appetite regulation 2728 which are linked to obesogenic child eating behaviors 2930 moreover caring for a small child is difficult and can be stressful for caregivers especially as children reach toddlerhood and demand more autonomy 31 the rapid development occurring in toddlerhood is often coupled with new behaviors that may add to familylevel chaos and create barriers to establishing household structure and routines which may protect against obesity in early childhood 32 thus examining chaos amidst the unique challenges of toddlerhood may provide critical information that can be used to inform early childhood obesity prevention strategies measuring chaos in childhood obesity research a recent systematic review of chaos and structure in family home environments in relation to early childhood obesity found associations with child weight outcomes in the majority of studies but the direction of results was inconsistent and measures of chaos differed substantially 33 this variability is likely due in part to challenges associated with measuring chaos chaos is complex and is thought to be composed of multiple constructs 34 yet most studies examining chaosobesity relationships refer to only specific indicators of chaos like crowding 35 or a lack of routines 3236 conversely other popular measures such as the confusion hubbub and order scale 37 may lack the nuance necessary to identify important subdomains of chaos 34 coinciding with this critique lumeng and colleagues used a subset of eight items to describe emotional chaos as a component of the chaos measure in their study of stress eating behaviors and earlychildhood weight outcomes 14 furthermore measures like the chaos rely on caregiver perceptions which tend to be subjective and influenced by factors such as coping strategies and personality traits 38 one potentially promising strategy for measuring familylevel chaos may include direct observations of family homes using numerous environmental indicators to the best of our knowledge no study has described such a strategy in the childhood obesity literature however examples exist in other research domains for instance lead investigators of the family life project 39 a study designed to longitudinally assess child health and development and family function among households living in lowincome rural regions of the us 39 conducted five direct observations of household chaos over a three year period using 10 indicators 34 factor analyses of these 10 indicators resulted in a two factor structure consisting of disorganization and instability 34 in subsequent analyses of these chaos findings from the family life project researchers showed that chaos in the form of disorganization was more important for outcomes like child language development 34 and academic achievement 22 than chaos in the form of instability thus a more objective approach to assessing chaos using multiple chaosrelated conditions may support efforts to reconceptualize aspects of chaos and determine which matter for earlychildhood weight outcomes study aims and objectives in the present study we aimed to characterize the home and neighborhood environments of a contemporary cohort of toddlers and explore potential contributors to chaotic environments our analyses utilized direct observations of family homes to accomplish our aim we examined chaos using a concurrent mixed methods research design the objectives for this study were to examine the underlying structure of environmental and household chaos using direct observations of the immediate neighborhood and family home environment and to establish preliminary evidence for construct validity using qualitative fieldnotes we hypothesized that more comprehensive and nuanced assessments of family home environments would provide additional evidence for a multifactor structure of chaos including disorganization noise and instability we then discussed our findings in the context of current early childhood obesity literature and offer considerations for future studies methods study population data are from play growa prospective cohort study of 299 parentchild dyads from central ohio study design and cohort characteristics for the play grow study have been previously described 40 but are briefly summarized here the target population for play grow included 18monthold children living in central ohio a sampling frame was constructed using patient medical records from nationwide childrens hospital in columbus ohio caregiverchild dyads were enrolled between 2017 and 2019 dyads enrolled included primary caregivers and children who were born singleton with gestational ages between 23 and 42 weeks enrolled dyads lived within 15 miles of nch with no family plans to move beyond that radius during the study and the participating caregiver attested to taking part in the childs meals on a regular basis participants were excluded from recruitment if the child had deafness blindness food allergies gestational age 42 weeks or if the child was tubefed or a patient for a clinical feeding disorder the final cohort consisted of caregiverchild dyads who were diverse with regards to gestational age raceethnicity household composition education and household income play grow is ongoing thus we utilized data from the first and second assessments which took place when children were approximately 18and 24months of age assessments included caregiver surveys and direct observations of family homes we limited or analyses to only records with complete data on the variables examined in this study our analytic sample differed from the original play grow cohort with regards to caregiver age food insecurity and household income the study was conducted in accordance with the declaration of helsinki and the institutional review board of nch approved study procedures researchers obtained written documentation of informed consent for all subjects data collection we utilized rapid assessment procedures 41 to simultaneously collect quantitative and qualitative data describing neighborhood and household conditions rap make use of traditional anthropological techniques such as participant observation interviewing and analysis of quantitative data over a shortened and more focused period of fieldwork 41 typically rap are implemented by multidisciplinary teams across multiple sites include prompt turn arounds on data analyses and are participatory in nature 4142 while rap may never meet the methodological standards sought by most anthropologists researchers across disciplines increasingly recognize the advantages of rap for gaining insight into complex social and material settings for example rap have been used in domains including health education 43 pandemic response in clinical settings 44 and health information technologies 45 our rap consisted of quantitative audits of neighborhood and household characteristics and participant observation techniques in neighborhoods and family homes observations of neighborhood and household environments as part of the second wave of data collection pairs of trained researchers drove to participant homes when children were 24months of age teams consisted of a lead and an assistant researcher the lead researcher directed the visit and led a variety of study protocols the assistant researcher provided support and was tasked with conducting an extensive mixed methods observation of neighborhood and household conditions to facilitate this observation we designed a novel data collection tool to describe a variety of neighborhood and household conditions by adapting existing environmental audits and questionnaires 3437 46 47 48 the assistant researcher was also trained to supplement quantitative observation data with a rapid participant observation to describe various conditions and interactions noted in participants neighborhoods and homes participant observation is a traditional anthropological technique often used when researchers aim to develop an understanding of participants lived experiences amidst natural settings 52 we adapted key features of participant observation to be implemented over numerous home visits lasting approximately 100 minutes each for at least 10 min prior to the start of the home visit the immediate neighborhood was observed from the vehicle with the windows down the assistant researcher also examined the exterior of the family home while unpacking study materials from the vehicle and walking to the entrance of the participants home the interior of family homes was observed for the remainder of the scheduled visit the assistant researcher was permitted to interact with participants in ways that built rapport however conversations between the study team and participants occurred mostly with the lead researcher this left ample time for the assistant to observe and discreetly write descriptive fieldnotes assistant researchers were also encouraged to practice critical selfreflexivity by writing notes describing their experiences challenges or personal biases they noticed while conducting observations following visits study staff returned to research offices where they logged their neighborhood and household observations and wrote a brief ethnography using their jotted fieldnotes research staff training and reliability prior to data collection research staff received a halfday training involving a twohour classroom session and a twohour field practice component a second classroombased review session was conducted once data collection was underway photos of varying neighborhood and household conditions were rated and discussed detailed descriptions of each rating were the telephone took up a lot of time in the home no yes provided based on group consensus definitions for ratings and descriptions were recorded and organized in a manual for reference and future trainings during the field component trainees traveled to the home of a research team member where each trainee completed and discussed the observation form trainees who consisted mostly of collegeeducated white middleclass females under age 40 years were required to demonstrate 80 rater agreement from a minimum of five observations before they were certified to collect data data analyses quantitative analysis we used items from the observation of neighborhood and home environments to describe chaos the original data collection tool consisted of 32 items however some of these items were better indicators of socioeconomic disadvantage or more aligned with constructs such as neighborhood social cohesion 54 or neighborhood disorder and decay 48 therefore we selected 14 items that were most like other measures of environmental and household chaos we also included another seven items derived from caregiver surveys that were administered as part of the 18and 24month visits to supplement measurements of household instability 18 we chose to do this because such indicators are not possible to observe during a 100min home visit we reviewed the distributions of responses for the initial 21 items and chose to exclude two due to little variability in item responses thus we sought to empirically derive measures of environmental and household chaos from a total of 19 items we developed scales describing chaos using exploratory factor analyses 55 with unweighted least squares and oblique rotation methods all items considered for the efa were ordinal or binary therefore our factor analysis was based on polychoric correlations rather than pearsons correlations 56 we chose to employ unweighted least squares for ordinal indicators because it has been shown to be robust to smaller sample sizes skewed data and provides greater accuracy and less variability in estimates when compared to diagonally weighted least squares 57 factor extraction was informed by a scree plot 58 and our theoretical understanding of chaos our final factor structure required factors to have a minimum of three items as fewer than three items generally results in weak factors 58 following previously published work we assigned an item to a factor if the primary loading was ≥ 040 57 and the item did not crossload 58 if an item failed to meet our criteria for factor assignment the item was removed during the structure development process once our factor structure was identified we generated summary scores for our measures of chaos because our efa included items with different response options we chose to rescale items within a range 0 1 using minmax feature scaling 59 to ensure items were equally weighted once rescaling was completed we summed items according to their factor assignments then estimated the internal consistency for each scale using cronbachs alpha we conducted descriptive statistics and p values from oneway anova to described how measures of chaos distribute across characteristics of the sample including child caregiver and household characteristics variables to describe cohort characteristics were predominantly derived from the caregiver survey administered at the 18month assessment quantitative analyses including the efa were conducted using sas qualitative analysis due to the large number of homes visited by researchers during the 24month assessment we chose to examine and compare qualitative records from a randomly selected subset of families to do this we categorized factor scores into quartiles and randomly selected records from the highest quartile and records from the lowest quartile of factor scores a thematic analysis 60 was conducted using the brief ethnographies informed by the indicators of chaos selected from the neighborhood and household observation we used a deductive approach to develop codes though an initial round of open coding was completed to assess patterns in the data and codes missing from our a priori coding structure 61 a final codebook was constructed with code definitions to ensure consistency across coding coding was conducted by the first author and records were coded until thematic saturation 52 was achieved a total of 88 records were coded and codes were managed electronically using qsr nvivo results quantitative findings the scree plot showed a large break between two and three factors and a smaller break between four and five factors the eigenvalues for the first five factors were 41 22 15 12 and 09 the total variance explained by two three and four factors combined were 582 724 and 834 respectively we examined the factor structures of a two three and four factor solutions to assess the face validity of each potential scale both the three and four factor solutions contained numerous indicators that crossloaded and factors with less than three items therefore we concluded a twofactor solution provided the best fit for our data our final factor structure required factors to have a minimum of three items factor loadings ≥ 040 and no crossloaded items as a result seven items were excluded from our factor assignments eight items were assigned to the first factor we labeled this factor household disorganization and it included items describing interior household conditions and household dynamics such as interior noise clutter commotion overcrowding with furniture telephone use communication between household members and overall preparedness for the study visit our second factor labeled neighborhood noise consisted of four items describing the types and amount of noise heard outside participants homes after rescaling items within a range of 0 1 theoretical scores for household disorganization could range from 08 though observed scores ranged from 0 73 theoretical and observed scores for neighborhood noise ranged from 04 cronbachs alpha was acceptable for both scales childrens gestational age and sex were not associated with measures of chaos as expected higher levels of both household disorganization and neighborhood noise were associated with characteristics often indicative of socioeconomic advantage though there was variability within these groups caregivers living in more disorganized homes and more noisy neighborhoods tended to be younger identify as nonhispanic black or nonhispanic other were less educated and were more often unmarried additionally participants from more disorganized homes and noisy neighborhoods less often lived in singlefamily homes and reported lower annual household income the number of household occupants was associated with household disorganization but not neighborhood noise with higher ratings of disorganization assigned to households with two occupants or five or more occupants and lower ratings assigned to households with three or four occupants symptoms of depression were marginally associated with household disorganization but not associated with neighborhood noise finally food insecurity was significantly associated with more household disorganization but only marginally associated with neighborhood noise qualitative findings household disorganization qualitative data from our brief ethnographies supported the quantitative indicators that were selected to describe household disorganization the indicator for commotion provided a summary of the amount of movement activities and noise occurring within the home thus other indicators like the interior noise rating interruptions and loud speaking were often intertwined with descriptions of commotion within households in homes with higher levels of disorganization researchers often noted people talking over one another or yelling staff also noted increased foot traffic within homes for example one observer wrote …several people… were coming in and out of the house while we were there… a teenage boy present at the beginning of the visit…left the… father also came home partially through the meal… people were entering and exiting from… the back of the apartment in contrast homes labeled as being the least disorganized were depicted as …not having a lot of activity going on observers used words like calm peaceful and relaxing to describe to overall atmosphere for such homes and family members were often described as speaking at low even volumes qualitative descriptions of telephone use also varied namely in households that were the most disorganized observers more frequently described noise from telephones or use of mobile phones during visit activities whereas in the most organized homes staff noted rarely seeing or hearing mobile phones descriptions of clutter inside homes were often interwoven with descriptions of crowding due to furniture together these indicators appeared to illustrate the organization of a homes physical space for example in homes that were the most disorganized staff illustrated environments where tables and other surfaces were covered in various items like household ornaments papers laundry or appliances during one home visit a household member shared her experience of losing her stuff in the home due to how cluttered it was staff also described environments that were so crowded with furniture and other items that the space appeared to be unusable or difficult to get around in contrast homes described as having the least disorganization appeared to have organizational systems in the form of bins or shelves that helped consolidate household items like childrens toys additionally furniture did not appear to interfere with mobility throughout the home the rating for family preparedness often reflected signs that participants remembered their scheduled visit and attempted to follow visitpreparation instructions provided by the research team in homes with high levels of disorganization observers frequently noted that caregivers did not complete surveys ahead of time and did not place pets in a separate space before allowing staff to enter their home additionally other family members sometimes appeared surprised by the presence of staff suggesting participants did not inform them of the visit conversely staff were often greeted promptly by caregivers from homes with the least disorganization family members could sometimes be seen waiting at the door or looking through windows in anticipation of study staff arrival caregivers often complete surveys within the recommended timeframe and placed family pets in separate rooms or outside prior to staff entering the home there was also evidence from the least chaotic homes of family communication in preparation for the visit for example one observer wrote …it was evident that mom and dad had discussed the study… before we got there… because there was no question about who would do what activities… in addition to themes directly supporting our quantitative measure of household disorganization we also noted excerpts describing aspects of the social environment that extended past our eight indicators for example in the least disorganized homes observers consistently noted exchanges and interactions between household members that were generally peaceful and harmonious in such cases both caregivers and children appeared to be very engaged and enjoyed their time together one observer wrote the child was engag ed and seem ed really happy to be with mom mom… always responded to him was chatting with him and smiling at him the child often looked to mom for feedback… even when mom was busy with the survey she was always paying attention to the child enough to respond to him when he addressed her peaceful exchanges noted by staff often occurred during home visits where more than one caregiver was present caregivers were described as behaving warm ly and friendly towards one another and were often successful at divide… tasks between each other caregivers ability to remain calm and patient with their children even during tantrums or moments of fussiness appeared to result in more peaceful interactions overall staff also noted displays of affection or support between family members living in more organized households such descriptions often included moments when researchers observed a caregiver and child hugging or cuddling caregivers shared with study staff positive feelings they had towards their children for example one father … spoke about his childrens school and about the child participants growth in vocabulary and mentioned that he had counted to eight in other instances staff noted other family members like siblings demonstrating support for the participating child older sister wanted to help her brother when he was upset during measurements by showing him how to do them and that they were easy and not at all scary she even held his hand during height measurements in contrast homes with higher levels of disorganization often included staff descriptions of more turbulent exchanges between household members in such cases caregivers and children were often observed struggling through visit activities mom… seemed very stressed when child did not understand or did not follow her requests… she table 4 the distribution of household disorganization and neighborhood noise according to cohort characteristics with the limited space siblings going up and down stairs parents going up and down stairs and elevated voices it felt very chaotic in the home the home was calm and peacefulboth parents… did not appear to be in any rush… the home did not have a lot of activity going on interior noise rating …there were six other siblings that were in the home two of which were very young and stayed in the kitchen with staff they all spoke in their normal speaking voices but with the small space it echoed loudly in the home and seemed louder… the smoke detector beeped during the entire visit indicating the battery needed to be changed and the washer was running during activities the home was mostly quiet the child whined but was not overly loud dad and sister played and read together they giggled and spoke but were mostly quiet indoor speaking volume i could not hear any sounds from household appliances interruptions a few minutes into the visit multiple siblings and friends walked through the back door they loudly spoke over one another and it was difficult to hear the mom and child over them throughout the visit mom would yell across the house at siblings to get them to do various tasks or to come join for the meal while family spoke often their voices were never raised i would describe it as using indoor voices loud speaking the great grandma got upset with the dogs for barking and yelled at them several times saying im going to bust you they never raised their voices to the children but were stern at times … telephone use moms phone made a lot of noise… mom spent most of our visit looking at her phone and playing with the youngest baby i never heard or saw mom or dad use their phone during the visit cluttered interior the sevenyearold cousin … described losing her stuff in the home due to how cluttered it is she said she carried her toys and clothes around in a trash bag to keep track of them playroom had lots of interactive toys cars with racetrack that could shoot off the cars into a loopdeloop play kitchen set animated toys that singdance blocksbuilding things toys were scattered around the edges of the room or in smaller baskets so it seemed like the space had an organization system crowded with furniture when we walked into the home there was a living room with a couch big chair two desk chairs highchair coffee table tv stand and tv in addition to the furniture there was a guitar big speakers random pieces of wood unidentified electronic devices and lots of wires this room was hard to navigate and i had trouble finding a spot to do anthropometric measurements i also felt like i kept accidentally bumping into furniture or knickknacks on the furniture the living room had a couple very large couches and a round leather ottoman and coffee table but it was not overcrowded and there was a lot of open space against the back wall were many plastic bins with kids toys organized in them and some toys out on the floor survey was done hours before the visit when we arrived grandma answered the door and seemed surprised we were there she spent at least 3 min wrangling the dogs to get them out of the way while we waited outside dad greeted us at the door promptly after we knocked the dog was locked away upstairs before we even entered dad showed signs of remembering details of the study and seemed prepared for what we were doing at the home visit mom was running a few minutes late but she wasnt the primary respondent and dad had already communicated that she was be home a few minutes after we arrived prior to us showing up for the home visit all signs indicated the family was wellprepared for our visit high neighborhood noise low neighborhood noise exterior noise rating the apartment complex was in was on the corner of a fairly busy cross section about 20 cars passed by in front of the home and about the same amount passed by on the other direction to the side of the building we heard a emergency vehicle siren and honking most likely more than one for about 3 mins or more occasionally heard a low rumbling of a large engine in the distance around the same time as the sirens we heard a small engine airplane and then a helicopter nearby when all was quiet there was a faint whoosh from the traffic in the distance the neighborhood was very quiet i could not hear any highway traffic only the occasional car driving past where we were parked or a nearby street traffic volume was light i only counted 45 cars passing by during the observation i did not note any noise from airplanes or trains neighbors from across the street were walking out to their car and yelling one person yelled oh my god unlock the door loud ambient sounds in the 15 mins we sat there 3 airplanes went by producing a very loud sound and lasting for at least a min each time the sounds of a very high altitude plane flying overheadit was so faint that i wouldnt consider it loud ambient noise hear exterior noise inside when sitting in the living room you can hear the carstrucks passing by from the street also hear peoples voices outside one airplane sound and music i rated it as very noisy because of the multiple sounds i was not able to hear any noise coming from outside even when we were hanging around the front door to hide out of site during the meal kept apologizing throughout the visit… and would make… comments to her son like come on you can do this i know you can do this for us why arent you in fewer cases staff witnessed family members engaging in active arguments during the study visit for example one researcher observed mom and partner having another hushed but agitated argument when they thought we were out of ear shot mom used several expletives finally researchers often used words like passive or lack of engagement to describe caregivers in households that were more disorganized neighborhood noise qualitative data from our brief ethnographies provided preliminary construct validity for our indicators of neighborhood noise in most neighborhoods the exterior noise rating represented a holistic description of the types of noise and the volume of such noises observed over a brief period across levels of neighborhood noise staff indicated car traffic in the neighborhood or on a nearby thoroughfare was a consistent source of noise however among a subset of neighborhoods with the highest noise ratings observers highlighted the homes proximity to major highwaysinterstates one staff member wrote the apartment complex was built directly next to the highway there was only a concrete partition separating the highway from the complex parking lot the partition did very little to cut down noise it sounded like i should be able to see the vehicles as they drove past but i couldnt the highway noise was extremely loud and constant i could identify every semitruck that went by conversely in the quietest neighborhoods observers would sometimes draw attention to the distance between the participants home and known interstate highways in such cases staff sometimes noted a participants home was in a more rural part of the city on a culdesac or had a dense forest of trees blocking… sounds from nearby highways ambient noises were often the same across neighborhoods despite the level of noise observed airplanes and emergency vehicle sirens were frequently heard occasionally staff would note the presences of noise from a nearby construction site or an individual vehicle with a loud engine however among homes described as having the lowest neighborhood noise researchers more frequently described sources of ambient noise as being noticeable to a lesser degree they did this by conditioning their descriptions using words like faint or muffled or described noise as being sporadic rather than constant unique to neighborhoods with the highest noise ratings some observers noted the presence of loud music playing from vehicles driving through the neighborhood one researcher wrote two cars pulled in at different times that had their music turned up very loud… we could feel vibrations from the bass the ability to hear neighborhood noises from inside participant homes differed according to neighborhood noise ratings in homes from the quietest neighborhoods research staff often made statements like no outside noises could be heard from inside the home sometimes staff would suggest that interior sounds such as subtle humming from appliances or family members talking might drown… out the exterior noises in the few cases where neighborhood noises could be heard while inside the home observers made a point to note that the family had the … windows and front door… open because of the weather or that study staff …were hanging around the front door… when they heard such noises in contrast while inside homes located in the noisiest neighborhoods observers repeatedly described hearing vehicle or highway noise and loud ambient noises such as sirens airplanes and at times construction for example one observer wrote we could also hear noise from the highway and construction outside especially the large trucks going by another offered i could hear some loud engines revving outside and then an airplane and train at one point in fewer cases research staff also noted being able to hear loud music playing from passing vehicles while inside the home for instance …there were several… cars with loud stereos that pulled into the complex that we could hear the beat and the tune of the song they were listening to from inside the home on the rare occasion that observers were unable to hear neighborhood noises while table 5 example excerpts providing preliminary construct validity of indicators of chaos selected from the exploratory factor analysis rating of exterior noise audible inside the sound from the road traffic outside was very noticeable inside the home the adults bedroom shared the wall that faced the street and so did the main living space childs room was towards the back of the house i could hear regular passenger vehicles but especially large semis as they drove past i was only able to hear some of the traffic from outside when we were hiding out of sight by the front door inside a participants home staff suggested the inability to hear such noises may be due to characteristics of the home for example one researcher wrote i tried very hard to hear highway noise and couldnt either the building materials did a good job insulating against noise pollution or the air conditioning was… loud enough… to cover the exterior noise or both discussion summary of findings chaos is known to negatively influence a wide range of family caregiver and child outcomes 19 in recent years researchers have considered the role of chaos in child weight status but results are mixed and conclusions are limited by the heterogeneity in which chaos is operationalized 153362 to improve upon limitations of previous chaosobesity investigations we proposed reconceptualizing aspects of chaos to facilitate future research efforts that aim to determine which matter for childhood obesity development thus in the present study we examined the underlying structure of multiple indicators of familylevel chaos from direct observations of neighborhood and home environments using a concurrent mixed methods approach we found evidence to suggest numerous indicators of chaos may be governed by higherorder constructs including household disorganization and neighborhood noise this evidence was further supported by themes derived from qualitative fieldnotes which provide preliminary construct validity for a novel chaos assessment tool the methodology and results in the present study closely align with those described by vernonfeagans and colleagues who assessed familylevel chaos via direct observations using multiple indicators of chaos 34 concurrent with their methods and results we utilized direct observations of family homes and found evidence to suggest chaos may be comprised of multiple constructs however our study incorporated both quantitative and qualitative assessment of chaos which presented opportunities for data triangulation expansion of descriptions of chaos and further contextualized the broader social and material environments in which chaos occurred 52 for example in addition to providing evidence to support our indicators of chaos themes emerged from our qualitative analysis to suggest family dynamics varied according to the level of household disorganization specifically among homes with the lowest levels of disorganization study staff described what appeared to be more peaceful and harmonious exchanges between household members in contrast observers noted a greater frequency of turbulent exchanges between household members from homes with the highest levels of disorganization previous research suggests greater family functioning 63 and high quality relationships between caregivers and children 64 65 66 may be protective against childhood obesity yet chaos may degrade the quality of such relationships 2467 it has also been proposed that the quality of interpersonal interactions occurring between family members may moderate the effect of chaos on childrens risk for obesity for example one qualitative study conducted semistructured interviews with 20 ethnically diverse caregiverchild dyads and described experiences where household chaos not only influenced the structure and quality of family meals but also created more challenging mealtime interactions among family members experiencing difficulties in their interpersonal relationships 68 similar findings were echoed from one quantitative study among 108 caregivertoddler dyads where researchers reported children exposed to higher levels of chaos engaged in obesogenic eating behaviors to a greater degree but only when maternal emotional responsiveness during mealtimes was low 69 the pathways by which chaos may be linked to child weight outcomes are likely complex and the unique challenges associated with caring for young children may add to familylevel chaos creating additional stress for caregivers our qualitative findings build upon emerging literature which suggests caregiverchild interactions may be important context for studies of chaosobesity relationships especially during early developmental periods like toddlerhood however given the exploratory nature of these findings this interpretation is speculative and requires additional study to determine how chaos and caregivertoddler interaction may work in concert to influence childhood obesity risk our scale describing disorganization closely aligns with what matheny and colleagues labeled environmental confusion in the development of the chaos 37 this suggests the chaos may provide a foundation for developing measurement tools designed for structured direct observations of disorganization in family homes we believe direct observations may be necessary to avoid potential bias often associated with caregiverreported measures 70 for example one study examining parent and adolescent perceptions of household chaos using the chaos found perceptions of chaos in shared home environments were only moderately correlated implying individual differences may influence perceptions of chaos 71 another analysis examined associations between maternal personality characteristics and perceptions of chaos using the chaos and concluded mothers with high stimulus sensitivity perceived home environments as more chaotic than what was objectively measured by trained observers 38 while caregiverreported measures offer quick costeffective alternatives to direct observations disentangling caregiver characteristics from measures of chaos may be impossible without more objective assessments still direct observations conducted by trained researchers are not without shortcomings including vulnerability to bias resulting from observers personality knowledge beliefs and experiences we were mindful of this limitation when designing our data collection procedures to mitigate potential bias in our direct observations staff were trained to collect both descriptive and reflecting fieldnotes which facilitated staff engagement in reflexivity as they assigned ratings nevertheless individual biases may have played a role in our observations therefore concurrent use of caregiverreported and objective measures of chaos in future studies may be an essential next step to inform future chaosrelated research a second factor of chaos neighborhood noise was identified through our efa studies examining noise as one feature of chaos suggest cardiovascular stress indicators and neuroendocrine stress hormones implicated in obesity development may be sensitive to louder environments 72 however current definitions of chaos include little specificity around types and sources of noise 1737 interestingly one indicator of chaos from our observation that described the level of interior noise was highly correlated with our factor of disorganization but minimally correlated with our factor of neighborhood noise such distinctions may suggest noise typologies are a necessary level of nuance for measuring environmental and household chaos with different implications for childhood obesity research for example our thematic analysis further contextualized our neighborhood noise ratings by indicating that participants living in the noisiest neighborhoods often lived close to interstate highways highway construction in the us has disproportionately burdened black and brown communities and contributed to the residential concentration of poverty 73 obesity is known to be a condition that disproportionately affects nonwhite children 7475 and children residing in households with fewer socioeconomic resources 76 thus neighborhood noise may be one aspect of chaos more closely linked with structural disadvantage and requires multifaceted interventions designed to address a variety of upstream social inequalities future studies of chaos within the context of child weight development may benefit from efforts to describe the variability of chaos within and across socioeconomic groups contrary to what we hypothesized our efa did not identify instability as an independent factor contributing to chaos prior to selecting our final model we considered other factor structures that incorporated indicators thought to be associated with instability such as mealtime routines bedtime routines and changes to the household composition however the internal consistencies associated with these alternative structures were poor the face validity was less convincing and we found little to no support for alternative structures in our qualitative data moreover our lack of support for instability as a factor of chaos may be attributed to the crosssectional nature of our study design for example vernonfeagans and colleagues identified instability as an independent factor of chaos through direct observations of family homes however vernonfeagans et al conducted repeated assessments over a three year period 34 unlike other aspects of chaos which tend to persist instability often occurs periodically thus single assessments of chaos may be insufficient for detecting factors like instability within this vein time may be a key component missing in most studies examining associations between chaos and earlychildhood weight outcomes for example null findings have been reported in crosssectional studies examining direct associations between caregiverreported chaos and earlychildhood weight outcomes 1314 conversely one study that assessed caregiverreported chaos twice over a six month period indicated infant bmi zscore was significantly higher when household chaos was higher 15 therefore longitudinal assessments may be necessary for identifying molar constructs thought to govern chaos as well as associations that may exist between chaos and earlychildhood weight outcomes limitations our study has limitations that must be considered observations of chaos were conducted during a single visit in participant homes as some aspects of chaos may be acute while others are chronic we may not have observed the true variation of environmental and household chaos furthermore the presence of study staff and execution of study protocols during the visit may have contributed to an unusual home environment that factored into our staffs ratings future studies incorporating objective measure of chaos should strive for repeated assessments to ensure what is measured is typical for households our data collection tool for measuring household chaos was novel thus without more rigorous testing of psychometric properties construct validity and generalizability of our tool may be limited furthermore protocols for conducting observations were developed and implemented by mostly middleclass white females and our initial training for our observation protocol was limited to a single field practice component in a neighborhood where one research team member resided while few studies have examined challenges to conducting direct observations of chaos a wealth of research demonstrates divergent descriptions of parenting styles when researchers seek to observe behaviors across diverse groups 7778 though our protocols and trainings attempted to overcome systematic error using multiple methodologies our homogenous research team did not reflect the diverse cohort of families making up the play grow study therefore it is possible that researcher observations reflect cultural differences that may or may not be symbolic of chaos furthermore most observers interacted and built rapport with families at previous assessments it is unknown whether these previous interactions influence ratings and fieldnotes finally though we included two items on household routines in our quantitative assessment household routines were largely neglected from our observations of chaos family routines may be key aspects of chaos with important implications for childhood obesity 3279 future research should combine factors such as disorganization and noise with measure of family routines to understand how best to operationalize chaos conclusions chaos represents a complex multifaceted construct with implications spanning various research disciplines 80 including public health research focused on early childhood obesity previous research investigating chaosobesity relationships in earlychildhood may be limited by the challenges associated with measuring chaos therefore this study advanced the literature by contributing to efforts to reconceptualize aspects of chaos and identifying conceptually distinct subdomains including disorganization and neighborhood noise as obesity prevention researchers look to family home environments as preferred settings for prevention efforts 81 more contemporary measures such as those relying on direct observations which account for multiple underlying factors of chaos may yield valuable insight on factors contributing to earlychildhood obesity risk abbreviations chaos the confusion hubbub and order scale nch nationwide childrens hospital rap rapid assessment procedures efa exploratory factor analysis authors contributions klk designed and conceptualized this research led data collection led analyses and interpretation of data and wrote the manuscript ap participated in the design and conceptualization of data collection methods assisted with data collection assisted with analyses and critically revised the manuscript ra advised the conceptualization of analytic methods supervised data analyses and critically reviewed the manuscript bz participated in early development of the data collection methods and critically reviewed the manuscript sak supervised data collection and critically reviewed the manuscript sea supervised the design and conceptualization of this research supervised analyses and interpretation of data and critically revised the manuscript the author read and approved the final manuscript competing interests the authors declare that they have no competing interests

background chaos has implications for child health that may extend to childhood obesity yet results from studies describing associations between chaos and childhood obesity are mixed new approaches to studying the environments of young children may help to clarify chaosobesity relationships methods we conducted a concurrent mixed methods analysis of quantitative and qualitative data describing home and neighborhood chaos among a diverse cohort of 283 caregivertoddlers dyads from ohio we examined the underlying structure of environmental and household chaos using exploratory factor analysis then sought to validate the structure using qualitative field notes we generated total scores for factors of chaos and described their distributions overall and according to cohort characteristics additionally we conducted a thematic content analysis of brief ethnographies to provide preliminary construct validity for our indicators of chaos results dyads varied according to household composition income education and raceethnicity we found evidence for a multifactor structure for chaos which included disorganization and neighborhood noise household disorganization scores ranged from 0 to 73 and were on average 21 sd 18 neighborhood noise scores ranged from 0 to 4 and were on average 11 sd 11 both disorganization and neighborhood noise were associated with indicators of socioeconomic disadvantage such as lower educational attainment and household income qualitative data from households with high and low scores on the two identified factors were aligned in ways that were supportive of construct validity and further contextualized the social and material environments in which chaos occurred

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interpersonal violence is among the most important preventable causes of premature mortality and morbidity excluding war it leads to around 410 000 deaths per year and is the 19th most common cause of death globally 1 morbidity is also substantial although there are large variations it is in the top five causes of disabilityadjusted living years in central and tropical latin america and southern subsaharan africa 2 trends in violence vary depending on the outcome used decreases in violencerelated mortality have been reported from 2000 to 2015 1 whereas morbidity has remained unchanged 12 public health has moved toward a prevention model for violence 3 and influential world health organization reports have focused on delineating risk factors 4 identifying modifiable risk factors could potentially reduce risks and assist in developing interventions however these reports are limited by being narrative reviews of the evidence without quantitative methods to evaluate the strength quality and consistency of risk factors to address limitations in previous work and provide an overview we conducted an umbrella review of the evidence from existing systematic reviews and metaanalyses on risk factors for violence methods no specific ethical approval was required for this research as it was a synthesis of secondary data from published sources search strategy the systematic search strategy was prospectively registered on prospero 5 the original search incorporated both risk factors for violence and suicide and this paper reports the violence search three databases were searched from their start dates until january 2018 psycinfo medline and global health supplemented by targeted searches on google scholar and pubmed keywords for violence were combined with search terms for risk factors and publications citations and reference lists of relevant reviews were handsearched targeted searches were used to identify additional studies by first author names and specific risk factors that were not identified in our initial search study eligibility eligible studies were metaanalyses or systematic reviews that examined risk factors for violence in the general population and provided effect sizes and data to calculate 95 confidence intervals we aimed to measure interpersonal violence and included a broad range of violence outcomes such as assault violent crime and sexual violence although this is a broad scope we aimed to include only those reviews that used some measure of interpersonal violence as outcome published and unpublished reviews in any language were considered excluded studies were those with methodologies other than a metaanalysis or systematic review such as individual casecontrol or cohort studies as the primary research question was risk factors in the general population reviews that investigated selected populations such as prisoners or those with a specific diagnosis were excluded reviews that focused on reoffending risks or those examined interventions for violence were also excluded 6 7 8 if more than one eligible review was found on the same risk factor the most recent one was included data extraction data were extracted with a standardised form reported effect sizes with 95 confidence intervals were recorded with other key information separate effect sizes for gender the effect size of the largest study included in each metaanalysis and the effect size for the different study designs were extracted when these data were not recorded we corresponded directly with authors extracted data were independently crosschecked by a postdoctoral researcher and any queries were resolved by discussion with the project supervisor statistical analyses as the reporting of effect sizes varied between studies they were converted to comparable measures for the primary outcome all effect sizes were converted to odds ratios for those reported as cohens d logtransformed odds ratios were calculated 911 effect sizes reported as correlation coefficients were converted first to cohens d and then to logtransformed odds ratios odds ratios were categorised as follows weak 1015 moderate 1625 strong 2699 and very strong ≥100 12 categorisation of risk factors and outcome measures risk factors and outcome measures were qualitatively analysed after the search and common categories were identified we identified distinct categories of outcome measures that were reported separately metaanalyses with other related outcome measures such as aggression and hostility were reported as secondary outcomes in supplementary appendix 2 population attributable risk fractions population attributable risk fractions indicate the proportion of an outcome that would theoretically not occur in a population if a given risk factor was eliminated assuming causality between risk factor and outcome we estimated the proportion of cases that could be attributed to each risk factor in the general population although causal inferences were not possible for some risk factors pafs provide a measure of the maximum possible effect that each risk factor has at a population level by taking into account the risk factors prevalence 13 thus if a risk factor has a large effect size but low prevalence its effect at a population level will be lower than a risk factor with low or moderate effect but a high prevalence tests of quality of evidence reviews were assessed for quality by various approaches first we scored the assessing the methodological quality of systematic reviews tool 14 scores of 03 are considered low 47 are medium and 811 are high 12 second we compared the effect size for the largest included study in each metaanalysis with the overall quoted metaanalysis effect size results where the largest included study effect size was close to the overall metaanalysis effect size were deemed to be more precise 15 third we calculated ratios between overall metaanalysis effect size and that of the largest included study in each metaanalysis a metaanalysis overall effect sizelargest included study effect size ratio of more than one indicates a larger effect size in the metaanalyses compared with its largest included study and is an indication of bias 16 fourth a comparison was made between metaanalyses overall effect size and the number of cases included in each metaanalysis when sufficient data were available fifth we assessed the relationship between study design and effect size where sufficient data were available results were extracted for pooled overall effect sizes of prospective studies alone and compared with overall metaanalysis effect sizes finally we presented prediction interval calculations for risk factors prediction intervals provide an estimate of the ranges in which future observations will fall risk factors with prediction intervals that did not cross the null value were deemed to be of higher quality those that cross the null value suggest that they may not be significant if tested in a new population 17 to summarise these quality tests a scoring system was developed which also included betweenstudy heterogeneity and whether adequate adjustments for confounders was conducted all analyses were performed with stataic version 13 results twentytwo metaanalyses on risk factors for violence were identified this included information from over 120 000 individuals from 1139 individual studies across 14 different countries risk factors were grouped into broad categories or domains of neuropsychiatric historic and other because of high heterogeneity and noncomparability results were not further pooled the largest effect sizes for violence were found in the neuropsychiatric category with substance misuse ranking most highly antisocial personality disorder had the strongest link to violence within the category of personality disorders some childhood and adolescent factors were important four metaanalyses examined parental factors that were associated with violence 20263135 these factors included poor attachment to parents parental incarceration antisocial attitudes in parents and more general problems within the family intimate partner violence six metaanalyses focused on intimate partner violence 32 33 34 35 36 37 two risk factors overlapped with risk factors for any interpersonal violence namely substance misuse and exposure to violence other risk factors for intimate partner violence appeared to be specific to relationships such as marital dissatisfaction and previous abuse by one partner toward the other sexual violence and homicide two reviews provided data for risk factors for sexual violence alone 3839 and only one review provided separate risk estimates for homicide 21 risk factors for sexual violence broadly overlapped with risk factors for any interpersonal violence data were more limited for the homicide review although two neuropsychiatric risk factors overlapped with interpersonal violence risk factors stratified by gender where possible results were stratified by gender effect sizes for women appeared to be larger than for men for all neuropsychiatric violence risk factors pafs although pafs assume causality they provide an estimate of the maximum possible effect that removing a risk factor could have and pafs for individual risk factors may overlap and add up to more than 100 40 the highest pafs for violence were substance misuse witnessing or being a victim of violence in childhood and personality disorder other reviews we identified a further 13 systematic reviews and metaanalyses that provided additional information for violence these were for the secondary outcomes of aggression and hostility rather than interpersonal violence risk factors for aggression included two main themes biological factors and witnessing violence negative findings included the lack of evidence for candidate genes associated with aggression in a metaanalysis and field synopsis of 185 studies of the field 41 quality assessments despite mostly high scores on amstar other analyses found indications of poorer quality there were small study effects and around 60 of reviews had overall effect sizes larger than the effect size quoted in each metaanalysis largest included study there was no statistically significant correlation between metaanalyses overall effect size and the number of cases included in each metaanalysis when sufficient data were available of the 12 included risk factors seven were found to exclude the null value using prediction intervals three metaanalyses enabled investigation of study design 212425 one review which examined being bullied as a risk factor reported a lower pooled effect size for prospective studies 24 two other reviews did not find statistically significant differences by study design overall using a scoring system based on quality indicators and a threshold of four or above for highquality studies seven risk factors for violence met these criteria none of the risk factors for intimate partner violence or sexual offending met this quality threshold discussion we have presented an overview of risk factors for interpersonal violence from 22 metaanalyses based on over 120 000 individuals we have presented associations pafs and measures of evidence quality and investigated risk factors for related outcomes of homicide intimate partner violence and sexual offending to our knowledge this is the first quantitative metareview of the field in addition novel features include bringing together relative risks and estimates of population effect using tests of methodological quality to determine the strength of the underlying evidence and the breadth of the outcomes and the ability to compare effect sizes between them there were three principal findings first based on relative risk the strongest risk factors were typically in the neuropsychiatric domain second in terms of population effect there was some overlap with factors that had the strongest relative effects with substance use disorders schizophrenia and personality disorders having high pafs and relative risks third the overall quality of the underlying evidence was not strong with the majority of reviews demonstrating small study effects and large heterogeneity by focusing on risk factors this umbrella review has identified individuallevel determinants socioeconomic causes of violence will rely on ecological studies that were not included a number of implications arise from this work first it suggests that many important risk factors for violence are modifiable and public health can realistically include substantial reductions globally if these factors are confirmed in treatment trials as causal 42 second violence prevention strategies should incorporate guidelines and targets for the identification assessment and treatment of psychiatric disorders however diagnostic categories themselves are not sole treatment goals and active symptoms and comorbidities which mediate the abovereported associations with violence should also be targeted our findings challenge the current view of criminology as a field that appears to underrecognise mental health in the aetiology of violent crime 43 in contrast this umbrella review found no relevant metaanalyses that were among the top five risk factors in terms of quality for socioeconomic variables and only one for a psychosocial factor one possible explanation is that the focus of many included reviews were neuropsychiatric conditions rather than socioeconomic factors in addition within the former the variation in socioeconomic factors is limited and thus studying their effects will require more general population samples at the same time it should be noted that criminal history variables are among the strongest for individuals with psychiatric scores prediction interval excluding null value 1 pvalue 005 for random effects model 1 low heterogeneity 1 number of cases 1000 1 no evidence to suggest small study effects 1 confounders adjusted for 1 disorders underscoring the need to strengthen the relationship between criminal justice and mental health services to manage future risks third on a population level antisocial personality disorder is an important risk factor for violence and more research on links between such disorders and these outcomes is warranted although little evidence exists to suggest that the underlying personality disorders are treatable some common symptoms arising from them are modifiable 44 another risk factor identified which has been less widely discussed is witnessing or being a victim of violence in childhood the mechanism for how this contributes to adult violence perpetration needs examination and may provide targets for intervention nevertheless it suggests that interventions in childhood and adolescence for antisocial behaviour should consider any such history and broaden treatments for victims to include children who have witnessed violence finally research should focus on longitudinal studies investigate sources of heterogeneity and improve adjustment for confounding sibling controls are one powerful approach to do so 45 and can provide important evidence as they account for familial confounding ultimately strong evidence of causal inference for identified risk factors will need to be tested in trials however many trials in this area may not be feasible for practical and ethical reasons and quasiexperimental designs will play an important role in developing the evidence base limitations of the current metareview include the possibility that the included metaanalyses have been superseded by more recent highquality individual studies for example the reviews on traumatic brain injury and schizophrenia are from 2009 2122 however both of these have been confirmed by more recent large populationbased studies 46 in relation to traumatic brain injury a large swedish population and sibling comparison investigation found robust links with violent crime after adjustment for sociodemographic confounders 47 and an australian study also found a link when violent crime was used as an outcome 48 in addition how violence was operationalised was necessarily heterogeneous reflecting the lack of a consensus in the field for the best outcome 49 importantly although these will alter prevalence of outcomes they does not appear to affect risk estimates as the prevalence of outcomes is consistently reported in the cases and general population controls how might treatment reduce violence one approach is simply to target and treat underlying psychiatric disorders as well as symptoms and other mediators of risk randomised controlled trials provide little evidence for this approach as they are not usually powered or designed to investigate rare outcomes observational data provide stronger support for antipsychotic medication reducing violence risk 50 and are important sources of evidence when randomised controlled trials are not feasible for example clozapine may have specific violencereducing effects 51 and psychological therapies that specifically target aggression could also be considered there is some evidence for structured group therapy in drugusing offenders to prevent reoffending 52 screening for violence risk in selected populations 53 needs further research to clarify its potential role including use of trial methodology targeting highrisk groups such as released prisoners and individuals with antisocial personality disorder should be prioritised for future intervention research treatments in childhood and adolescence require improvement 54 in addition preventative approaches should be developed to address the potential importance of the two childhood risk factors that we have identified being bullied and witnessing or experiencing violence

interpersonal violence is a leading cause of morbidity and mortality the strength and population effect of modifiable risk factors for interpersonal violence and the quality of the research evidence is not knownwe aimed to examine the strength and population effect of modifiable risk factors for interpersonal violence and the quality and reproducibility of the research evidencewe conducted an umbrella review of systematic reviews and metaanalyses of risk factors for interpersonal violence a systematic search was conducted to identify systematic reviews and metaanalyses in general population samples effect sizes were extracted converted into odds ratios and synthesised and population attributable risk fractions paf were calculated quality analyses were performed including of small study effects adjustment for confounders and heterogeneity secondary analyses for aggression intimate partner violence and homicide were conducted and systematic reviews without metaanalyses were summarisedwe identified 22 metaanalyses reporting on risk factors for interpersonal violence neuropsychiatric disorders were among the strongest in relative and absolute terms the neuropsychiatric risk factor that had the largest effect at a population level were substance use disorders with a paf of 148 95 ci 90216 and the most important historical factor was witnessing or being a victim of violence in childhood paf 122 95 ci 65174 there was evidence of small study effects and large heterogeneitynational strategies for the prevention of interpersonal violence may need to review policies concerning the identification and treatment of modifiable risk factors

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intensive and thus reserved for the elite from one population to another from one level of wealth to another humans will cope with resources that are often far below what technology can offer the least resourceintensive systems will be the most used while the development costs of a chatbot equipped with medical expertise may seem prohibitive their occasional use by individuals incurs minimal costs access to medical expertise is about to become universal the question of whether this will include the use of sensors interfaced with or embedded in mobile phones is unclear in the short term today validated technologies are relatively few majumder 2019 they utilize cameras leds and mobility sensors to measure heart rate and variability to examine the retina or to identify skin lesions requiring special attention no other technologies particularly biochemical ones have proven themselves in this format to date and research on smartphonecontrolled microfluidic systems has not yet led to mainstream applications even without these sensors in a context of a dwindling number of healthcare providers the development and generalization of automatic consultation is inevitable it will likely be widely shared worldwide similar to the rapid global dissemination of mobile telephony a complex technology that has reached even the most remote parts of the globe this inevitable evolution is already taking place in a liberalized environment while the illegal practice of medicine used to be subject to control and sometimes to repressive action the necessary structures are not in place today to guarantee the dissemination of harmless reliable solutions the strategy adopted by open ai is symptomatic of this challenge since its chatbot systematically responds to any medical question by saying that a specialist opinion should be taken and is not capable of providing medical advice establishing a shared quality assurance system therefore emerges as a crucial priority another pressing issue concerns the role of empathy in healthcare what will be the consequences of the diminishing human contact in patient care this question is pertinent will synthetic empathy be capable of substituting for human empathy in patient care perry 2023 while this query may sound thoughtprovoking it is equally important to be concerned about the existing challenges patients face in accessing empathetic caregivers for meaningful conversations statements and declarations authors contribution emmanuel lagarde is the only contributor to this manuscript role of funding source emmanuel lagarde is employed by inserm a french governmental biomedical research agency no other funding source was involved in the preparation of this manuscript

the emergence of artificial intelligence in healthcare is probably leading to another twospeed world on one hand widely accessible ai applications such as language models are becoming ubiquitous while on the other resourceintensive technologies like robotic surgery and personalized medicine will be reserved for a privileged few this development signifies a growing disparity in access to ai advancements in this context the role of empathy and emotional aspects in patient care comes to the forefront with the rise of ai theres a critical examination of whether synthetic empathy can adequately replace human empathy in patient care emphasizing the necessity of maintaining human elements in an increasingly automated healthcare environment

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introduction currently the state and prospects of the healthcare industry are among the toppriority issues in european countries socially oriented states involve the parallel development of the economic political and modern technological sectors as well as the efficiency and quality of the medical sector to improve the populations quality of life the quality of life and health of its people constitute an indicator of the success and competitiveness of a country therefore the attention of states and societies is focused on the sustainable development of the medical system to make it able to respond flexibly and adapt to new complex and largescale challenges in recent years there has been significant progress in the health systems of european countries ensuring the proper quality of medical care is one of the main tasks of the transformation processes of european states however some states have many questions about the medical industry this requires strengthening national health systems and developing policies and strategies for medical systems at the level of certain countries in response to modern challenges related to human health threats relevant officials are constantly monitoring evaluating and developing progressive health policies in all european countries these policies will allow for adapting medical services to the populations needs identifying the latest priorities in the rapidly changing and difficult financial and economic situation choosing the best medical technologies and regulating the balance between therapeutic and preventive measures health authorities strive to improve the efficiency of the health system to improve peoples health and meet the growing expectations of public satisfaction with medical services in turn improving and regulating the medical system and the quality of medical services requires understanding the indicators used to measure and evaluate the healthcare system currently there are many qualitative and quantitative indicators for measuring various health system characteristics used in countries worldwide such key indicators for each country may differ significantly depending on the socioeconomic and political development of the country therefore it is essential to define the most relevant indicators of each country and why it is necessary to introduce and ensure international world standards of the healthcare system to be able to compare and analyze the experiences of advanced countries around the world in this matter in the future it should be noted that health scientists within countries identify certain official sets of indicators with different balances of the key aspects used by the state regulatory authorities in the medical fields of their specifc country the following scientists have studied the development research analysis and monitoring of the dimension indicators of the health care system beaussier a et al 1 highlighted indicators of health care quality measurement khan s et al 2 explored public health indicators gartner j et al 3 reviewed key health performance indicators labella b et al 4 calculate patient safety indicators and carini e et al 5 evaluated the performance indicators of medical institutions etc other notable publications include lyeonov s et al 6 tiutiunyk i v et al 7 smiianov v a et al 8 aliyeva z 9 kolosok s et al 10 piven d et al 11 shipko a et al 12 strangfeldova j et al 13 privara a 14 and ivankova v et al 15 the peculiarities of the formation of the integral health care system indicators are reflected in the scientific studies of the following scientists stelzer d et al 16 suggest the use a regional integrated health care model healthy kinzigtal using quality indicators for optimizing health care and economic efficiency and van den akker e f m m et al 17 describe the development and implementation of a comprehensive integral assessment approach to health status in patients etc particular attention should be paid to the paper by vasilyeva t et al 18 on the formation of integral indicators of the sociopolitical and economic situation in a country for the assessment of the dynamics of bifurcation transformations in the economy cabinova v et al 19 is another noteworthy source on the topic it is also worth researching the degree of satisfaction with medical services this issue is quite specific and has mixed coverage in the scientific literature however the following specialists are engaged in particular approaches to this topic baranska a et al 20 conducted an assessment of the level of satisfaction with medical care among patients as an indicator of the quality of medical care vitale e et al 21 investigated the satisfaction level of the population regarding health care during the covid19 pandemic man e et al 22 defined patient satisfaction with private recovery services during the covid19 pandemic ren l et al 23 presented a survey on the crosssectional degree of consumer community satisfaction with the primary care system lee y et al 24 studied the subjective frame of patient satisfaction with the comprehensive nursing service smith et al 25 tested the determinants of hospital service quality and carmo cacciabava m et al 26 revealed important factors for success in hospitals other notable publications on this topic include probst dt et al 27 louis r 28 lesniewski ma 29 mrabet s et al 30 gavurova b et al 31 zaharia r et al 32 gavurova b et al 33 halicka k et al 34 rosenberg d et al 35 and zain nam et al 36 studying the scientific achievements of scientists regarding the research methods used in world practice we note that factor analysis is one of the most common methods used in scientific research as evidenced by information from the scopus database 3664361 publications on the topic moreover factor analysis is most often used by specialists in the field of medicine and publications in this field account for 4906 of the total volume of published papers indexed in scopus related to factor analysis using this research method healthcare scientists have solved some complex analytical problems such as machine methods of risk factor analysis and prediction of epidemiological studies proposed by tran v et al 37 a factor analysis study on the publics perspectives of qualities and behaviors a good doctor by grundnig j s et al 38 and many others zhang l et al 39 kuzior a et al 40 rajan d 41 awojobi on 42 hinrichs g et al 43 and kadar b et al 44 are other notable works employing factor analysis social sciences researchers also use the factor analysis method in their work the paper by vasilyeva t et al 45 46 47 regarding the use of factor analysis as one of the methods in modeling social and economic patterns associated with the covid19 pandemic arouses particular interest researchers from other scientific fields also widely use factor analysis in their works considerable attention should be paid to the works of the following scientists using the elements of factor analysis kuzmenko o v et al 48 regarding an approach to managing innovation to protect the financial sector against cybercrime and kuzmenko o v et al 49 who employed factor analysis in the economic modeling to determine the influence of relevant indicators of gender policy on the efficiency of a banking system other notable papers in this regard include didenko i et al 50 brychko m et al 51 dao lt et al 52 streimikiene d 53 coman i et al 54 uslu a et al 55 ibe r et al 56 and quinonez tapia f et al 57 according to the scopus database scientists widely use descriptive analysis in many branches of science descriptive analysis is most commonly used in health system research6090 of the total number of publications related to descriptive analysis indexed in scopus were from health system research thus modern healthcare scientists suggest studying various issues using the descriptive analysis method for example riediger n d et al 58 used descriptive analysis of food pantries in twelve american states taljaard l et al 59 conducted a descriptive analysis of the case mix in east london south africa bayou n b et al 60 used a descriptive structural analysis of quality of labor and delivery care in ethiopia and wylie c a et al 61 described a retrospective descriptive analysis descriptive analysis is also very often used in social sciences scientists in this field are currently studying some aspects based on descriptive analysis which include a descriptive analysis of complaints related to covid19 in california by thomas m d et al 62 a descriptive qualitative analysis of older adults accounts in chile by shura r et al 63 and others such as njegovanovic a 64 sarihasan i et al 65 pop ra et al 66 dai x et al 67 xuechang zhu et al 68 halina waniakmichalak et al 69 and zaharia r m et al 70 other scientific fields account for 2054 of scientific publications in the scopus database related to descriptive analysis lyeonov s et al 71 used descriptive analysis during the implementation of gravitational and intellectual data analysis to assess the money laundering risk of financial institutions as well as tommaso f d 72 gallo p et al 73 barrientosbaez a et al 74 alshoubaki h et al 75 vysochan o et al 76 belascu l et al 77 kramarova k svabova l et al 78 wildowiczszumarska a 79 blazevic bognar z et al 80 loi n t n 81 and capolupo n et al 82 the use of the canonical analysis toolkit is three times less than that of descriptive analysis but it still attracts considerable interest among scientists most often biochemistry genetics and molecular biology specialists use canonical analysis in their research in contrast to descriptive analysis canonical analysis is less used in medicine and social sciences the following works using canonical analysis deserve attention a new insight from canonical correlation analysis when determining the relationship between the quality of work of medical professionals was presented by wang w et al 83 canonical correlation analysis of factors that influence the quality of life among patients was carried out by liu y et al 84 the combination of canonical correlation analysis and holohilbert spectral analysis was used by lee p et al 85 a canonical correlation analysis for testing the specificity of environmental risk factors for development was used by bignardi g et al 86 and canonical correlation analysis was applied in determining relationships between anthropometric variables by malakar b et al 87 other notable uses of canonical analysis include lyeonov s v et al 88 and gavurova b et al 89 the aim of this study is to conduct a theoretical analysis and qualitative and quantitative assessments of indicators by developing an integral indicator in the context of behavioral social demographic and economic factors that characterize the level of healthcare system development in european countries using multivariate statistical modeling methods thus the theoretical basis of the main constructions of the research model is based on wellknown and proven methods of this branch of science namely cluster analysis factor analysis descriptive analysis and canonical analysis 83 84 85 86 87 88 89 it is also based on previous authors research 464790 although these sources have not yet been properly disseminated in the field of health protection and have not been applied in the proposed integrated form of modeling considering the existing threats to human health and accordingly the associated problems in the organization and functioning of health systems this study will address such gaps in the knowledge of the health system as imperfections and gaps in the complex assessment of the level of healthcare system development in terms of some important behavioral social demographic and economic factors not being used in the work of specialists in this industry while characterizing the level of healthcare system development in european countries imperfections in the existing integrated indicators of the health system which do not take into account many of the relevant factors the lack of effective methods and approaches for assessing the level of health systems in european countries materials and methods the study was implemented in three stages based on the world bank indicators for european countries from 2000 to 2020 using statistica 10 and statistica portable statistical packages when conducting the study the following restrictions were imposed for the study countries in the first stage of the study 42 european countries were selected from all countries of the world 10 of which were studied in the second and third stages selected by cluster analysis for the study period years from 2000 to 2020 were used stage 1 of the study included the formation and modeling of the statistical base of the study using descriptive analysis and applying the statistica 10 and statistica portable statistical packages to build models that would help establish the influence of certain factors on the indicator of the level of healthcare system development in european countries it was proposed to define four groups of indicators according to the following constituent features behavioral social demographic and economic the information base of the study is based on the world bank indicators which determine the public health systems behavioral social and demographic features in conjunction with the economic aspect the source of the research data is the world bank databasea reliable database of statistical data created by specialists at the world bank the formation and dissemination of this database are based on internationally accepted professional standards the world bank also cooperates with the international scientific and statistical community namely un agencies the organization for economic cooperation and development the international monetary fund and regional development banks the world bank ensures that all data in its database are highquality and complete the selection of european countries for the study was based on cluster analysis 91 which was conducted using statistica 10 and statistica portable the clustering of countries was based on iterative divisional kmeans clustering four key indicators were initially selected as a statistical base for the further clustering of countries then cluster analysis verified the adequacy of dividing 42 european countries into groups to evaluate and compare clusters we used variance analysis to select clusters 3 4 and 5 at the descriptive analysis stage of throughput indicators the values of the intergroup variances and intragroup variances of these characteristics the value of the fisher criterion and the probability of a possible rejection of the null hypothesis were determined to indicate the adequacy of clustering we used the the multivariate exploratory techniquescanonical analysis package of the statistica toolkit at this stage where k means clustering ie the analysis of variation was used to directly identify specific groups of countries that are typical of their characteristics stage 2 of the study involved the determination of the degree and significance of the interrelations between the components characterizing indicators selected for the integral indicators construction of the level of healthcare system development in european countries using canonical analysis this stage involves causal analysis ie identifying which groups of indicators are the causes of the issue under study and which are the consequences thus canonical analysis makes it possible to reduce a multidimensional set of characteristic features to a narrower concentrated system consisting of pairs of elements that are the most correlated with each other this procedure allows for a statistical assessment of the significance and relationships of the studied features mathematically the primary purpose of canonical analysis involves determining the correlation of weighted sums linear combinations called canonical variables from each possible set of characteristics that make up causal and effective features the procedure for implementing canonical analysis uses the statistica 10 and statistica portable packages this approach makes it possible to obtain a processed standardized source base of easytoanalyze tabular data in the above table x ≥ y x is the number of system attributes in the first equation from the first group and y is the number of system attributes in the first equation from the second group the estimation of the relationship between canonical variables h and f is described in formula h p 1 a 1 p 2 a 2 p x a x f q 1 b 1 q 2 b 2 q y b y where p i i 1 x q j j 1 y are the corresponding weights of coefficients calculated when solving a problem with eigenvalues moreover the change in these weights determines the difference in the value of canonical variables and the canonical correlation coefficient k in turn the canonical correlation coefficient evaluates the dependence of two variables and determines the density of the dependence between canonical variables k cov varvar the significance of correlation dependence is assessed using a standard statistical criterion υ and the standard statistical confidence interval moreover a higher significance level value corresponds to a lower level of trust statistica 10 and statistica portable software tools were used to implement canonical analysis initially panel data were generated as a table of input data for the period for 10 european countries selected according to cluster analysis next the dependence between groups of indicators was alternately determined in six tables by applying the function multivariate exploratory techniquescanonical analysis based on the generated data we first checked the adequacy of the analysis at this stage of the canonical analysis the bandwidth indicators are as follows r is the canonical correlation coefficient showing the strength and direction of the relationship between groups of indicators chi 2 is the adequacy criterion p is the probability of rejecting the hypothesis that there is no relationship between groups of indicators and the total redundancy which shows how much the variation of one group is explained by the variation of another group and shows which group of indicators total redundancy is greater where the group of indicators is a consequence stage 3 of the study involves determining relevant indicators for assessing the level of healthcare system development in european countries as well as the construction of an integral indicator of the level of healthcare system development in european countries factor analysis was performed using the principal component method the selected type of factor analysis ie principal components is a mathematically based methodology that identifies relevant indicators and their structures determines hidden indicators establishes statistical relationships and excludes noninfluential indicators to simplify the analysis results factor analysis involves a simple logical construction of a generalization of the values of certain features and replaces correlated measures with uncorrelated factors according to the method of principal components the main components and generalized features are distinguished from the input indicators moreover the mathematical model of the principal components method implies a logical assumption that a certain general result is produced from a set of interrelated features modeling according to this method provides the following 92 the beginning of the construction of the matrix of input indicators formation of a matrix of standardized values formation of the matrix of pair correlations formation of a diagonal matrix of eigenvalues a matrix of unnormalized vectors matrices of normalized vectors and calculation of the contribution of variable indicators the formed matrix of the factor expression and the matrix of principal components as well as the values of the factors that allow determining the relevant factors and their weighting coefficients based on the weighting coefficients of the relevant factors the weighted influence of the indicators under consideration is determined r → s → k → d n → v → f → q therefore the method of principal components involves constructing a factor space in which variables and observations are simultaneously classified to form the principal components a vector space of variables and observations is constructed a matrix of correlations or covariances is formed to obtain a new system of uncorrelated variables that is principal components principal components are formed as linear combinations of initial variables that is the input variables are transformed into new variables factor analysis is implemented using the statistica 10 and statistica portable software packages using the multivariate exploratory techniques function principal components and classification analysis the factor analysis was based on input data sampling where panel data were taken as input data in the form of a table of initial data for the period from 2000 to 2020 for 10 european countries selected according to cluster analysis within the framework of this stage the principal components method was used to substantiate the expediency of considering the most influential ones that have the greatest weight in the group when assessing the level of development of the healthcare system in european countries all four social demographic economic and behavioral groups of selected indicators were used for further analysis at this stage however according to the results of the canonical analysis special attention is paid to groups of social and demographic indicators that significantly impact other groups of indicators to assess the level of healthcare system development in european countries based on the data of indicators a scree plot of eigenvalues of the correlation matrix of the input data was built using the multivariate exploratory techniques principal components and classification analysis and scree plot functions multivariate exploratory techniques principal components and classification analysis and eigenvalues functions were used to form a table of eigenvalues of the correlation matrix and to derive statistical indicators of the group to assess the level of healthcare system development in european countries conducting the eigenvalues analysis of the correlation matrix of the input data indicators for assessing the level of healthcare system development of european countries confirms that the first three factors determine the relevant indicators because together they account for at least 70 of the variation of the resulting characteristic then using the multivariate exploratory techniques principal components and classification analysis and contributions functions we attain variable indicators of the group to assess the level of healthcare system development in european countries the table named intermediate values for the calculation of the relevance of indicators of the group for assessing the level of development of the healthcare system of european countries was formed based on the eigenvalues of the correlation matrix of the input data to assess the level of healthcare system development of european countries considering the first three factors and the contribution of the variables the information in this table depicts the logic of calculating the arithmetic mean of the weighted impact of social indicators for assessing the level of healthcare system development in european countries on the value of this level by calculating the sum of the products of the weight coefficients of the factors ie the eigenvalues of the correlation matrix of the input base of the selected factors as a result of calculations the values of the column weighted impact of indicators in table 2 are obtained that is a weighted impact of indicators is obtained at the stage of the factor analysis of throughput indicators to define an integral indicator of the level of healthcare system development of european countries we emphasize that a qualitative description of the structure of the studied healthcare system in terms of determining the level of healthcare system development of european countries requires the development of an integral indicator either using all the main components or a large enough quantity for analysis thus we use the values of all indicators initially disincentives are reduced to a comparable form of disincentives as a unit divided by the disincentive after that the input data are standardized using the statistica 10 and statistica portable software tools using the datastandardize function furthermore to define the integral indicator of the level of healthcare system development in european countries we carry out a convolution procedure that allows us tp calculate the integral indicators for each group in the context of each year as well as the general integral indicator for each year r t ∑ f i m ∏ i1 s f i i where r t is an integral indicator of the level of healthcare system development of european countries ∑ f i is the sum of the frequencies f i is the frequency of the studied value for the iindicator s i is the studied indicator from an economic point of view the interpretation of the calculations is as follows the higher the value of the calculated integral indicators the better the level of healthcare system development the overall integral indicators take values from 0 to 1 in the factor analysis stage the integral indicators for each group in the context of each year and the general integral indicator of the level of development of the european countries healthcare systems each year are output the performance indicators include the arithmetic means by year in the context of each country and by country in the context of each year results in the first stage the statistical base of the study was formed and modeled in the form of four groups of indicators behavioral social demographic and economic using descriptive analysis a group of 10 european countries was identified using a cluster analysis based on the application of an iterative divisive kmeans method multiple units of indicators are determined by the factor analysis of indicators separately for each group in the context of each of the 10 european countries for each year of study evaluation indicators were selected for the period from 2000 to 2020 thus in the proposed modeling package the following statistical data were selected to implement quantitative formalization and as indicators to be input intothe models economic indicators incentives e0gdp per capita e1government expenditure on education total e2government expenditure per student territory e4research and development expenditure e5gni per capita atlas method disincentive e3poverty gap at usd 190 a day ten european countries were selected for the study austria belgium germany denmark finland france the united kingdom the netherlands norway and sweden four key indicators were initially selected as a statistical basis for further clustering of countries behavioralb0 socials0 demographicd0 and economice0 an aalysis of the results of the clustering of european countries into three four and five clusters determined the adequacy of the threecluster grouping of countries thus three separate clusters were identified containing a grouping of european countries according to the selected key indicators in a systematic graphical form indicating the number of member countries of each cluster euclidean distances from the grouping center as the defining metric of this type of grouping of european countries analyzing the clusters of european countries shows that the grouping fully corresponds to the overall level of development of the public health system in countries from the same cluster thus the smallest cluster includes three countries the averagesized cluster includes 10 countries and the largest includes 29 countries according to the number composition socioeconomic development and best practices of the countries in the groups the second cluster was selected to define the countries for the study austria belgium germany denmark finland france the united kingdom the netherlands norway and sweden in the second stage the degree and significance of the interrelations between the components characterizing the studied groups of indicators were determined using canonical correlations that form an indicator of the level of healthcare system development in european countries panel data were generated as a table of input data for the period from 2000 to 2020 for 10 european countries selected according to cluster analysis the dependence between groups of indicators was alternately determined in the form of six tables behavioralsocial behavioraldemographic socialeconomic demographiceconomic socialdemographic and behavioraleconomic the data analysis shown in table 5 determined first of all that the analysis is adequate since the value of the canonical correlation coefficient is r 096512 which is close to 1 the value of the adequacy criteria chi 2 1180 is large enough to aim for infinity and the value of the probability of the deviation of the hypothesis p 00000 tends to 0 similarly the adequacy of the analysis is confirmed in other cases in this study second the total redundancy for groups of behavioral indicators is 601847 and is 439606 for groups of social indicators which indicates the existence of a relationship between behavioral and social groups of indicators that is an average influence of the group of social indicators on the group of behavioral indicators the analysis of indicators in table 6 also indicates that there are averagestrength relationships between groups of behavioraldemographic indicators and socialeconomic indicators the analysis of indicators in table 7 indicates that there is a weak relationship between the groups of demographic and economic indicators in table 7 the total redundancy for the demographic indicator group is 314496 and is 483923 for the economic indicator group ie economic indicators depend on demographic indicators where demographic indicators are the cause and economic indicators are the consequence special attention should be paid to the analysis of indicators in table 8 which indicates that there is a strong relationship between groups of social and demographic indicators in table 8 the total redundancy for the group of social indicators is 699279 and is 727378 for the group of demographic indicators ie demographic indicators depend on social indicators where social indicators are the cause and demographic indicators are the consequence according to the indicators of table 9 it is concluded that the relationship between the groups of behavioral and economic indicators is either a twoway relationship where behavioral indicators affect the economic ones and the economic indicators affect behavioral ones or the data should be taken with a time lag thus we emphasize that special attention in further research should be paid to the groups of social and demographic indicators which according to canonical analysis are indicators and causes that significantly impact the corresponding groups of indicators the third stage of factor modeling conducted by applying the analysis of the principal components made it possible to determine the relevant indicators for assessing the level of development of the healthcare system in european countries allowing us to build which were the integral indicators thus a scree plot of the eigenvalues of the correlation matrix of the input data was built to assess the social data of the level of healthcare system development in europe in the context of austria belgium germany denmark finland france the united kingdom the netherlands norway and sweden we formed a table of eigenvalues of the correlation matrix and derived statistical indicators of the social group to assess the level of healthcare system development in european countries thus we emphasize that special attention in further research should be paid to the groups of social and demographic indicators which according to canonical analysis are indicators and causes that significantly impact the corresponding groups of indicators the third stage of factor modeling conducted by applying the analysis of the principal components made it possible to determine the relevant indicators for assessing the level of development of the healthcare system in european countries allowing us to build which were the integral indicators thus a scree plot of the eigenvalues of the correlation matrix of the input data was built to assess the social data of the level of healthcare system development in europe in the context of austria belgium germany denmark finland france the similarly scree plots of the eigenvalues of the correlation matrix of the input data of the groups of demographic economic and behavioral indicators have been built to assess the level of the healthcare system development in european countries the multivariate exploratory techniques principal components and classification analysis and eigenvalues functions were used to form a table of eigenvalues of the correlation matrix and derive statistical demographic economic and behavioral indicators to assess the level of healthcare system development in european countries the multivariate exploratory techniques principal components and classification analysis and eigenvalues functions were used to form a table of eigenvalues of the correlation matrix and derive statistical demographic economic and behavioral indicators to assess the level of healthcare system development in european countries an analysis of the eigenvalues of the correlation matrix of the input data in the indicators of the social group for assessing the level of the healthcare system development in european countries provides an opportunity to confirm that the first three factors should be taken to define the relevant indicators these factors are as follows factor 13852 factor 22299 and factor 3 1077 then we form a table of variable indicators of the social group to assess the level of healthcare system development in european countries like the indicators of the social group the relevant indicators for each group of indicators were determined and the contribution of variables for evaluating the level of healthcare system development in european countries was determined for each group of indicators next intermediate values were obtained to calculate the relevance of indicators in the social group in assessing the level of healthcare system development in european countries similarly to the social group intermediate values for calculating relevance for each group of indicators were obtained thus based on the data in tables 14151617 we can conclude that among the indicators of the social group the most important indicators with the greatest impact on the formation of an effective indicator of the level of healthcare system development in european countries are as follows s6mortality rate infant and s8mortality rate under 5 accounting for11 of the total impact in the group s1birth rate crude and s7mortality rate neonatal accounting for 10 each indicators with an average impact are s4maternal mortality ratio s9prevalence of anemia among children and s10fertility rate total accounting for 9 of the total impact in the group each s3incidence of tuberculosis and s5mortality caused by road traffic injury accounting for 8 each and s0population growth accounting for 7 the least important indicators are s2death rate crude accounting for 5 and s11population total accounting for 3 the demographic indicators with the greatest influence on the formation of an effective indicator are as follows d0age dependency ratio and d4population ages 1564 accounting for 13 of total influence in the group d3life expectancy at birth male d6population female and d7refugee population by country or territory of asylum accounting for 12 each indicators with an average impact are d5population ages 65 and above and d8refugee population by country or territory of origin accounting for 11 of the total impact in the group d2life expectancy at birth female accounting for 10 the least important indicator is d1adolescent fertility rate births per 1000 women ages 15 16 17 18 19 accounting for 7 the economic indicators with the greatest impact on the formation of an effective indicator are as follows e5gni per capita atlas method accounting for 20 of the total impact in the group e0gdp per capita and e3poverty gap at usd 190 a day accounting for 19 each and e1government expenditure on education total accounting for 17 e2government expenditure per student territory had an average impact accounting for 14 of the total impact in the group the least important indicator is e4research and development expenditure accounting for 11 the behavioural indicators with the greatest impact on the formation of an effective indicator are b1hospital beds accounting for 21 of the total impact in the group b2immunization dpt b3immunization measles and b0life expectancy at birth total accounting for 20 each e1b4risk of catastrophic expenditure for surgical care had an average impact indicators with no impact were not detected among the behavioral group we propose that the most influential indicators should be considered in further studies disincentives were reduced to a comparable form after the input data were standardized each countrys integral indicators are calculated separately each year as well as arithmetic mean by year in the context of countries and by country in the context of years the economic interpretation of the calculations performed for the group of integral social indicators shows that the following countries have the highest average values of integral social indicators according to table 19 norway 075 the united kingdom 073 finland 067 these values indicate the best states of social indicators that determine the level of health system development in countries average values were found for germany 059 france 054 and sweden 054 the lowest but not critical values are observed for the netherlands046 belgium045 austria044 and denmark04 indicating shortcomings in the state of social indicators for these countries which requires additional attention for the group of integral demographic indicators that act both as results and as factors influencing the functioning of the health system the economic interpretation of calculations shows that according to table 20 the largest average values are observed for germany 064 finland 062 and denmark 061 these values indicate the best state of demographic indicators that determine the level of health system development in the studied countries average values were found for the countries france austria and sweden and below average values were found for the netherlands norway and the united kingdom it should be noted that among these countries the countries with the highest levels of the integral indicators in recent years were france and sweden which indicates a particularly positive trend in these countries the average values of integral demographic indicators are confirmed by the average values of these indicators in recent years and their relatively positive dynamics the netherlands for 2020050 norway for 2020041 however this indicator for austria for 2020 was 022 and 021 for the united kingdom thus indicating unstable dynamics and existing problematic aspects the lowest value was found in belgium at 036 which shows shortcomings in the state of demographic indicators requiring additional attention for a group of integral economic indicators that act both as factors of influence and as a result of the functioning of the health system the economic interpretation of the calculations shows that according to table 21 the largest average value of the integral economic indicator is observed for norway at 101 high values are observed in denmark sweden the united kingdom and the netherlands these values indicate the best state of economic indicators that determine the level of health system development in the studied countries an average value is observed for france and below average for austria finland and germany the lowest value indicates shortcomings in the state of economic indicators which requires additional attention the economic interpretation of the calculations performed for the group of integral behavioral indicators which act both as results and as factors influencing the functioning of the health system shows that according to table 22 the highest average value of the integral behavioral indicator was found in austria high values were observed in france sweden finland denmark and the united kingdom which indicates the best state of behavioral indicators that determine the level of healthcare system development in the studied countries average values are observed for germany at 058 belgium at 058 the lowest but not critical values are observed for the netherlands at 048 and norway at 046 which indicate shortcomings in the state of social indicators requiring additional attention however we note the positive dynamics for norway the highest indicator for 2020 being 079 the general integral indicators are derived together for all countries indicators each year as well as by the arithmetic mean for years in the context of countries and for countries in the context of years thus the economic interpretation of the calculations performed for complex integral indicators shows that according to table 23 the highest average values of complex integral indicators are observed for norway at 061 and sweden at 060 indicating the best state of indicators that define the highest level of healthcare system development in these countries among the selected cluster of countries average levels of integral indicators were found in the following countries france at 059 the united kingdom at 058 denmark at 058 finland at 056 austria at 056 germany at 054 and the netherlands at 050 this indicates the good state of indicators that show the level of health system development in these countries belgium has the lowest but not a critical value of 041 this indicates shortcomings in the state of indicators that determine the level of health system development in the country and requires additional attention a high level of integral indicators indicates the positive development of the health care system in the country and a low level of integral indicators for the state is an alarming indicator since this shows a low level of healthcare system development therefore the representatives of healthcare management should regularly carefully and continuously monitor the factors that lead to a decrease in integral indicators and take appropriate measures discussion this study refers to proposals to improve healthcare system by further developing the approach to qualitative and quantitative assessments of health system indicators by developing an integral indicator in the context of behavioral social demographic and economic factors that characterize the level of the health system development in european countries using the selected methods of multidimensional statistical modeling the steps of this complex scientific study of behavioral and social analysis of the public health system were based on the the work of the authors 90 in the health care field as a result of this study of the behavioral and social dimensions of the public health systems of the world based on the use of bibliometric analysis the main scientific categories of the study were determined the most potential priority areas of policy and strategy formation of the healthcare system were identified and the territorial component was theoretically determined for further considerations in addition the previous works by the authors of 46 used the method of clustering countries into specific groups which confirmed the appropriateness of the obtained distribution this technique was applied to group european countries into appropriate clusters for further analysis in the current study previous healthcare research by the authors of 47 studied the factors of the healthcare system and their influence on the vulnerability of the population of a certain region relevant factors are identified the analysis of literary sources shows the practicality of using the selected types of analysisdescriptive analysis cluster analysis canonical analysis and factor analysisfor research in the healthcare field moreover descriptive analysis allows various relevant indicators available in databases to be combined into appropriate groups with the help of cluster analysis it is possible to adequately divide countries into corresponding comparable research groups canonical analysis makes it possible to determine the relationships between the component characteristics of the studied groups of indicators and the nature of such relationships by conducting a factor analysis the relevant indicators of the studied indicator are determined and the integrated indicator of the selected indicators is modeled the authors contributions to the knowledge of healthcare system include the determination of the degree and significance of interrelations between groups of behavioral social demographic and economic indicators of the level of healthcare system development in european countries based on the use of canonical analysis in terms of using canonical correlations the definition of relevant indicators to assess the level of healthcare system development in europe based on the use of factor analysis in the form of principal component analysis the construction of integral indicators of the level of healthcare system development in europe in the context of behavioral social demographic and economic factors based on factor modeling and using the convolution procedure the authors approaches to the behavioral and social measurement of the public health system were developed separately these approaches so not act as one fullfledged integrated approach to assess the level of health system development since the study uses a limited list of indicators selected by the author in the context of behavioral social demographic and economic factors characterizing the state of healthcare systems however the developed approach is the best addition to the existing systems for measuring the state of health systems in european countries because this approach conducts a statistical assessment of the significance and relationship of the studied characteristics that is it conducts a causal analysis of groups of behavioral social demographic and economic indicators of the level of health system development in european countries based on canonical analysis which in contrast to existing approaches takes into account canonical correlations between groups of indicators determines the significance of factors within each group of behavioral social demographic and economic indicators for assessing the level of the european health system development based on factor analysis the method of analyzing principal components was used to effectively determine relevant indicators in other scientific fields identifies integral indicators of the level of health systems development in european countries by groups of behavioral social demographic and economic factors based on factor modeling which allows the use of procedures and convolution to quickly determine common general indicators for each group and a common integral indicator greatly facilitating further analysis the validity of the results is confirmed by the fact that the chosen research methodologies namely descriptive canonical and factor analyses are reasonably suitable for study of the state of european health systems and achieved the set goal of the study the calculated data obtained correspond to the actual situation and dynamics of the healthcare sector for 20002020 conclusions and recommendations the descriptive analysis made it possible first to form and model a multiaspect array of groups of behavioral social demographic and economic indicators which are relevant for the further formation of an integral indicator of the level of healthcare system development in european countries second based on cluster analysis which involves the application of the iterative divisive kmeans method it was possible to determine a group of 10 european countries for the study the canonical analysis specifies the degree and significance of relations between the constituent features of the studied groups of indicators to establish systems of pairs of features that are most correlated with each other and form an indicator of the level of healthcare system development in european countries such indicators and reasons that significantly impact the corresponding groups of indicators are the components of the groups of social and demographic indicators considering the results of the canonical analysis research stage researchers should take into account the most correlated pairs of features to form narrowly concentrated combinations of relationships at the same time practitioners should focus on casual and effective characteristics thus it is recommended to consider social characteristics that affect behavioral economic and demographic indicators demographic characteristics that affect economic indicators and twoway communication between groups of behavioral and economic indicators the factor analysis conducted by applying the study of the principal components made it possible to determine the relevant indicators for evaluating the level of healthcare system development in european countries the most relevant indicators among the indicators of the social group were mortality rate mortality rate birth rate and mortality rate the most relevant indicators among the demographic group were age dependency ratio population ages 1564 life expectancy at birth population and refugee population by country or territory of asylum among the economic indicators the most important were gni per capita gdp per capita and poverty gap at usd 190 a day finally the most important indicators of the behavioral group were hospital beds immunization immunization and life expectancy at birth factor analysis allowed for building an integral indicator of the level of healthcare system development of european countries the highest average values of integral social indicators are observed for the following countries norway the united kingdom and finland the highest integral demographic indicators were found in germany finland and denmark the highest integral economic indicator were found in norway denmark sweden the united kingdom and the netherlands the highest integral behavioral indicators were found in austria france sweden finland denmark and the united kingdom considering the results of the factor analysis it is recommended that future studies focus on a deeper study of certain relevant indicators which have the greatest impact on the group therefore it is recommended that further studies also analyze them separately to determine the factors that affect the formation of these relevant factors to achieve the maximum level of healthcare system development furthermore according to the results of factor analysis it is recommended to analyze in detail the levels of integral indicators in dynamics in the context of each country it is first recommended to study the integral indicators that comprehensively cover the overall level of healthcare system development and provide a comprehensive picture of the direction under study at the same time specialists are recommended to focus on integral indicators the levels of which as indicated in the study have the lowest values and unstable or negative dynamics thus the results were summarized using the following indicators the integral indicators for each group in the context of each year and the general integral indicator of the level of healthcare system development of european countries for each year the arithmetic mean by year in the context of each country and by country in the context of years other generalizations are not provided by the proposed model when constructing the model we considered explicit hypotheses of the presence of relationships between the indicators of the behavioral and social behavioral and demographic behavioral and economic social and demographic and economic demographic and economic groups nonexplicit hypotheses were ignored the need to improve the level of healthcare system development in european countries was confirmed shortcomings and possible reserves for potential improvement of the healthcare system were identified based on the statistically significant models and by analyzing relevant factors therefore for the effective development of the healthcare system in the countries of europe and of the world it is advisable to review theoretical approaches and practical results of the state of development of the medical system on an ongoing basis taking into account the dynamic changes in the influencing factors that determine the priorities of this field the results of this study will help managers and organizers of the public health system of european countries to use the received factual and analyzed data in making managerial decisions to build strong substantiated links between the available objective data and the policies of the healthcare system the level of the healthcare system development in european countries and positive changes in the health sector the studys results can help government officials employees of the healthcare sector and those providing medical services identify possible reserves for potential improvement of the level of the health system based on developed statistically significant models as well as by analyzing relevant factors based on the research results state authorities can conduct effective timely highquality regulation and adjustment of the regulatory and legislative framework to improve the level of healthcare system development in european countries and the healthcare system data availability statement not applicable

background the state and prospects of the healthcare industry of a country are among its top priorities because the quality of life and health of its citizens are indicators of its success and competitiveness the aim of this study is to conduct a theoretical analysis and qualitative and quantitative assessments of indicators by developing an integral indicator in the context of behavioral social demographic and economic factors that characterize the level of healthcare system development in european countries using multivariate statistical modeling methods methods the study was implemented using statistica 10 and statistica portable statistical packages the statistical base of the study was formed using descriptive analysis a group of 10 european countries was identified using a cluster analysis based on the application of an iterative divisive kmeans method the degree and significance of the interrelations between the components characterizing the studied groups of indicators were determined using canonical correlations by conducting a canonical analysis factor modeling is conducted by applying the analysis of the main components to determine the relevant indicators for assessing the level of healthcare system development to build integral indicators of the level of healthcare system development in european countries results the need to improve the level of healthcare system development in european countries was confirmed shortcomings and possible reserves for potential improvement of the healthcare system were identified conclusions the results can help public authorities officials and employees of the healthcare sector organize and conduct effective timely highquality regulation and adjustment of the regulatory and legislative framework to improve healthcare system development

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marijuana or inhalants compared to their and nonai peers similarly other studies indicate that ai youth begin to use substances at very young ages and may progress more rapidly to regular use than nonindigenous youth while variability is noted in the literature with respect to substance use rates research agrees that ai youth suffer disproportionate negative effects associated with substance use further early substance use is associated with higher risk of developing substance use disorders which are also associated with other mental and physical health problems for example similar to other nonindigenous youth early alcohol intoxication by indigenous youth by the age of 14 is related to a number of negative outcomes including higher rates of subsequent use and greater likelihood of a later substance use disorder ai adolescents also report higher rates of driving while intoxicated health issues and negative social consequences due to substance use understanding factors associated with increased substance use in indigenous populations especially among youth is of great importance and public health concern several factors have been identified as important in indigenous and nonindigenous youth including peer substance use exposure to stress parental abuseneglect and other family factors and perceived discrimination meanwhile there is a growing awareness of the important role that extracurricular or other activities play in buffering against engagement in substance use among nonindigenous adolescents however there remains a dearth of research focusing on potential alternative reinforcers to substance use such as alternative activities with indigenous adolescents according to behavioral theories of choice substance use behaviors are determined by the availability of substances and the availability of alternatives to engaging in substance use this theory is critical to understanding substance use in this population as it has long been described that indigenous youth live in communities that are devoid of alternative reinforcers and may drink or use substances out of boredom presumably for the reinforcement that it might bring despite the intuitive sense that this makes in congruence with btc to the best of our knowledge there has been little systematic or empirical effort to study activities or alternative reinforcers of youth living in indigenous communities meanwhile among nonindigenous samples reduced substance availability increased costs of substances and greater availability of alternative activities have been associated with reduced drug and alcohol use in one theoretical paper spillane and smith describe how btc could be adapted in adult indigenous populations theorizing that increased disparities in substance use in indigenous communities could be explained by a lack of availability of alternative substancefree reinforcers which lead to community members being more likely to rely on substance use for reinforcement additionally some positive reinforcers in these communities may be relatively less contingent on avoiding substance use so individuals perception of the costs of use are relatively low indeed this was found to be true in a study of reservedwelling fn adults when compared to middle socioeconomic status caucasians the fn group had reduced expectations for access to socalled standard life reinforcers or slrs including employment quality relationships and sound financial status and also reported expecting that drinking would not decrease access to slrs though this work has demonstrated the applicability of btc in adults the theory has yet to be further adapted to indigenous adolescents to be applied to adolescents the concept of slrs may need to be modified to be more developmentally appropriate we use the term competing life reinforcers defined as things that are consistent with values and inconsistent with substance use among adolescents and are also available on a fn reserve we believe that btc can be modified to help explain some of the variability in substance use among indigenous youth for adolescents having substances available has already been found to be one of the strongest correlates of substance initiation and continued use regarding the effect of alternative reinforcers a core component of btc one longitudinal study of nonindigenous youth found prosocial leisure activities to be protective against substance use other activities such as participation in sports or athletic teams have shown mixed findings with studies indicating both increases and decreases in substance use in relation to participation in sports however these findings may not necessarily generalize to indigenous youth living on reserves who have unique cultural experiences and many experiences of trauma health and economic disparities existing research has been limited to a few studies examining activities in relation to substance use for example among indigenous populations higher perceived availability of extracurricular activities team sports and playing music and intensity of participation have been found to be associated with less substance use among nonreserve dwelling fn youth research has shown that participation in weekly recreational activities was associated with lower frequency of alcohol use and heavy drinking while fewer school strengths and more tribal strengths were related to greater substance use with the above mixed findings in mind the present study aimed to examine the application of btc to fn adolescent substance use by exploring activities and other culturally and developmentally appropriate alternative reinforcers we performed qualitative focus groups and individual interviews of fn youth to explore risk factors for substance use how potential clrs including family peers community culture and availability of alternative reinforcers appear in their lives and how the clrs relate to substance use these findings can help to inform future research that will focus on the role of alternative reinforcers to substance use among indigenous youth method study design and ethical considerations this is a qualitative study involving semistructured indepth focus groups and individual interviews with fn adolescents between the ages of 1417 in alignment with the tenants of communitybased participatory research the researchers formed an advisory committee to help guide the study the committee consisted of band and council members with experience in health andor mental health and substance use in adolescents who assisted with the development of the interview guide for focus groups and identification of strategies to recruit youth in the community within the target age range in addition the study projects assistant is a member and resident of the fn community and the principal investigator and firstauthor is a band member though she does not live on the reserve the semistructured interview guides were reviewed and approved by the chief council and the advisory board all study procedures were reviewed and approved by the university institutional review board prior to beginning data collection research setting the research was conducted in one rural fn community located in eastern canada the qualitative interviews and focus groups were conducted at the health center located on the reserve procedure the present study used a modified grounded theory design to develop a semistructured interview protocol to examine sociocultural influences on substance use among reserve dwelling fn youth we conducted 4560minute semistructured focus group and individual interviews with indigenous youth over an 8month period from october 2012 to may 2013 the interview protocol was created based on the btc in that participants were asked to identify various aspects activities and influences in their environment that are both supportive of and inconsistent with substance use grounded theory stresses the importance of the development of a theoretical model and to allow themes and categories to derive from the data as content analysis takes place a modified grounded theory methodology was used as we aimed to develop culturally appropriate constructs that related to the btc model while we utilized predetermined categories based on btc we employed practices consistent with grounded theory including the use of open coding techniques memomaking and simultaneous data collection and analysis to generate specific codes and themes within each predetermined category using a directed or deductive approach for collection of data we used open ended questions with directed followup questions based on the predetermined categories interviews both in focus group and individual formats allowed the pi to guide the questions asked during interviews as is appropriate when the behaviors of interest cannot be directly observed by the research team such as potential adolescent substance use and various activities adolescents engage in focus groups and interviews were audiotaped data management and data analysis audio recordings from focus group and individual interviews were transcribed by a professional transcribing company and checked by the first author for accuracy as suggested by the electronic and hard copy of transcripts were retained for analysis transcripts of group interviews were then reviewed by the principal investigator for a preliminary identification of preliminary repeated ideas that arose using the interview guide to inform individual participant interviews as indicated by hays wood dahl kirkjenkins 2016 next based on guidelines of the consensus process set forth by hill thompson williams 1997 a doctoral student research assistant read all of the transcripts to independently identify broad themes that arose and coded the data using directed content analysis consistent with guidelines by charmaz memomaking procedures were utilized writing analytic notes to elucidate categories and break categories down into their components at each stage of coding transcripts as suggested by elo and kyngäs we approached analysis using a predetermined theoretical model btc where we analyzed the content through the identification of general a priori categories we then identified main codes and themes derived from the data as suggested for grounded theory and by auerbach and silverstein with this approach we highlightedcolorcoded the relevant text that fell within each of the eight categories followed by open coding within each category to identify repeating ideas followed by grouping the repeated ideas into recurring themes and theoretical constructs transcripts were then reviewed and analyzed using the same processes described above by a second doctoral student research assistant upon completion of the second coder both research assistants met with the pi to discuss the themes that emerged from the data until consensus was reached findings participants thoughts about substance use focusgroup participants were asked about the types of problems they noticed within their community or for peers their age when asked this question a member of the girls group stated these are pretty broad questions because there is so much stuff like drinking smoking dope other drugs confidence racism ignorance theres just so much i dont know you could just elaborate on and on and on i think similarly a member of the boys group simply stated drugs using a directed approach the focus groups were asked to elaborate on these responses both groups identified alcohol and marijuana use as specific substances which are heavily used by adolescents in their community with the boys group additionally identifying cigarette use as a major concern during both the focusgroup sessions and the individual followup sessions several negative consequences of substance use were identified specifically adolescents identified substance use as often leading to school dropout negative consequences within their families and substantial health risks it was further noted that one potential reason for such severe consequences and high rates of use was due to the availability of substances both on and off the reserve thus substance availability was identified as another major problem faced by these adolescents risk factors participants identified three major risk factors for youth substance use 1 peer influences 2 familyparent influences and 3 community influencesissues peer influencesa common theme influencing adolescent initiation of substance use that was identified during the focusgroup interviews and individual interviews was peer and social influences and the desire to fit in with peers specifically these adolescents indicated that substance use particularly marijuana alcohol and cigarette use was very common among their peers both on and off the reserve one boy stated if you go to a party and youre the only one thats not there not smoking weed or not smoking or drinking then you kinda feel outta place and you kinda feel pressurized into doing it if you feel pressurized then youre more susceptible to doing it and then that leads to background noise that happening too furthermore one 16yearold female reported that substance use is common both on the reserve with her indigenous friends and off the reserve with her nonindigenous friends from school my friends they smoke drugs like they smoke dope and they do what they do they can just relate to the same stuff my friends at school they drink and stuff but theyre not people i hang out with every day…i have my high school people and then i have my at home people my high school people are different than my home people but they smoke and stuff too a male participant echoed the idea that adolescents are exposed to substances in their social environments stating that students often smoke on school grounds as the nosmoking policy is not typically enforced additionally members of the boys focus group described kids first beginning to engage in substance use such as smoking cigarettes at very young ages while at school they stated a lotta kids do it in elementary school they start in the bathroom and about more than half the kids that are coming in grade nine from middle school smoke cigarettes and they start smoking dope start drinking… what is more these substances were often easily accessible through their peer networks when asked who provides substances adolescents explained whos ever old enough you just ask them to go… and …go tell someone to go pick it up yeah you can just yeah basically text or something like that whatever as well as because its easy access people are getting older they have older friends so they can get it that way one 16yearold girl stated yeah everybody knows even little kids know where to get its crazy easy kids these days know way too much for their age familyparent influencesfamily and parental influences also were raised as common risk factors for adolescent substance use it was reported by the majority of participants that youth are often exposed to alcohol and cigarette use and may even begin using at very young ages when parents or important family members engage in such behaviors moreover five individual interview participants stated that parents often engage in substance use with their children supply their children with substances or that children begin experimenting with substance use after parents or important family members model the behavior one 16yearold girl recounted exactly as ive grown up with my parents like my dad was an alcoholic always hes always drank when i was growing up id go to parties with him ive seen everybody i dont know i just grew up way too quick i can just say that ive seen people do this so i thought it was okay to do when i did do it it backfired on me another adolescent explained you have parents around here getting drunk walking down the street with a joint in their hands that smoke dope people around here selling coke and you just know that if you grow up with a parent or a parental figure doing that youre going to think thats okay and thats not okay additionally respondents reported that they felt as if parents often dont care if youth are using substances and feel there is a lack of discipline from parents and family members as well as a lack of monitoring of childrens behaviors one girl aged 15 explained she first began smoking at the age of seven and a half when she had the house to myself while her father worked interestingly many participants including three individual interviewees reported viewing parents as hypocrites when they do not condone their childrens substance use one participant described how it is not meaningful when adults tell youth to stop smoking you cant go telling your kids stop smoking or dont smoke while youre sitting there puffing away too at the same time several adolescents further reported that they do not look up to adults who engage in alcohol or drug use as role models community influencesissuesbeyond immediate family and peer influences adolescents further identified their community as a whole as a potential influence for engaging in substance use while on the reserve the adolescents reported that many individuals engage in substance use because there is nothing else to do at the same time ten of the 11 individual interviewees endorsed the belief that their community as whole does not care if kids are using substances and that youth do not tend to experience any legal discipline for underage substance use moreover when events are held in the community engaging in substance use while participating is often the norm for example numerous participants reported that smoking cigarettes in public was extremely common and that when the community engaged in various celebrations public intoxication was readily occurring one participant recounted ive heard it happening on cultural feast days thats the thing community events when we were younger i thought they were awesome we had so much like rides and stuff then now its like oh at a specific community gatheringredacted to maintain confidentiality of the community everyone get drunk tonight wheres the party i never realized what it was about when we were young another 15yearold girl described community events such as ballgames involving everyone getting drunk substances were reported to also be easy to obtain from adults and because the behavior is normalized through interactions with adults in the community for instance one 16yearold girl stated i drink and smoke with adults all the time i mean at first it was weird because i just started and stuff but now its just normal its just like one of the friends just gonna go get drunk or high its just normal its nothing bad everybody does it competing life reinforcers participants elaborated on six protective factors against substance use based on btc 1 future goals 2 peer influences 3 familyparent influences 4 community influencesissues 5 alternative activities and 6 culture future goalsduring the interviews the adolescents were asked about their future goals many responses focused on goals that would help the participants stay away from substance use or to not have substance use problems these youth reported that having supportive adults in their life would help with achieving future goals with over half of the individual interviewees suggesting ways in which parents and family could provide support for childrens futures more specifically two individual participants indicated that having supportive adults in their life that specifically checked in with them regarding school attendance and their hopes for the future would be beneficial in helping them obtain their goals as well as to stay away from substances this idea of having support in obtaining their goals was largely tied into adolescents aims and plans to finish their high school education and for many to go on to postsecondary education furthermore four individual participants identified having an education as being important in general and other youth indicated that education was vital in helping them obtain a lucrative job or career for example when asked what her goals were for the next five years a 16yearold reported i see myself i dont know i dont want to be here i hope im not gonna be here in five years i want to be out getting a job maybe have my own family in five years i dont know i want better for myself i want to graduate i want to get a good paying job that i love when she was further asked how using alcohol fit into this plan she stated i hope im not into those at all i think about trying to give them up for christmas or whatever but i hope not knock on wood that im not doing drugs or alcohol in five years other than that i dont know having a job was identified as a major future goal amongst this group and being involved with substance use was identified as a potential barrier to achieving that goal thus having goals about the future specifically regarding education and jobs likely may serve as a clr given that adolescents are provided with appropriate support systems peer influenceswhile many participants remarked that peer and social influences were often contributing factors to adolescents use of substances one participant described her boyfriend encouraging her to quit smoking stating im trying to quit my boyfriends making me he doesnt do it and he hates it he hates it with a passion this description reveals that for some youth having relationships with peers who do not use substances may serve as an important clr against starting or continuing to use substances familyparent influencesmany participants described that for some adolescents there was a feeling of lack of support or guidance from parents or family often resulting in youth substance use not being monitored or discouraged however six participants noted ways in which their parents and families could be supportive of them which in turn may be protective against substance use specifically one participant described his mom pushing him to succeed in school my mom she was kind ofshes been really hard on me in terms of school because she knew it was so important and stuff she kind ofwhen i was going out was always like education first and everything else behind that ive been kind of living off of that for my life other than that even other people in my family are like you got to have your education you got to go somewhere you got to have a successful life basically thats what i did… additionally extended family members were reported to be helpful when individuals felt they did not have support from their immediate family members in particular grandparents aunts and uncles were indicated as especially helpful people to look up to although a common theme about substance use was that adolescents often begin to miss or dropout of school when using substances particularly marijuana these adolescents identified ways in which they would like to receive support it was suggested that having parents or parental figures that would help them get out of bed to go to school or providing supportive messages while growing up may lead to a decrease in substance use related problems for example when asked what could work for prevention one participant stated i just see a lot of parents giving up on their kids you cant give up on your kids… or just letting themjust let them start sleeping in start sleeping in start missing school more and more then the next thing you know…every kid on there needs someone that will make sure he gets up for school every day and make sure theyre up ready i dont know going to school every day community influencesissuesthroughout the qualitative interviews it became apparent that respondents had difficulty identifying positive community influences including role models which were useful in protecting against engagement in substance use however when the interviewer used guided questioning participants were able to identify characteristics that they would like to see in an adult role model interestingly but perhaps not surprisingly a recurring sentiment was that a role model is an adult who does not use substances and has bettered themselves more specifically a role model is someone who is not a hypocrite meaning that not only are they encouraging youth to abstain from substance use but also are sober themselves specifically regarding alcohol marijuana and other drugs one 16yearold female described a role model as …they didnt do drugs or alcohol or if they did like if they recovered about it or doing better for themselves because i dont know i see that being a role model for me…yeah and to stay clean that whole time and did better for themselves…i dont know it just shows that they can overcome something that washaving a drug addiction is hard i dont know i just think its good that they did because it shows how strong they are i guess these adolescents noted that having positive caring role models that provided structure and discipline in their lives would be beneficial and protective against substance use and help with achieving their goals potential role models included friends parents extended family members parents teachers and elders in the community while many agreed that role models should be sober that having used in the past but currently being clean demonstrated resilience and could be helpful to youth at the same time participants were also able to identify potential activities they would like to see available within their communityactivities they believed would help protect against problems with substance use a recurring theme that arose was the desire for increased community celebrations or activities that are sober interestingly based on these interviews there are mixed messages and ideas as to whether tobacco use is appropriate for a role model as well as within the community alternative activities as reinforcersbeyond identifying characteristics of people who can serve as clrs the participants were asked to identify various activities that are already in place serving as clrs to substance use one of the most cited activities endorsed by over half of the individual interview participants was organized sports particularly hockey soccer rugby and baseball however beyond organized sports many adolescents had difficulty identifying protective activities currently available moreover this sample expressed that they wished there were a greater number and variety of alternative activities available within their community first it was suggested that having various organized sports available during the offseason would be useful as the climate in this location gets cold and people tend to stay inside which may lead to substance use next these youth reported both during the group and individual interviews that organized agespecific youth groups and events would provide an alternative to engaging in substance use some examples included outdoorcamping trips and an organized recreation program andor recreation center during the girls group one individual mentioned past recreation trips to amusement parks and another girl agreed that trips could be protective stating trips be bomb thats an amazing idea i can see how kids would be more interactive and do stuff and stop drugs and stuff other adolescents stated that they would enjoy engaging in volunteer opportunities within the community while some noted that other groups such as a videogame league could be a good option specifically regarding youth groups these adolescents indicated that starting organized programs and consistent youth groups at a young age would be a welcomed idea during her individual interview a 17yearold expressed i think that the youth group i think if we made that betterlike if people stayed committed to that i think it would keep them from drinking its almost like they wont enjoy what they did and stuff if they make plans like trips and all i think itd be really fun just to get away and itd keep other people from doing drugs and alcohol the participants further suggested that adolescents may be more likely to continue to engage in such groups if they were agespecific and provided ageappropriate activities two individual interviewees reported that there are activities available through the schools offreserve yet it appears that most fn youth within this community do not participate this further suggests that community based alternative activities to substance use and appropriate influences may be of greater importance to this population than having such resources available off the reserve culturewhile describing desired alternative activities the theme of culturally based activities arose both the boys and girls focus groups as well as three individual interviewees reported feeling a lack of culturally based activities and programming within their community participants described having the desire to learn more about their culture as well as to learn cultural practices such as indigenous arts including beading basket weaving learning their native language engaging in sweats dancing and drumming and other traditions regarding cultural traditions one girl in the focus group mentioned i dont think that its taught its not being passed down from parents but they dont really know either moreover respondents endorsed wanting to learn about these activities and engage in their practice alongside of parents and adults from within the community including elders one girl in the group further emphasized this point by indicating she would like to see parents and other adults committing to cultural practices these qualitative responses reveal that increased cultural traditions and practice within the community would likely act as appropriate clrs of note while we had hypothesized that stereotyping and discrimination would be a recurrent theme linked to substance use we found this to not be the case while some participants mentioned stereotypes and discrimination as occurring from nonindigenous peers these factors were not frequently cited as reasons why these youth decide to engage or not engage in substance use discussion the purpose of the current study was to begin the process of understanding risk and protective factors for substance use and problems for indigenous youth in order to design prevention programs that are tailored to their unique cultural needs within the framework of btc our results paint a complex picture with multiple factors that likely interact as we noted subthemes being brought up in multiple sections first and foremost youth identified substance use as a problem for both adults and youth in their community within that environment youth discussed peer family and community level factors that they believed places them at risk for substance use regarding peer influences consistent with previous research there was an overwhelming sense that youth engage in substance use to fit in with their peers our results further indicate that because youth are not only using or being exposed to substances in their community but in school as well schoolbased programs may be appropriate perhaps feeling connected to the school community may offer an incentive to participate in school activities and thus could serve as a clr to engaging in substance use acting as an alternative reinforcer in alignment with btc such schoolbased programs should be considered in addition to those received within adolescents immediate community other possible interventions including multilevel interventions may need to be considered that focus on both individual and community factors consistent with research suggesting that family management practices such as parental monitoring and limit setting are highly correlated with the extent of adolescent substance use youth in our sample felt that parents were not setting boundaries around substance use this led to youth receiving inconsistent messages with regards to acceptability of using substances when discussing familybased protective factors one individual stated that having parents who push you in school is a protective factor strengthening prosocial family dynamics and adaptingdeveloping familybased prevention programs that maybe include a broad definition of the family structure may be one strategy to implement perhaps of more importance is the finding that family members were often the source of substances and often modeled excessive use this indicates that substances are readily available from multiple sources at times and consistent with btc would suggest that availability is one key determinant in the decision to use substances some programs such as those that focus on alcohol sales have been effective in targeting alcohol availability through liquor stores but may not be as effective for these youth and others who report primarily obtaining substances from others in their community therefore our results suggest that prevention programs targeting multiple sources from which adolescents can obtain substances is warranted our findings also suggest subtle nuances that have not been captured in other studies of indigenous substance use youth reported that having role models available to them would be an important clr when probed into their definition of a role model it became clear that while it would be all right if individuals had used substances in the past these are individuals whom do not currently use substances at all and are sober related to this point they expressed that parents are seen as permissive in their substance use norms because they did not want to be seen as hypocritical these are important distinctions that highlight the necessity for those who work with youth to have awareness of how their own behavior may be perceived additionally increasing opportunities to engage with positive adults identified by youth as role models is likely to serve as a clr as it would provide substancefree alternatives within their community the lack of alternative activities within the community was a prevalent community level factor that youth reported as contributing to the risk of substance use consistent with principles of btc the lack of activities or experienced boredom has also been examined in other studies as a reason for the increased substance use rates observed among indigenous youth therefore a critical substance use prevention strategy could be targeting the lack of clrs such as increasing the availability of structured substancefree extracurricular or community activities for youth living in indigenous communities participants were further asked about potential protective factors against substance use however individuals had a difficult time coming up with factors in their community that they saw as being protective this is likely one example of how historical trauma and forced colonization may be related to the perpetuation of substance use in indigenous communities the restoration of culture could provide indigenous communities with healing by offering cultural activities and strengthening an attachment among youth and the community indeed research suggests that adolescents who are high in community attachment show negative associations with cigarettes alcohol marijuana and other drugs strengthening community attachment in these youth perhaps through culturallybased practices and activities could be a potential prevention strategy given the protective effect it has shown for other groups for instance fn communities could be encouraged to increase youth access to or interest in valued community activities which could include traditional crafts powwows talking circles sweats and learning about their culture interestingly there was some overlap in the factors that were ultimately identified future aspirations peers family communitylevel factors alternative activities and cultural factors youth expressed some future aspirations but these were limited some expressed wanting to finish high school fewer expressed college aspirations many wanted to be employed with little specifics as to what type of job or what they would like to be when they grow up this may reflect the limited opportunities that exist within indigenous communities and the sentiment that leaving the community to attend college or find a job is unacceptable previous research found college aspirations to be the most influential protective factor against tobacco use in one indigenous sample of american indian and alaskan natives and our findings suggest that these indigenous adolescents may also view academic aspirations as a protective factor against substance use based on previous work in indigenous populations we anticipated that perceived discrimination would be highlighted as a dominant theme in relation to substance use therefore it was somewhat surprising that we did not find this to be the case however this finding is consistent with other research that has not found perceived discrimination to be significantly related to substance use it may be that perceived discrimination is less likely to be related to substance use for those living in an indigenous community than for those living outside of reservereservation communities simply because their primary influential social contact may be with others from their community while the present study provides important knowledge regarding risk and protective factors for substance use and clrs against substance use for fn youth they should be considered within the context of the studies limitations first because we only sampled from one fn community findings from the present study cannot be assumed to be generalizable to other communities or populations second the present study consisted of a small sample size again limiting generalizability these occurrences are often the case with qualitative research investigations therefore future studies should aim to replicate findings in other communities third the hypothesized theories derived from this qualitative study need to be complemented by quantitative research to examine the ways in which these themes relate to substance use behavior in line with the btc our sample of youth identified a number of important factors that they would perceive as reinforcing and that would influence their likelihood of using substances the results of the present study highlight several important areas of substance use prevention to target among indigenous groups these risk and protective factors are particularly important targets for designing prevention strategies given that they were identified by indigenous youth as contributing factors for and against substance use within their environment it is likely going to take an effort at multiple levels in numerous settings to decrease substance use in this population

indigenous youth are at increased risk of initiating substance use at early ages and suffer greater negative consequences related to substance use as compared to nonindigenous youth the present study aimed to investigate risk and protective factors associated with substance use in one group of first nation adolescents using a modified grounded theory approach the present study conducted qualitative focus groups and individual interviews assessing categories of risk and protective factors based upon behavioral theories of choice behavioral theories of choice suggests that substance use is contingent on the availability of substances and the availability of alternatives to substance use fifteen reservedwelling 75 female m age 152 years first nation adolescents identified peer influences parentalfamily influences and community influences and issues as risk and protective factors associated with substance use results highlight possible targets of culturally appropriate prevention strategies for indigenous populations

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introduction intimate partner violence is the most chronic and costly burden the united states has faced accounting for the deaths of more than 58139 women between 1980 and 2008 an average of 2000 women killed per year in the brazilian scenario these data are even more alarming 13071 deaths of women between 2009 and 2011 which represents an average of 4357 deaths per year the centralwest northeast and north regions had the highest numbers it is estimated that in this context 40000 brazilian women seek treatment for problems resulting from violence representing an annual cost to the unified health system of more than five million reais in hospitalizations costs alone despite the high burden this value is still underestimated since the statistics do not include costs with health demands that do not require hospitalization as well as those related to other sectors such as the social police and legal due to the high mortality and costs generated marital violence has been the object of study in different parts of the world mainly focusing on womens perception of this form of abuse however including the perceptions of men is essential for proposing strategies to prevent this phenomenon through spaces that allow for gender reflection among men this is a perspective supported also in the maria da penha law a brazilian public policy to combat violence against women which highlights the need to include men in recovery programs in addition to prioritizing the discussion of the gender issue among men involved in criminal actions it is emphasized that gender is considered a constitutive element of social relations based on the perceived difference between the sexes under this perspective it is a set of cultural characteristics that dictate what roles men and women should play in each society in addition it ultimately confers a hierarchy between these attributes giving men a position of authority and ownership regarding women which makes male power socially legitimized and marital violence often justified considering that the process of deconstruction of conjugal violence requires a theoretical deepening of the phenomenon it is necessary and relevant to value and investigate the male discourse in this sense it is questioned what the perception of male defendants in criminal cases is about marital violence by taking marital violence as a study object the research adopts as its objective to analyze their perceptions about marital violence method ethical aspects the study was approved by the research ethics committee of the federal university of bahia the purpose of the research the potential risks study benefits and the right to refuse participation at any time were explained to the participants the preservation of the recorded images and the confidentiality of the data generated in both stages were also guaranteed in compliance with the ethical guidelines of the research with human beings proposed in resolution 4662012 type of study this is a qualitative exploratory descriptive study part of a doctoral dissertation linked to the anchor project reeducation of men and women involved in criminal prosecution a strategy to combat marital violence developed by the study and research group in violence and quality of life of the ufba school of nursing methodological procedures data source and study scenario the selection of the study population was intentional consisting of men who were criminally prosecuted for marital violence the inclusion criteria were men who experienced pretrial detention and were responding without deprivation of liberty for criminal prosecution for marital violence men who had lawsuits whose cause was based on violence against the woman other than the conjugal one were excluded the locus was the jurisdiction of domestic and family violence against women from the city of salvador bahia brazil initial contact was made with the help of a social worker a jurisdiction employee and later via telephone by the researchers the men were invited to participate in a reflection group which was developed during nine meetings lasting seven months and with a total workload of approximately 50 hours this quantitative considers the three facetoface hours of each meeting added to others spent on dispersion activities delivered at the end of each meeting and held by the participants until the next facetoface meeting in the first meeting they were informed about how the gr worked and about the current research those who agreed to continue to participate in the group in the research or in both signed the free and informed consent term the meetings of the gr addressed varied topics such as family domestic and conjugal violence gender honor and peaceful resolution of conflicts data collection organization and analysis of data the data were collected using multimethods using the techniques of individual interviews and focal groups the interviews were individual in a private room of a municipal public school also the locus of development of the rg with an average duration of half an hour each as a data collection instrument a semistructured script was used containing the following guiding question tell me what you understand by marital violence the nine members of the gr and another 14 men participated in this phase making a total of 23 participants in order to deepen our findings a focus group was held in the last meeting of the rg after he completion of all the interviews for this stage the same guiding question of the interview was adopted the research was carried out between may and december 2015 by nurses and nurseresearchers masters and doctors candidates under the supervision of doctors with extensive experience in this area of knowledge the interviews and the focus group were recorded and their contents transcribed in full in order to ensure rigor in the study the transcribed material was fully available to all participants in order to verify if it was reliably expressing what they had said for this strategy as a support tool the consolidated criteria for the reporting qualitative research was adopted the data collected were initially categorized using the nvivo® 11 software program which also enabled the creation of a word cloud which supports the findings next the data were organized into central ideas and discoursessynthesis according to the discourse of the collective subject method participants were identified by the letter h followed by numbers corresponding to the order of interviews the results were discussed and interpreted according to the theoretical basis of violence gender and masculinities results the study participants are mostly black ranging in age from 25 to 62 years old at basic education level and income between one and two minimum wages regarding marital aspects the relationships ranged from four to 40 years of coexistence mostly in stable union with children the collective discourses allowed us to analyze the male perceptions about conjugal violence organized into the following categories central idea 1 it is inherent in the conjugal relationship men perceive violence as being part of the conjugal daily life a reason that arouses resentment and nonunderstanding of the prison they also highlight its cyclical and intergenerational aspect as follows fights occur with every couple there have been several misunderstandings of this and it has always been like a cloud the cloud would pass the problem would pass and the next day it did not look like it had happened that kind of thing is normal in every relationship i remember that my parents fought a lot and my father beat my mother my hatred is because it was not necessary to put me in a cage because this is natural and every couple faces that central idea 2 it is a private problem men understand that marital violence is private and should be resolved between the couple in the domestic environment without interference from third parties including the police as seen in the following discourse she brought the whole event to the public i tried to pull her into the house so that we both could work it out but she became altered and we started to quarrel right there in the street there were a lot of people watching when the policeman arrived by car in my house i said that i did not want to talk that it was a family problem just our problem i thought it was wrong to be arrested to end up at the police station because of this because what happens in the family is kept right there there was no need for it because it was our problem central idea 3 it is reciprocal another perception was that the aggression started initially from the companion and because the mans action was retaliatory it was not understood as violence the discourse also reveals a conduct based on the nonacceptance of subjection of man to woman she started giving nicknames to me i did not like it and did the replica of the nicknames then she assaulted me slapped me on the face i do not think its right for the man to hit the woman or for the woman to hit the man am i going to be beaten by a woman no so i did not think twice i used two closedhand slaps and put her things out on the street i did not hit i just retaliated central idea 4 it leaves body marks although the understanding about the different forms of expression of conjugal violence psychological moral sexual and physical is clear the collective discourse reveals that in the perception of men in criminal proceedings physical aggressions with visible marks are highlighted there is violence that is more hidden such as the verbal and the threats which despite not including spanking also hurts but cursing is normal its just offenses normal discussions between couples a verbal offense is not important if it were everyone would be arrested because everyone does that for her to say that i emotionally harass her she needs to have a medical report that confirms that violence also occurs when a person is forced to do sex even when he or she does not want to even if they are married there is the corporal violence pushing hitting kicking stabbing and shooting this can leave bruises cause bleeding and lead to death it only becomes violence when the person is beaten or a weapon or firearm was used this is violence and cowardice if i hit a woman she has to have marks on her body these mens perceptions of conjugal violence unveiled in the illustrated categories are backed by the cloud of words whose words express the essence of the central ideas of the study discussion the naturalized male perception of violence in marital relations present in the masculine discourse is related to the transgenerational and cyclical characteristics of the phenomenon having witnessed violent relationships between their parents since childhood children tend to naturalize and reproduce this model in their own marital bonds this finding is corroborated by a study carried out in romania which argues that children of couples living in violent relationships are more likely to repeat this behavior in their future relationships because it occurs intergenerationally and is apprehended as inherent in the marital relationship national and international studies have shown that women as well as men understand the violent act as love which favors its perpetuation authors further posit that these aggressive behaviors are used even if implicitly as a method of domination entailing different phases in a study carried out in brazil authors describe the cycle of violence as beginning in a phase of accumulation of tension and small misunderstandings of a more psychological and moral character in turn there are brief episodes of lack of control with the occurrence of physical aggression and or situations considered more serious finally there is the phase of reconciliation and promises of change the discourse of men also reveals that the fact that the aggravation is cyclical in the relationship with alternation of violent episodes and peaceful moments creates the idea that that moment was fleeting this cyclical and progressive nature could also be evidenced in a study of 1296 women in nepal asia it is noticed therefore that the intergenerational and cyclical characters incite the naturalization of the violence by the couple the reason why men do not understand the reason for their prison a study found that men have difficulty in recognizing the author of a violent act and accepting the reasons that led to their arrest reinforcing the findings of this research also corroborating them other studies indicate that the denial and nonaccountability of aggressions by these men are frequent characteristics in the dynamics of conjugal violence this lack of understanding shifts the responsibility of the fact to the companion as found in this study when the man justifies that the happened occurred by way of retaliation to an action initiated by the woman in relationships permeated by violence the roles of victim and aggressor alternate between partners but with different means of aggression the woman often uses profanity and mild physical violence such as scratches whereas the man by having superior physical strength tends to cause more serious injuries which reaffirms his superiority still with respect to the retaliation to the woman the study points out that it is a way for the man to rescue his masculinity threatened since he was beaten by a woman corroborating that authors argue that when a man is violated by his partner social questioning about the role of the man in the relationship arises making him assume an aggressor position to show his superiority this asymmetry is based on relations of power domination and oppression between the genders which is related to a patriarchal and phallocentric culture in which the companion and children are to obey the man who must be respected the males discourse also reveals the understanding that marital problems interest only the couple this perception is socially shared in popular sayings such as nobody can do any good between man and wife thereby clarifying the social understanding that marital problems are intimate should not be discussed publicly nor should they be objects of intervention the findings from the study also confirm those found in a survey conducted in the state of espírito santo brazil in which men agreed that marital violence should be resolved in the domestic environment the authors also affirm that this is a conduct that favors male power over the wife as well as protects him from possible legalpolice involvement in this discourse on the privatization of conjugal violence it is possible to perceive that when a woman takes the situation outside the walls the man tries to bring the problem back to the intimate forum when analyzing data from the map of violence 2015 homicide of women in brazil it is observed that the home is the privileged place for nonlethal violence with 719 of records made by women this finding is opposed to the ideal that affective bonds would make the home a safe and propitious place for the whole family to live in peace and harmony showing that marital problems need and must be solved in the public context in this respect one of the main achievements of the feminist movement concerning these abuses was the judicial interference in the private space which consists of using the police power of the state to intervene in the relations of the private space the maria da penha law is the most expressive mechanism of this juridical conception by criminalizing domestic and family violence against women in addition to criminalization it has brought a new approach to this type of violence based on the concept of gender and typifying the forms of expression of the phenomenon as physical sexual psychological moral and patrimonial it should be pointed out that the discourse evidenced the masculine perception about various forms of expression of violence listed in the maria da penha law except for the patrimonial which may represent a greater difficulty in understanding this form of the offense the noncomprehension that retention subtraction partial and total destruction of personal objects constitutes crimes results in underreporting and therefore the percentages of this classification are not significant although in a little exploited way patrimonial violence has been investigated in national and international studies evidencing its seriousness since it implies difficulties to provide for ones own and family support among the expressions unveiled in this study the masculine discourse expresses the hidden character of psychological violence although it recognizes its capacity to leave sequels authors found that psychological violence can compromise the selfesteem wellbeing and the development of womens psychological and physical health as well those of the children who witness the offense another expression recognized was the sexual one which occurs when the man forces the sexual act without the will of its companion a study shows that marital rape suggests the male understanding that it is the womans obligation to satisfy him sexually although the discourse reveals the perception about various forms of expression the greatest severity is evidenced when conditioned to the presence of apparent physical injuries or those confirmed by health professionals studies in brazil and uganda 31 corroborate the findings showing that punches kicks burns strangulation and injuries with a white or firearm are the most perceived forms of violence because they leave visible marks this fact is in line with current statistics since international and national studies show ever increasing percentages of physical violence which is related to its being easily recognizable this masculine perception of violence as one that generates visible and serious marks allows us to understand that threats provocations and insults are sometimes denied as violent behavior because they do not measurable marks it signals therefore toward the nonrecognition of the gravity of this phenomenon scholars point out that this is an understanding that needs to be deconstructed which may arise from the reflection of men and women but above all by the proper education of children so that they may act differently in their future relations breaking the intergenerational cycle of conjugal and family violence in this context researchers defend the importance of training professionals working in family health teams to prevent marital violence in the community and school environment in relation to the word cloud the size of the letters indicates the relevance of the term in the context in which it is displayed in this manuscript the image shows that the following words stand out no violence fault she problem natural beat marks woman this reinforces the collective perception that the phenomenon is only understood when there are physical marks still the word guilt corroborates the central idea 3 in which the retaliation emphasizes the blame on the other as guilty for initiating the problem limitations of this study the limitation of the study relies on the fact that it is applicable only in societies that maintain the same stereotype of gender and marital relations because it is a social phenomenon marital violence can present different perceptions in realities that have different customs from those of the participants of this study because it is a public health problem it is essential to understand the different perceptions that permeate the imaginary of those involved this understanding is essential for the process of addressing this phenomenon since it offers subsidies to think about prevention actions and consequently to promote the reduction of cases of conjugal violence and its complications for health contributions to the area of nursing health or public policy the preparation of health professionals is deemed as extremely important in the most diverse spaces teams working in primary health care are at a privileged locus insofar as this is a space focused on the prevention of offenses and diseases and the promotion of health in this context emphasis is placed on the nurses who are the main managers of these centers and who have a greater link with the community and community health agents which favors the articulation with neighborhood associations schools social welfare reference centers anonymous alcoholics programs and others so that the perceptions about violence as well as the social ideation of the gender roles can be worked seeking a respectful solution in the fight against violence conclusion collective discourses revealed that in men understand the phenomenon of conjugal violence as a natural conduct located in the intimate forum of the couple and which occurs in a reciprocal manner while acknowledging the most veiled forms of violence such as insults they sometimes consider that in order to characterize violence it is necessary to prove it which is done by means of visible marks thus highlighting the physical forms the study evidenced gender dissymmetry as a social construct signaling the need to create spaces for reflection and resignification of men and women from a gender perspective concerning the transgenerational character schools are privileged spaces to break this cycle and should incite actions that promote equitable relationships between girls and boys based on mutual respect which enable the deconstruction of the current patriarchal model moreover they should give visibility to the magnitude of each of the forms of expression of violence favoring the deconstruction of the idea that it is restricted to physical aggression it is also necessary a type of education that encourages the peaceful resolution of conflicts as well as an understanding that retaliation is not a defense but a form of perpetuation of violence which must be recognized as such furthermore professionals in the social judicial police educational and healthcare areas must be better prepared to understand this phenomenon of such magnitude and complexity therefore it is essential that the theme be discussed in different scenarios and in a specialized way in the core undergraduate curriculum moreover qualification processes are necessary for those who already work in the labor market

objective to analyze male criminals perception about marital violence method an exploratory descriptive qualitative study undertaken with 23 men who were criminally prosecuted for marital violence a multimethod data collection was conducted with individual interview and focal group techniques combined between may and december 2015 the data collected were initially categorized using the nvivo® 11 software program and then organized using the collective subject discourse method results the collective discourses reveal that in the males perception conjugal violence is inherent in a marital relationships it is a private reciprocal problem that leaves body marks conclusion gender dissymmetry as a social construct is evidenced signaling the need to create spaces for refl ection and resignifi cation of men and women from a gender perspective

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introduction climate change is a global threat that affects the planet and an individuals quality of life it is considered one of the pivotal problems of the 21st century 1 scholars and policymakers worldwide are working to lessen the impact of climate change 1 2 3 in the intergovernmental panel on climate change report the scientific community revealed that greenhouse gas emissions have escalated over the past few decades in spite of an increasing number of efforts to solve this issue 4 the numerous harmful effects of climate change include the melting of ice sheets increasing sea levels and dangerous weather events as a result of severe heat waves similarly land degradation water scarcity and pollution pose threats to future generations in terms of hunger and food security thus urgent attention should be demanded 14 the devastating effects of human beings patterns of living on the environment cannot be ignored one significant example is the substantial impact of food choices and consumption patterns on climate change 256 prior studies have shown that dietary choices have a substantial effect on the environment 7 and are considered a key strategy to mitigate climate change 48 in particular food consumption accounts for a significant amount of ghges 3 prior studies have also found that food production processes contribute to ghges by 2030 59 furthermore previous studies have demonstrated that minimizing meat consumption by substituting organic and vegetarian food has decreased the ghges in sweden and china 910 this is because meat generates higher emissions per unit of energy due to the energy lost at each trophic level compared with plantbased foods 7 hence the relationship between food intake and climate change are evidenced in prior studies eg 1245 8 9 10 11 12 recently research evidenced that foodrelated carbon savings come primarily from dietary changes particularly the adoption of a vegan diet 6 according to a study that examined individual food choices and measured their potential impact on reducing ghges in developed countries eating a plantbased diet can reduce annual personal emissions by 08 t co 2 eyr 6 the environmental impacts of dietary choices can be minimized by decreasing animal product consumption energy intake and food waste 4 the path toward a sustainable society can be pursued through governmental efforts and innovations and the sustainable actions of human beings hence a cultural change is recommended for sustainable development 13 concerns over climate change have led to climatefriendly food consumption involving the entire food consumption supply chain from selecting purchasing cooking and sorting food to disposing and recycling food waste climatefriendly food consumption refers to an individuals voluntary actions limiting dairy and meat product intake to help protect the environment 6 the extant literature showed that adopting climatefriendly food is among the mitigating strategies for climate change impact 12 13 14 prior studies have also demonstrated that individual awareness of food choices and their subsequent impact on the environment is growing 1516 a recent study by jalil et al 17 investigated the effects of an awarenessraising intervention on meat consumption through a randomized controlled trial the study found that interventions that advise individuals and support voluntary change can substantially decrease meat consumption 17 in western countries such as scotland australia and finland the majority of previous research focused on peoples awareness of food choices and their environmental impact 21112 developing countries on the other hand have only conducted a small number of studies furthermore there is still a lack of evidence linking climate change awareness and concern with subsequent mitigation behaviors in developing countries such as saudi arabia 18 this study closes the knowledge gap this problem is worsening in saudi arabia where dietary products are more prevalent in saudi individuals daily food choices prior research investigated female food choices in the eastern region of saudi arabia using qualitative methods and found that females are unaware of the impact of their food choices on environmental sustainability 19 accordingly in a developing country such as saudi arabia few studies have examined the understanding of and concern about climate change and its association with dietary choices 18 hence this research investigated an individuals understanding of and concerns over climate change in saudi arabia the study also examines the associations between sociodemographic characteristics and dietary choices with the understanding of and concern over climate change within the saudi population materials and methods the current research is underpinned by the positivist paradigm a school of thought which believes that only knowledge gained through observation and measurement can be trusted 20 studies based on positivism limit the researchers responsibilities to data collection and objective interpretation this paradigm assists positivist researchers in better understanding phenomena through empirical methods such as sampling measurement and questionnaires positivists are primarily associated with quantitative research since it involves gathering and converting data into numerical form to perform statistical calculations 20 hence the use of a questionnaire as a primary tool of data collection is justifiable study population this crosssectional study included 280 participants between the ages of 18 and 60 years study participants were recruited from march to june 2021 in jeddah city saudi arabia recent statistical reports on saudi arabia based on unified national data indicated that the total population in jeddah in 2019 was 2867446 21 therefore the sample size required to obtain sufficient statistical power is 271 based on a 5 margin of error 90 confidence level and response distribution of 50 22 the study was approved by the bioethics committee of scientific and medical research university of jeddah saudi arabia study questionnaire a selfadministered online questionnaire was used to collect data through a web link shared over email and social media such as facebook twitter and whatsapp participants were randomly invited through the official channels of the university of jeddah and king abdulaziz university google forms was used to construct the questionnaire which included closedended questions written in arabic the questionnaire took less than 57 min to complete in the online survey on the first page the inclusion criteria of study sample were clearly stated the inclusion criteria were adults above 18 years of age living in jeddah city and it was asked that any person outside of the inclusion criteria not to fill the questionnaire information explaining the study objectives and the target population was included on the first page of the questionnaire the first page of the questionnaire also confirmed voluntary and confidential participation in the study signed online consent forms were obtained from all participants prior to data collection the survey was anonymous there was no collection of sensitive information and the participants were able to leave at any point if they felt uncomfortable the questionnaire was composed of three sections sociodemographic characteristics of the participants understanding of and concern over climate change and dietary choices assessment of understanding of and concern over climate change the second part of the survey included participant understanding and concern regarding climate change the questionnaire was adapted from korkala et al 1 and hope 23 with slight modifications the question what do you think is meant by climate change was used to evaluate participants understanding of climate change five options were provided an increase in sunspot activity and solar radiation a change in the axial tilt of the earth an increase in population growth energy consumption and exploitation of nature an increase in the greenhouse gas concentration of the atmosphere due to human actions and a natural fluctuation of climate periods on earth based on the ipcc report 24 alternatives 3 and 4 indicated sufficient understanding resulting in a score of 1 whereas alternatives 1 2 and 5 indicated a poor understanding of climate change resulting in a score of 0 furthermore two questions were asked to assess the degree of concern over climate change the first question was how serious of a threat do you think climate change is to humankind the choices were a very serious threat quite a serious threat not a serious threat not a threat at all and i do not know alternatives 1 and 2 indicated a high level of concern whereas alternatives 3 4 and 5 indicated low concern over climate change the second question was what are the possible future effects of climate change in saudi arabia the choices included hotter temperatures more rain and floods colder temperatures rise in sea level loss in animals and plants no effect and i do not know alternatives 1 to 5 indicated a high level of concern while alternatives 6 and 7 indicated low concern over climate change the answers that reflect high levels of concern were given a score of 1 and the sum of scores for the two questions was calculated for all participants assessment of dietary choices the third part of the questionnaire collected information regarding food consumption during the past 12 months via a short food frequency questionnaire with 14 items adapted from a previous study 1 the food items were selected based on their climatefriendliness the ffq included both climatefriendly and nonclimatefriendly food items the climatefriendliness of food items has been defined in previous studies based on their ghges climatefriendly foods include fresh fruits 25 fresh vegetablessaladroot vegetables 2526 potatoes 25 vegetable oil 25 margarine 27 soy products 28 and organic foods 2930 nonclimatefriendly food items include french fries 31 rice 25 beeflamb 2526 poultry 25 milk 25 lowfat cheese other cheeses 25 and butter 27 the calculation to determine climatefriendly food consumption involved summing the intake of fresh fruits fresh vegetables potatoes vegetable oil margarine soy products and organic food divided by seven the calculation for nonclimatefriendly food consumption involved summing the intake of french fries rice beeflamb poultry milk lowfat cheese other cheeses and butter divided by eight statistical analysis all statistical analyses were performed using the statistical analysis software program spss version 27 descriptive statistics including percentage and frequency distributions were calculated from the data the scores for the understanding of and concern about climate change and food intake are presented as the mean± standard deviation the score for understating and concerns were stratified to low and high a high score for understating reflects participants with a score of one and for concerns reflects participants with a score of two a regression model was used to determine differences in the understanding and concern scores between participants according to their sociodemographic data adjusted for sex age group nationality marital status education occupation and income food scores were also compared with understanding of and concern about climate change via a linear regression analysis adjusted for sex age group nationality marital status education occupation and income statistical significance was set at p ≤ 005 results a summary of the participant sociodemographic characteristics is presented in table 1 nearly onethird of the study participants were between the ages of 1829 years of age while a quarter were between 30 and 39 years of age and a quarter were between 40 and 49 years of age the majority of the study participants were females saudis married and employed in the government sector almost 61 of the study participants held a bachelors degree and 32 had a postgraduates degree a total of 36 of the study participants earned less than sar 3000 monthly and 21 earned sar 700012000 monthly nearly 87 of study subjects acknowledged that they had heard about climate change whereas a small percentage said they had never heard about it likewise approximately half of the study participants stated that they understood the term climate change and 39 said they understood it to some extent in contrast only a small percentage said they did not know what climate change meant in addition 77 of the participants believe that human activity is largely responsible for climate change while 10 believe that human activity is not responsible for climate change and a further 13 are unsure whether human activity is responsible or not overall 45 of the study participants demonstrated a sufficient understanding of climate change and 55 exhibited a poor understanding approximately 56 of study participants displayed a high level of concern over climate change and 44 exhibited low concern climate change understanding and concern scores stratified by sociodemographic characteristics are presented in table 2 regarding the climate change understanding score there were significant differences between males and females where males displayed a higher understanding score compared with females there were no significant differences in the climate change understanding score between participants in different age nationality marital status education occupation and monthly income groups regarding the concern over climate change score males demonstrated significantly greater concern over climate change scores compared with females additionally participants with a postgraduate degree demonstrated the greatest concern about climate change scores compared with the other two educational groups there were statistically significant differences in concern over climate change scores between participants in different income and occupational groups participants working in the public sector and with a monthly salary between sar 7000 and 12000 exhibited the highest level of concern over climate change scores there were no significant differences in concern over the climate change score between participants in different age nationality and marital status groups table 3 displays participants intake of selected food items according to their understanding of the climate change score the participants were categorized as low and high according to their understanding of the climate change score there was a significant positive association between understanding of climate change score and vegetable oil intake when comparing participants with high scores to those with low scores additionally participants in the high score group consumed more vegetables compared with participants in the low score group after adjustment there were no significant differences between the intake of fruits french fries potatoes rice red meat poultry milk lowfat cheese other cheeses butter margarine soy products and organic food and understanding of climate change score participants intake of selected food items according to their concern over climate change scores is presented in table 4 participants were categorized according to their concern over climate change scores into low and high groups higher scores for concerns about climate change were negatively associated with the intake of red meat poultry margarine and soy products the intake of red meat poultry margarine and soy products among participants in the high score group were lower than that in the low score group there were no significant differences between the intake of fruits vegetables french fries potatoes rice milk lowfat cheese other cheeses butter vegetable oil and organic food and concern over climate change score overall the participant intake of nonclimatefriendly food was higher than that of climatefriendly food discussion climate change is a major threat to public health it has critically damaged various life support systems and cycles endangering human lives dietary choices play a significant role in reducing climate change and alleviating its environmental impacts 514 the current study investigated the levels of understanding and concern about climate change in saudi arabia and examined their associations with sociodemographic characteristics it also examined the associations between the study participants levels of understanding and concern about climate change and dietary choices the results revealed a poor understanding of climate change but high concern among the study participants in addition males and mediumhigh monthly income individuals were associated with higher understanding of and concern over climate change scores similarly higher education and government employees were associated with higher concern over climate change scores furthermore subjects with a higher understanding of climate change scores exhibited a higher consumption of vegetables and vegetable oils in addition subjects who demonstrated higher concern over climate change scores exhibited lower red meat poultry margarine and soy product consumption although 87 of the study participants had heard about climate change and 45 admitted that they understood the term climate change only 45 of study participants demonstrated a sufficient understanding of climate change a poor understanding of climate change was reported in bangladesh 32 33 34 whereas a greater understanding of climate change was reported in finland 1 in the current study some participants expressed an understanding of human activities being responsible for the rise in ghges however more believed that climate change is a natural fluctuation of climate periods on earth which reflects a poor understanding of climate change in contrast the study participants exhibited high levels of concern over climate change nearly 62 of participants believed that climate change is a major threat to humans a previous study reported that 36 of the finnish population had high concerns and 47 demonstrated medium concerns about climate change 1 several studies have found high levels of concern over climate change 3234 which is consistent with our findings this study demonstrated that males exhibited a good understanding and greater concern over climate change than females even though the number of females participating in the study was higher than that of males previous studies have demonstrated a greater female understanding of and concern over climate change than males 12333 a previous study in turkey determined that females were more concerned about climate change than males 33 similarly a study in finland illustrated that females exhibited a superior understanding and awareness of climate change compared with males 1 however a study in guyana found no significant difference between both sexes in their understanding of climate change 23 scientific evidence has indicated sex differences regarding obtaining health knowledge and adopting healthy behaviors since females are more conscientious and more likely to seek reliable health information 3536 our results can be explained by the fact that the males were more educated and older than the females in this study 40 of males were postgraduate degree holders whereas only 28 of females held a postgraduate degree in addition 39 of males in the study were 4059 years of age whereas 35 of females were 1829 years of age thus since the males in our sample were older and more educated than the females they may be more knowledgeable about climate change topics and news moreover previous research indicated that the education level is a strong predictor of climate change knowledge and awareness 3233 which aligns with our findings that participants with higher education levels were highly concerned about climate change a study from bangladesh demonstrated that subjects with a sufficient level of education were more aware of climate change 32 other studies from the philippines nepal and china have reported similar results 37 38 39 therefore increasing knowledge about climate change among students is a valuable strategy that can be used to enhance awareness of climate change furthermore the results of this study indicate that a higher income is associated with a greater concern about climate change one study from china illustrated that lowincome individuals were less aware of climate change than those with a high income 39 this is likely because individuals with higher income levels can afford higher levels of education the current study results demonstrated that a sufficient understanding of and higher concern over climate change were associated with a greater intake of vegetables and vegetable oils and a lower intake of red meat poultry margarine and soy products among the study subjects these results corroborate with those of previous studies demonstrating that concerns about the environment are associated with sustainable behaviors such as increasing ecofriendly product consumption 1 specific food item consumption and production are a primary cause of ghges 40 previous research indicated that animal products such as red meat poultry cheese and butter are associated with high ghges whereas fruits vegetables and margarine are associated with low ghges and can thus be considered climatefriendly food items 253140 a study in finland illustrated that individuals who demonstrated sufficient knowledge about climate change exhibited a higher intake of fruits vegetables vegetable oils organic foods and soy products the study also indicated that individuals with a high level of concern over climate change consumed less red meat and french fries however they consumed more fruits vegetables vegetable oils organic foods and soy products 1 these findings are consistent with our results except for soy product and organic food intake the consumption of soy products and organic foods was low in our study nearly half of the study subjects reported that they never consumed soy products or consumed them less than once per month in the last 12 months the consumption of organic foods was also low 20 of participants admitted that they never bought organic food and 40 stated that they consumed organic food less than once per month in the last 12 months one possibility for this finding is the higher prices of these food items in saudi arabia particularly organic food food and livestock production is the primary cause of environmental harm since it typically consists of excess water use and deforestation 4 for example the production of meat and dairy products is responsible for 1524 of ghges worldwide which explains why climate change scientists consider these food items nonclimate friendly 435 in the united kingdom one study indicated that reducing meat consumption decreased the production of ghges by 35 in addition eliminating food waste also decreased ghges by 12 41 similarly a study in the united states suggested that replacing meat with plantbased food effectively reduced ghges and improved human health 42 research demonstrated that vegan and vegetarian diets are highly associated with reduced ghges compared with a diet rich in meat 43 a study in lebanon indicated that the western diet which is rich in meat dairy products and processed foods was highly associated with ghges in contrast the mediterranean diet which is rich in vegetables fruits and legumes produced minor amounts of ghges 44 our results demonstrated that individuals with higher concern over climate change scores exhibited significantly lower red meat and poultry consumption this implies that the effect of concern on individual behaviors including environmental behaviors may be higher than the effect of knowledge on behaviors that has been demonstrated in previous research 145 however our results also showed that individuals with a higher concern of climate change score had no increase in the intake of vegetables indeed previous studies reported that the population of saudi arabia had a generally insufficient intake of fruits and vegetables 4647 which may be the reason for this finding climatefriendly foods can also improve human health and prevent chronic diseases hence people may increase their intake of these food items for health purposes instead of climate change mitigation numerous studies have demonstrated that reducing the consumption of red meat prevents coronary heart disease type 2 diabetes and several types of cancers in addition to decreasing the production of ghges 4849 chronic diseases such as coronary heart disease obesity hypertension high blood lipids and type 2 diabetes are highly prevalent in saudi arabia 50 saudi arabia ranked number 84 in the global climate risk index since it has many environmental challenges that place the kingdom at great risk these challenges include air pollution restricted freshwater sources coastal flooding high rates of energy consumption and high rates of co 2 emissions per capita 51 the kingdom of saudi arabia has implemented numerous strategies for climate change mitigation including green building projects and sustainable transportation such as light rail transit in riyadh jeddah makkah madinah and dammam as well as the riyadh metro 51 the green saudi initiative was launched in 2021 as part of the national 2030 vision the initiative aims to increase vegetation cover and reduce land degradation air pollution and co 2 emissions nationwide 52 regardless of the massive efforts of the saudi government to mitigate climate change the study indicated poor understanding and medium concern over climate change in the kingdom therefore enhancing the knowledge and concerns about climate change increasing the intake of climatefriendly food choices and reducing or replacing the intake of nonclimatefriendly food among the population of saudi arabia can simultaneously benefit human and environmental health limitations and future studies the current study has several limitations the ffq required study participants to accurately remember their food intake in the last 12 months introducing some recall bias in addition information such as the portion size of the food and the amount of food wasted was absent which is considered a weakness of this study since this information is highly related to reducing climate change further the results cannot be generalized to all saudis since the study was only conducted in one city future studies should include representative samples from all regions of the country in addition using an online survey to recruit study participants may introduce selfselection bias and nonprobability sampling however the online survey was a safe way to collect the data for this study due to the covid19 pandemic similarly selection bias may be an issue in this study because participants who were interested in the topic dietary choices as determinants of the understanding and concerns over climate change in saudi arabia might have been more enthusiastic to complete the survey moreover this study did not assess the participant awareness of the relationship between food choices and climate change issues therefore their consumption of specific food items may be related to managing health instead of climate change mitigation a previous study in saudi arabia reported that females were unaware of the impact of their food choices on the environment 19 future studies should also explore the barriers to organic food consumption in saudi arabia and examine the saudi attitudes and behaviors surrounding ecofriendly food consumption further research is needed to determine whether the decrease in meat consumption is related to the growing level of concern this study also exhibits several strengths this is the first study to examine the associations between the understanding of and concern over climate change and dietary choices in saudi arabia to the best of our knowledge the study included many food items that were considered either climatefriendly or nonclimatefriendly food items based on previous research the findings of the current study offer insight into how individuals of saudi arabia understand and believe in climate change issues it also provides a foundation for future studies to promote healthy dietary choices and mitigate climate change in the country managerial implications we proposed the following recommendations based on our results public health representatives should increase awareness of the impact of climate change on public health universities and schools should also play a pivotal role in protecting the environment specific curricula should be dedicated to educating students about the importance of protecting the environment and how sustainable behaviors can mitigate the impact of their consumption on the environment in particular initiatives and campaigns that disseminate knowledge about individual dietary habits and their subsequent influence on the environment and public health should be increased further efforts should be made by the ministry of environment water and agriculture to increase saudi population awareness of the benefits of sustainable consumption on the environment and to broaden their knowledge about their responsibility toward the environment businesses as part of their social responsibility should encourage green products services and operations to foster green consumption behaviors these efforts can be supported by social marketing campaigns that foster and encourage the consumption of green products and services among saudi consumers expanding communication through social media such as twitter facebook instagram and snapchat is the most common approach used by saudis to disseminate information specific campaigns can be directed to saudi females to increase their knowledge about the negative impact of climate change on the environment and health and encourage their engagement to protect the environment governments businesses and communities should work together to enhance awareness of the benefits of climatefriendly food choices for climate change mitigation and public health to encourage sustainable behaviors conclusions climate change is a global phenomenon that threatens human health biodiversity and the environment the extent to which human practices and behaviors have an impact on the environment and specifically climate change has been documented in the literature choosing what to eat is one of them in particular dietary choices have an enormous impact on the environment and are important strategies to combat climate change hence the current study investigates climate change awareness and concern in saudi arabia as well as the association between these factors social demographics and dietary choices data were collected for this crosssectional research using an online questionnaire we retrieved 280 completed forms 45 of the study participants had sufficient understanding of climate change and 56 were concerned about climate change participants who understand climate change and are concerned about it are more likely to be male have a mediumhigh monthly income have a high education level and work for the government the findings also revealed that participants with a sufficient understanding of climate change ate more vegetables and vegetable oils while those with a high level of concern for climate change ate less red meat poultry margarine and soy products furthermore the intake of nonclimatefriendly food was typically higher than the intake of climatefriendly food among the study participants these findings are critical for encouraging people to adopt healthy behaviors and consume climatefriendly food to minimize the risk of climate change and improve public health the current study contributes to the body of literature about climate change by investigating the relationship between food intake and its subsequent impact on the environment as far as we are aware this is the first study of its kind to measure saudi citizens awareness of the effects of climate change and its impact on their food choices the findings of this study shed light on how citizens in saudi arabia perceive and believe in climate change as a result we have a better understanding of saudi arabians perspective about climate change it also lays the groundwork for future studies aimed at promoting healthy eating habits and reducing climate change in the country data availability statement the datasets generated andor analyzed during the current study are not publicly available because the authors require them for further publication they are available from the corresponding author upon reasonable request signed online consent forms were obtained from all participants prior to data collection supplementary materials the following are available online at 103390ijerph182010605s1 table s1 informed consent statement informed consent was obtained from all subjects involved in the study

sociodemographic characteristics and dietary choices as determinants of climate change understanding and concern in saudi arabia int j

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poor diet is a major contributor to the burden of noncommunicable diseases and in the uk costs the national health service £6 billion annually evidence from the annual rolling national diet and nutrition survey shows that uk adolescents aged 1118 years have poorer diets than other age groups additionally the health survey for england indicates that 23 of adolescents aged 1115 years are already obese a figure that has gradually increased from 14 in 1995 implementing strategies that improve adolescents dietary behaviours are crucial because a suboptimal diet in adolescence affects immediate health as well as raising the risk of obesity and noncommunicable diseases later in life and in the next generation nonalcoholic beverages are the primary source of free sugars in adolescents diets most of which are sugary soft drinks and energy drinks a survey of energy drinks for sale in the uk indicates that their average sugar content was 9•7 g100 ml with some drinks containing up to 16 g100 ml approximately half of the energy drinks available also have a serving size of 500 ml meaning a single bottle markedly exceeds the current dietary recommendation for free sugars which is 30 gd for individuals aged over 11 years energy drinks are distinguishable from other soft drinks because they contain large amounts of caffeine and potentially other stimulants such as guarana taurine and ginseng the energy drink survey described above identified that the average caffeine content of energy drinks is also high at 31•6 mg100 ml equating to 158 mg of caffeine in a 500 ml bottle the current european caffeine recommendations specify a daily allowance of 3 mg of caffeinekg body weight a single serving of these drinks therefore surpasses this recommendation for adolescents with a body weight below 53 kg among adolescents energy drink consumption has been linked to several physical symptoms including headaches stomach aches hyperactivity and insomnia these symptoms largely relate to the high caffeine and sugar content of energy drinks energy drink sales have grown substantially over the past decade with current uk sales estimated at 680 million lyear alarmingly a european food safety authority report indicated that young people aged 1017 years are the greatest energy drink consumers the reports statistics indicate that british adolescents consumed the greatest quantity of energy drinks of all participating european countries consuming over a litre a month more than the european average of 2 lmonth the report also showed that more older adolescents and boys reported consuming energy drinks than younger adolescents and girls increased awareness of the potential dangers that energy drinks pose to young peoples health has led several major retailers to impose voluntary bans on the sale of energy drinks to minors under 16 years many uk schools have also introduced voluntary bans to prevent students drinking them on school premises in 2018 the uk government undertook a consultation on their proposal to introduce legislation to ban the sale of energy drinks to minors they proposed this would create consistency across retailers and protect young peoples health the house of commons science and technology committee released an advisory report at the end of 2018 outlining their interpretation of the evidence and recommendations to government they concluded that there was insufficient evidence to warrant introducing a ban on selling energy drinks to children the committees report acknowledged that energy drinks were consumed disproportionately by disadvantaged groups but noted that evidence of this trend worsening over time or undermining educational or health outcomes was needed for action to be taken additionally insufficient evidence about the impact of voluntary bans was highlighted with recognition that qualitative evidence from teachers and parents could indicate societal concerns that would provide legitimacy for a statutory ban contrary to the committees recommendations the advancing our health prevention in the 2020s green paper released in 2019 announced that the uk government intended to introduce a ban on the sale of energy drinks to individuals aged under 16 years the basis for this ban was largely founded on the rationale that reductions in energy drink consumption would decrease calorie intake and improve diet thereby helping to lower obesity rates providing scientific evidence of these associations would further support government intervention and is necessary because the exact details of this policy are yet to be published to address existing evidence gaps and provide robust scientific evidence to inform policy change we conducted a mixedmethods study combining data from a national dietary dataset with qualitative data from interviews with adolescents parents and teachers the specific aims were 1 to determine the prevalence of energy drink consumption among adolescents in the uk and assess how consumption varies by gender and age group 2 to examine associations between energy drink consumption among adolescents in the uk and deprivation and dietary inequalities 3 to explore teachers parents and adolescents perceptions of adolescent energy drink consumption and the effectiveness of current voluntary energy drink restrictions in schools and supermarkets method study design and setting this study adopted a mixedmethods study design quantitative data were used to address the first two research aims and qualitative data used to address the third aim qualitative and quantitative datasets were then combined to corroborate findings and expand the breadth and depth of interpretation quantitative data were taken from the ndns rolling programme a repeated crosssectional survey conducted with a representative sample of the national population each year the ndns programme recruits approximately 500 adults and 500 children aged over 18 months from randomly selected households across the uk participants are asked to complete a facetoface questionnaire about household and individual demographics as well as an estimated food diary qualitative data were collected as part of the development work for the engaging adolescents in changing behaviour study a multicomponent intervention to support adolescent diet and physical activity this formative work was conducted in community settings in hampshire uk all elements of this study were conducted according to the declaration of helsinki and data protection regulations and were approved by the university of southampton faculty of medicine ethics committee quantitative data national diet and nutrition survey dietary intake data were derived from food diaries participants recorded details of all foods and drinks consumed on up to four consecutive days with estimated portion sizes brand names or ingredients for homemade meals trained ndns coders classified the items in the diaries into 154 food groups and assigned energy values detailed descriptions of the design and methodology can be found elsewhere our analyses were performed on 2587 adolescents aged 1118 years from the combined survey waves 18 from 2008 to 2016 frequency of energy drink consumption was calculated for each participant adjusting for the number of diary days completed as energy drinks are not categorised into their own ndns food group the names of all items categorised in the soft drink not diet and soft drinks diet categories were extracted and reviewed energy drinks were defined as drinks containing over 150 mg of caffeine were excluded in accordance with european union labelling regulations for highcaffeine products requiring warning labels for children energy drinks with low or no sugar were included total daily energy intake was calculated for each participant by summing the energy for all the food and drink items consumed and averaging over the number of diary days a diet quality score was derived for each participant using ndns data using a published methodology diet quality scores were generated using principal component analysis on 139 food groups vitamins minerals and artificial sweetener groups were removed principal component analysis is a commonly used method for generating dietary patterns the first component of the principal component analysis explained the greatest variance in the dietary data and represented a diet consistent with uk dietary recommendation higher consumption of fruit vegetables wholegrains and lower intake of sugarsweetened beverages chips and processed meats the principal component analysis allocated coefficients to each food group to quantify their contribution to the overall component the coefficients and reported frequencies of consumption were used to calculate a dietary quality score for each participant to facilitate interpretation of the results dietary quality scores were standardised to a mean of zero and a sd of one with higher scores representing better quality diets dietary scores have been validated against fourteen nutritional biomarkers including serum folate homocysteine total carotenoids and vitamins b 12 c and d an equivalised household income variable was developed using total household income reported by the main food provider adjusted for household size and demands index of multiple deprivation the official measure of relative deprivation for small areas in england was calculated for each participant based on the household postcode imd scores were divided into quintiles and used to determine the neighbourhood deprivation for each household imd was not recorded in the ndns for waves 5 and 6 due to changes in the study protocol bmi zscores were created to adjust for age and sex and categorised according to cutoffs defined from nationally representative surveys with adolescents qualitative data interviews with adolescents parent and teachers semistructured interviews were conducted with parents teachers and adolescents to learn about adolescents daily food and physical activity habits and what could support healthier choices interviews were conducted with an additional sample of adolescents to explore energy drink consumption in more depth all interviews were conducted using semistructured topic guides distinct for each participant group participants were not shown the questions in advance participants were recruited in 2018 from a secondary school a community youth club and at a hospital open day adolescents were interviewed at their school or youth club the school was a nonselective mixed secondary school where aboveaverage numbers of students were eligible for free school meals compared to the national average the youth club targeted adolescents from disadvantaged backgrounds with low school attendance teachers at the school were interviewed during working hours parents were interviewed at their workplace or home by telephone or in person at a hospital evening event for parents adolescents and teachers were interviewed in either pairs or groups of three to six participants parents were interviewed individually or in groups containing three participants all facetoface interviews were conducted by one researcher with an observer present who took notes telephone interviews were conducted by one researcher and with a single participant interviews were transcribed verbatim and pooled together into a single nvivo project participants did not comment on their transcripts quantitative data analyses summary statistics were used to describe ndns sample characteristics mean for normally distributed continuous variables and median for nonnormally distributed continuous variables frequencies are quoted for binary variables frequency of energy drink consumption was calculated per participant adjusting for the fact that 1•8 of diaries were completed for only three of the 4 d energy drink consumption was highly skewed with 93•0 of children reporting consuming no energy drinks in their food diaries these data were therefore analysed as a dichotomous variable to assess differences in energy drink consumption according to age gender and neighbourhood deprivation the proportions of energy drink consumers were calculated across categories of demographic variables logistic regression models were fitted with energy drink consumption as the outcome to describe the effects of demographic variables on energy drink consumption a logistic regression model was fitted with imd year of study and the interaction between the two as predictor variables the interaction term describes whether the effects of imd differ as the year of study increases to assess whether energy drink intake related to dietary quality diet scores were divided into tertiles describing poorer medium and higher quality diets age was divided into two groups 1115 and 1618 years because most adolescents commence secondary school at age 11 and college at age 16 household income was divided into two categories which is reflective of the uk median household income in 2012 the midpoint for the data time period daily energy intake was divided into four groups changes in diet quality score are interpreted in terms of the original foods consumed by calculating the equivalent change on the original scale to the change from the median on the fisheryates transformed scale weights were provided in the ndns dataset to adjust for the underrepresentation of children in households with more than one child and for the cluster identifier the weights were rescaled to reflect different sample sizes in different waves so all data could be combined weighted analyses are presented throughout qualitative data analysis nvivo queries were used to extract the broad context of any references to energy drinks and popular brands in the uk eg red bull monster and rockstar lucozade was also included because brands with lower caffeine levels are colloquially called energy drinks quotes were analysed using conventional content analysis following established guidelines initial codes were developed by cv and sj by creating nodes in nvivo as new topics arose after all transcripts had been coded nodes were refined with input from ssh sst and mb and organised into themes and subthemes this approach is aligned with a relativist ontological and subjective epistemic position which purports that reality is a matter of individual perspective and based on personal experience and insight to ensure the interpretation was an accurate representation of interviewees views and data analysis decisions were transparent a rigorous process was adopted in which data were doublecoded by pairs of the researchers and disagreements were resolved in team discussions throughout the coding process the five researchers involved in the qualitative analysis were all women their expertise were in nutrition andor psychology and their ages varied from young adult to middle age results participant characteristics quantitative data the quantitative analysis sample comprised all 2587 adolescents 1305 girls and 1282 boys in waves 18 of the ndns dataset the majority were aged 1115 years of white ethnicity and lived in households with £27 000year the distribution of bmi zscore was similar by age categories such that 31 of those aged 1115 were classified as overweight or obese compared to 27 of those aged 1618 participant characteristics qualitative data of the fiftyseven interviews conducted twentyeight were with adolescents twenty with parents and nine with teachers demographic data were not collected from two adolescent group interviews due to time restrictions of the adolescent participants who provided demographic data most were aged 1314 years and of white ethnicity fewer than half were girls the majority of parents and teachers were women and of white ethnicity most parents were aged 4049 years while almost threequarters of teachers were aged 2039 years aim 1 prevalence of energy drink consumption among adolescents in the uk the ndns data showed that 7•0 of adolescents consumed at least one energy drink in a 4 d period older adolescents were more likely to consume energy drinks than younger adolescents a 1year increase in age was associated with a 21 increase in the likelihood of energy drink consumption p 0•001 this trend of increased energy drink consumption through adolescence did not decline over time despite the known increase in public awareness of safety concerns regarding energy drinks no difference was observed between the proportion of girls and boys consuming energy drinks aim 2 associations between energy drink consumption and deprivation and dietary inequalities adolescents in more deprived areas consumed energy drinks more frequently than those in more affluent areas a one quintile increase in imd was associated with a 40 increased likelihood of consuming energy drinks p 0•001 similarly adolescents from lower annual income households were more likely to consume energy drinks compared to those from higher annual income households a £1000 increase in household income was associated with being 2 less likely to consume energy drinks p 0•001 between 2008 and 2016 energy drink consumption among adolescents living in the most deprived areas increased whilst consumption among those living in the most affluent neighbourhoods decreased adolescents consumption of energy drinks was also associated with poorer dietary quality a 1 sd increase in dietary quality score was associated with being 54 less likely to consume energy drinks p 0•001 changes in diet quality scores can be achieved in many ways an illustration of 1 sd higher dietary quality score is consuming seven additional portions of nuts and seeds and six additional portions of salad and other raw vegetablesweek plus six fewer portions of chips and six fewer portions of sugarsweetened carbonateddrinksweek a 100 kcal increase in daily energy intake was also associated with 4 increased likelihood of consuming energy drinks additionally a 1 sd increase in bmi score was associated with 9 increased likelihood of consuming energy drinks p 0•40 aim 3 to explore teachers parents and adolescents perceptions of adolescent energy drink consumption and the effectiveness of current voluntary energy drink restrictions in schools and supermarkets three dominant themes were identified from the qualitative interviews which are summarised below along with illustrative quotes theme 1 a lot of young people drink energy drinksfriends and price are key reasons why many of the adolescents interviewed mentioned consuming energy drinks weekly or monthly and a number reported more frequent consumption for several adolescents energy drinks were part of their daily routine adolescents sometimes struggled to say no to energy drinks when they were offered them by their peers but some had made a conscious decision to reduce their consumption after learning what the drinks contained these adolescents expressed confusion when they saw their parents or other adults drinking them if someone buys me one i have a sip of it but then give it away i know whats in them now parents and teachers were also aware that many adolescents consume energy drinks regularly teachers raised concerns about the social desirability of energy drinks among adolescents and most acknowledged that energy drink consumption had become an accepted norm among their students and conformed to the social pressures you can see what theyve been buying on this app and these fruit drinks which are energy drinks he bought four in 1 day theres definitely a social pressure if their friends say oh i have five energy drinks a day there is just a constant pressure i think theyre at that point where theyre thinking about who they are and who they want to be theme 2 energy drinks are not good for health and cluster with unhealthy diets adolescents largely recognised that energy drinks are not good for their health and some had experienced negative physical side effects from drinking them many however adolescents also felt that profits were more important to some businesses than following the voluntary bans to sell energy drinks to minors these sorts of statements were said with disdain towards the shop owners indicating disapproval of this approach shops just dont care as long as theyre making their money teachers also reported that voluntary bans in schools had limited effectiveness on reducing energy drink intake teachers were aware that students smuggled energy drinks into school and acknowledged that enforcing the school bans were not always easy i know quite a few of them still have lucozade though and red bull they do they hide it in their bags very well teacher interview 13 some adolescents felt that if energy drinks are detrimental to their health access to them in stores should be restricted so they were more difficult to buy other adolescents however were adamant that they would find ways around stricter sales restrictions but then energy drinks if theyre that bad and theyve gotta have id then surely they shouldnt be in the fridge they should be behind the tills with all the alcohol wed get people to get them for us and id get it from the shop myself cose i know all the shops round here and they all love me discussion main findings this mixedmethods study used a nationally representative dietary dataset to characterise inequalities in energy drink consumption and semistructured interviews with a large sample of adolescents parents and teachers to provide deeper insight into adolescent energy drink intake and effectiveness of its current regulation the findings showed that the overall prevalence of adolescents energy drink consumption over a 4d period was 7•0 and that consumption rates were higher among older adolescents regardless of gender additionally this trend of greater energy drink consumption with age did not decline over time this study demonstrated clear associations between adolescent energy drink intake and markers of socioeconomic deprivation and dietary inequalities adolescents living in more deprived areas and from lower income households were considerably more likely to consume energy drinks than those from more affluent areas and households and higher energy drink consumption was associated with poorer dietary quality higher energy intake and greater body mass worryingly inequalities in energy drink consumption by area deprivation increased over the 8 year timeframe of the quantitative dataset with rates increasing among those from the most deprived areas and decreasing among those most affluent three themes were identified from the interviews with adolescents parents and teachers first many adolescents who drink energy drinks do so because of their friends and because the unbranded drinks are cheap second energy drink consumption clusters with other unhealthy eating behaviours and the harmful physical effects of energy drinks have been witnessed by teachers and some parents yet many adolescents do not know exactly why energy drinks are unhealthy third participants generally felt that voluntary bans in retail outlets particularly smaller stores and in schools do not work many favoured the introduction of legal restrictions on selling energy drinks to minors but some felt they could find ways to circumvent tougher restrictions comparison with previous research the prevalence estimate of adolescent energy drink consumption from this study seems lower than previous research from a similar point in time including findings from the world health organisations european health behaviour in schoolaged children study which indicates that energy drink consumption rates across countries range from 9 to 24 such differences in prevalence rates may be due to variations in data collection methods these previous studies asked about energy drink intake within the past week and reported prevalence rates of 15 21 and 24 for adolescent consumption at least once a week and 9 prevalence for consumption 24 times a week the current study used food diaries of up to 4 d it is therefore likely that due to this short time frame our findings offer a more conservative estimate of energy drink consumption compared with other studies and indicate the prevalence of very frequent or daily energy drink intake among adolescents in the uk teachers and parents perceived that energy drinks were associated with a specific social identity which fuelled their popularity among adolescents energy drink consumption has previously been linked to group membership and social identity among young people in this study social status acquired from energy drink consumption was not expressed explicitly by adolescent participants and it is unclear how aware they were of their behaviour being influenced by cultural norms some adolescents however did mention feeling pressured to partake when energy drinks were being circulated by their peers adolescents are known to value social acceptance and group membership but simultaneously strive for autonomy these somewhat conflicting determinants of behaviour may help to explain a reluctance in revealing or understanding the true motives for their energy drink consumption internationally research has shown that energy drinks are consumed more frequently by older adolescents and by those from more disadvantaged backgrounds our findings align with this previous work showing that each additional year of age increased the likelihood of consuming energy drinks by 21 with highest rates among 17 and 18 year olds this pattern likely reflects the growing levels of independence over food choices that adolescents acquire with age and challenges the uk governments proposal to prohibit the sale of energy drinks to those under 16 years of age applying the cutpoint at 18 years of age would be more consistent with the evidence on energy drink intake and could help protect older adolescents from more disadvantaged backgrounds who appear to be particularly vulnerable to the regular intake of energy drinks a disturbing pattern of increasing inequalities in energy drink consumption was revealed in our study whereby intakes among adolescents from the most deprived communities increased over an 8year period while intakes among those from affluent communities decreased clustering of unhealthy behaviours among energy drink consumers was also apparent in both our quantitative and qualitative data results showing that energy drink consumers had poorer quality diets higher daily energy intake and larger bmi previous research has shown that multiple unhealthy behaviours cluster among young people from disadvantaged backgrounds particularly low fruit and vegetable intake and high tobacco and alcohol use as well as low fruit and vegetable intake and low physical activity levels coupled with high sedentary behaviour and high sugary drinks intake in our study each additional sd increase in bmi was associated with 9 greater likelihood of adolescents consuming energy drinks although not statistically significant this may suggest the simultaneous occurrence of healthcompromising behaviours that could accentuate the risk of noncommunicable diseases among these young people this higher risk has implications for themselves their future offspring and society interventions to reverse entrenched inequalities are likely to be most successful if they target multiple risk behaviours and address social and environmental drivers implications for policy the findings from this study support the uk governments plans to introduce legislation to end the sale of energy drinks to minors it suggests that voluntary bans in large supermarket chains and schools are not implemented effectively and are undermined by smaller convenience stores who continue to sell these products to adolescents more deprived neighbourhoods have higher concentrations of convenience stores and poorer instore environments such unhealthy environmental exposures have been shown to exacerbate existing dietary inequalities and may be contributing to the increasing disparity in energy drink consumption between adolescents from more deprived and more affluent areas legislation may therefore help to address inequalities importantly this study highlights that the proposed legislation would miss the opportunity to reduce consumption among the highest energy drinkconsuming adolescents those aged 1618 years the limit of 16 years may be challenging to implement and easier for younger adolescents to work around wellestablished age restrictions on the sale of tobacco and alcohol to those aged under 18 years already exist in the uk aligning the limits on the sale of energy drinks with these established legislations would provide a clear message to the public that these drinks are not suitable for adolescents as well as facilitating consistent enforcement across all retail premises for the proposed legislation to be maximally effective additional actions could be considered by policymakers including minimum pricing of energy drinks and positioning them in restricted areas of retail outlets the cheap price of ownbrand energy drinks was identified as a key determinant of their consumption by adolescents particularly those from disadvantaged backgrounds in this and previous research introducing a minimum pricing of energy drinks could successfully limit intake in a similar way that the introduction of minimum alcohol pricing in scotland showed immediate impact reducing alcohol purchases among lower income and higher alcoholpurchasing households additionally adolescents interviewed in this study suggested that placing energy drinks behind counters with tobacco and some alcohol products would clearly indicate a health warning and make them less accessible to young people there is increasing evidence that product placement influences purchasing patterns and could be used to support health behaviours including among adolescents a communications campaigns about the harmful effects of energy drinks may also be warranted while there is good evidence illustrating the harmful and unpleasant physiological effects of energy drinks adolescents taking part in this study did not truly understand what made energy drinks so dangerous recent evidence indicates the harmful physiological effects of energy drinks on the cardiovascular system occur independently from caffeine possibly caused by the additional energyboosting substances such as taurine guarana and sugar overuse of energy drinks has caused sudden cardiac death poor mental health and hinders academic performance these risks need to be appropriately communicated to young people and their families future research could test how labelling strategies such as warning labels may help to inform adolescents about the dangers of energy drinks and cocreate the design of communication strategies that align with adolescents values of autonomy and fun while informing them of healthier alternatives to energy drinks strengths and limitations the use of mixedmethods is a strength of this study because it enables a more nuanced understanding of how energy drinks fit into the lives of young people in the uk the quantitative analyses used a nationally representative dataset that is representative of and generalisable to the uk adolescent population selfreport dietary assessment methods have been shown to be prone to underreporting and thus reporting bias may have been possible particularly among adolescents from more advantaged backgrounds the qualitative data included views from a range of population groupsadolescents parents and teachersdifferent genders and individuals living in more disadvantaged areas the interviews were conducted in pairs or groups which may have affected the responses received due to the dynamics between participants for example very close friends being interviewed as a pair may have given more detailed responses than a larger group interview with members from different friendship groups or different genders offering only large or smaller groups may have limited the scope of information received from participants a methodological consideration is that the qualitative data were collected from a single southern county in the uk and that most participants were white unlike the quantitative data the qualitative sample is therefore not representative of adolescents across england however recruitment strategies targeting lower income youth clubs and schools aimed to improve representation across the socioeconomic spectrum interviews with more diverse groups of adolescents from a different area may have produced different information conclusions this study supports the introduction of legal restrictions on the sale of energy drinks to minors but indicates that prohibiting energy drink sales to those under the age of 16 years would miss the opportunity to reduce consumption among the highest consumers those aged 1618 years from disadvantaged backgrounds such restrictions would level the playing field between retailers and may be maximumly effective if coupled with minimumpricing strategies placement restrictions and a communications campaign detailing their harmful effects

objective to examine energy drink consumption among adolescents in the uk and associations with deprivation and dietary inequalities design quantitative dietary and demographic data from the national diet and nutrition survey ndns repeated crosssectional survey were analysed using logistic regression models qualitative data from semistructured interviews were analysed using inductive thematic analysis setting uk participants quantitative data nationally representative sample of 2587 adolescents aged 1118 years qualitative data 20 parents 9 teachers and 28 adolescents from hampshire uk results ndns data showed adolescents consumption of energy drinks was associated with poorer dietary quality or 0•46 per sd 95 ci 0•37 0•58 p 0•001 adolescents from more deprived areas and lower income households were more likely to consume energy drinks than those in more affluent areas and households or 1•40 95 ci 1•16 1•69 p 0•001 or 0•98 per £1000 95 ci 0•96 0•99 p 0•001 respectively between 2008 and 2016 energy drink consumption among adolescents living in the most deprived areas increased but decreased among those living in the most affluent neighbourhoods p 0•04 qualitative data identified three themes first many adolescents drink energy drinks because of their friends and because the unbranded drinks are cheap second energy drink consumption clusters with other unhealthy eating behaviours and adolescents do not know why energy drinks are unhealthy third adolescents believe voluntary bans in retail outlets and schools do not work conclusions this study supports the introduction of agedependent legal restrictions on the sale of energy drinks which may help curb existing socioeconomic disparities in adolescents energy drink intake

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introduction over the past decade with some exceptions accumulating research has found that the neighborhood food environment specifically the types of food outlets available and food products offered is associated with dietary intake and obesity risk research has shown that lowincome and africanamerican neighborhoods have fewer supermarkets and more liquor stores and convenience stores than higher income and white neighborhoods respectively fewer healthy food options and lower quality foods even after accounting for store type in lowincome and africanamerican neighborhoods have also been documented thus residents of africanamerican and lowincome neighborhoods tend to face more environmental barriers to healthy eating than residents of other neighborhoods while much of this research has been quantitative qualitative studies on food shopping and influences on dietary behaviors have recently emerged the include perceptions of neighborhood food environments similar to quantitative studies many of these studies have found that lack of physical access to supermarkets and highquality reasonably priced healthy foods are perceived barriers to healthy eating however few of these studies have explored environmental factors in depth or included substantial numbers of africanamericans especially urban africanamericans furthermore little is known about food acquisition behaviors among individuals living in neighborhoods with restricted food environments understanding perceived environmental influences on food acquisition in neighborhoods with few food resources is critical to inform environmental and policy interventions to expand access to healthy food and promote healthy eating the purpose of this qualitative study was to describe perceptions of the food environment among lowincome africanamerican women residing in an urban community with limited food resources and strategies they use to acquire food given the disproportionate burden of obesity and dietrelated diseases among africanamerican women and that the prevalence of obesity is highest among women in large midwestern urban centers it is important to gain greater insights into the perspectives and experiences of urban africanamerican women in the midwest methods setting the study took place in greater englewood a lowincome africanamerican community in chicago illinois greater englewood is comprised of englewood and west englewood two of the 77 officially designated community areas in the city of chicago in 2000 englewood and west englewood were almost exclusively africanamerican and 3244 of individuals had family incomes below the federal poverty line both communities experience a high burden of chronic dietrelated diseases prolonged economic disinvestment from greater englewood is evident in aspects of the physical and social environment including the food environment based on a 2006 inperson audit of 398 food stores in southwest chicago including 66 stores in greater englewood greater englewood had no fullservice chain supermarket and only seven small grocery stores for over 85000 residents stores were much less likely to carry healthy food options as compared with less healthy food options though no consistent pattern was found for food prices likewise suggesting dissatisfaction with neighborhood food options a 2005 market analysis report indicated that an estimated 1074 million is annually spent outside the community on groceries by greater englewood residents approach and sample this study drew upon semistructured indepth interviews with 30 africanamerican women conducted in 20062007 inclusion criteria were women who identified as africanamerican between the ages of 21 and 45 had a child less than age 18 years and resided in englewood or west englewood women were recruited from the englewood neighborhood health center one of five comprehensive health clinics operated by the city of chicago through flyers and onsite by africanamerican research staff five women enrolled through snowball sampling table 1 shows demographic and other characteristics of the study sample the research was conducted by a partnership of health center staff with knowledge of the population and academic researchers with substantive and methodological expertise the team collaborated at each stage of the research design data collection data analysis and interpretation of findings interviews the semistructured interview guide was based on the food environment literature and our prior work interview topics included perceptions of the neighborhood food environment process used to obtain food environmental barriers and facilitators to food acquisition and retail food outlet preferences and concerns the interview guide encouraged interviewer flexibility and enabled participants to raise issues describe experiences and share stories that were relevant to them this included the use of standard probes to elicit more detail such as tell me about what happened what happened next and can you tell me more about that table 2 provides examples of major interview questions and contentrelated probes to better understand where they acquired food in one section of the interview guide women were asked to identify the name and location of each retail store where they normally shop for food each person was individually interviewed once by an interviewer matched on raceethnicity and conducted at a location of her choice including her own home the health center or another community site consistent with semistructured interviewing he length of the interviewsincluding any interruptionsranged but the average interview lasted about an hour the number and length of stories told by participants contributed to variation in interview length following the interview participants were asked to complete a brief demographic questionnaire each woman received a 25 gift certificate to a local discount grocery store to compensate them for their time all interviews were audiotaped and transcribed verbatim the transcripts checked against the audiotapes for accuracy institutional review boards at the university of illinois at chicago and chicago department of public health approved the research data analysis qualitative data analysis was guided by conventional qualitative content analysis an inductive approach qualitative content analysis uses a systematic process of open coding category creation and abstraction to condense and interpret raw data specifically in qualitative content analysis codes are generated from the data that is data relevant to the research question are extracted and coded data are further reduced by combining similar codes into overarching themes utilizing this approach academic members of the research team began data analysis by conducting a review of five transcripts to gain a better understanding of data content and develop a preliminary guide for coding using an iterative process of coding review and discussion the transcripts were coded line by line including breaking down transcripts into quotations and labeling these quotations according to their meaning the preliminary list of codes was expanded as new codes emerged this process generated descriptive codes that were entered into atlasti a computer software qualitative data management program and used to code remaining data all transcripts were coded independently by two research team members who met at least once every five transcripts to compare coding resolve discrepancies by consensus and review code definitions summaries of themes were also presented to health center staff to contextualize and refine themes and to identify potential implications for practice and local community action in addition to identifying thematic codes in the data we also identified each store identified by study participants including its precise street address by using telephone directories and online searches we then geocoded the stores along with the participants homes using arcgis 91 and calculated the street network distances between each participants home and the stores where she shopped using arcgis network analyst based on these data we generated descriptive statistics such as mean number of stores and mean distance to the stores where shopped using spss 140 findings environmental barriers data analysis revealed numerous environmental barriers to acquiring desired food in an acceptable setting we classified emergent themes into three categories material economic and socialinteractional women discussed barriers that existed when shopping both inside and outside the neighborhood detailed findings for each are discussed below materialwomen described several material barriers to food acquisition these material barriers were related to store availability and upkeep and food product availability and quality first with regard to store availability several women indicated that lack of a fullservice supermarket in the neighborhood was an obstacle in obtaining food they wanted a supermarket that was convenient and within walking distance this was particularly true for women without an automobile when asked about the availability of grocery stores in the community one woman replied over here just one and thats discount grocery for me it is fine because it is closer but it is not like for other people that have to walk…in the community there could be about two or three more grocery stores where they wouldnt have to walk so far poor upkeep was another material barrier to acquiring food women associated poor upkeep with poor quality food poor upkeep was particularly raised in reference to stores in the neighborhood and included lack of cleanliness disorganized shelves and aisles and poorly maintained shopping carts with respect to cleanliness women reported that foul odors dirty unmopped floors and cockroaches and rodents turned them off besides these obvious signs women also judged cleanliness based on whether they saw employees cleaning or attending to customer spills promptly a couple of women explained that they determined store cleanliness based on bathroom sanitation if its dirty i wont shop there thats usually the first thing because im pregnant and so ive always got to go to the bathroom so thats the first thing that i do is go to the bathroom and then i go grocery shopping if its dirty in there then im like i aint going not today next related to food products women expressed concerns about lack of availability and variety of some foods at neighborhood retailers this included but was not limited to healthy foods fresh produce was commonly among the foods identified as missing from the neighborhood but finding baby food and food products that were low fat low sodium organic and soy was also challenging many felt that food options were particularly limited when compared with other types of neighborhoods even among stores of the same type and expressed that they should have access to the same choices when desired foods were stocked women reported that stores often ran out or it was difficult to locate healthier options due to their placement and marketing within stores in contrast one woman reported that at stores in other areas of the city you see the vegetables when you first go in you see the fruit when you first go in youre not looking at the flaming hots and all that stuff which i cant stand…i see myself just going into different grocery stores especially in the african american community that the media is the key its the cake its the chips its the soda… then you have to hunt for the fruits the vegetables the bottled water and things like that of the foods available in the neighborhood poor quality was another material impediment to obtaining food especially for fresh foods but sometimes packaged foods as well women described withered fresh fruits and vegetables rotting green fresh meats and expired canned and packaged foods one woman reported healthy foods are not really available in neighborhood like i would like them different vegetables they usually dont have it or they might have it for a day i would definitely say it influences you…and the things that are healthy are sometimes old and outdated economicanother category of environmental barriers to obtaining food was economic specifically high food prices at both small local stores and supermarkets with respect to neighborhood corner and convenience stores women proposed multiple explanations for what they perceived as inflated prices some recognized that high prices may be due to the inability of these stores to purchase foods in large enough quantities yet others felt that local stores were taking advantage of local residents without transportation who depended on the stores explaining that these stores were owned by arabs or caucasians several women thought that these owners were overcharging and getting rich off the africanamerican clientele a couple reported that stores jacked up prices because they knew customers receiving food assistance relied on their stores when asked whether she could get the foods she wanted in the neighborhood one participant explained no you basically get the basic type of food and the only place you can get it cheap is discount grocer and everywhere else they jack it up a little bit because they know that a lot of customers are link customers they cant charge taxes so they jackup the regular price of the food so that they can make their money that way while they generally were satisfied with food variety and quality many women thought the prices at fullservice supermarkets outside the neighborhood were too high to the point of being ridiculous socialinteractionalwomen identified multiple socialinteractional features of stores that hampered their ability to obtain desirable food in an acceptable environment including safety concerns poor customer service or treatment crowding and unsupportive sales practices first lack of safety was identified as a major socialinteractional deterrent to food acquisition at local stores many safety concerns stemmed from problems with people hanging out in front of stores panhandling soliciting drugs and harassing shoppers one woman explained i dont really like going certain places…cause i just dont feel safe but not only that say if i go to a grocery store and say a guy try to talk to you…in front of the store if you dont talk back to them they will spit on you the proximity of liquor stores and a strip club to some stores was seen as contributing to the problem second several women described poor customer service or treatment as another socialinteractional barrier to food acquisition that was encountered both inside and outside the neighborhood among commonly reported grievances were employees surly or snotty attitudes and lack of basic courtesy such as not asking if they may help you saying thank you and counting back change women also identified inappropriate employee behaviors such as smoking at checkout cursing flirting with customers and watching like youre going to steal something some women attributed these problems to owners or employees being of a different raceethnicity from outside the neighborhood or young crowding was a third socialinteractional impediment to food acquisition in addition to weekends and evenings when more people shopped women reported that stores were particularly crowded at the times of the month when food assistance benefits are distributed women described long lines and aisles so congested it was difficult to pass fourth sales practices that women perceived as unsupportive were another barrier to obtaining food women objected to some local stores selling cigarettes and alcohol to minors and not accepting food assistance benefits failure of retailers to provide food on credit or accept food assistance benefits were also viewed by some women as a barrier to obtaining food women also described use of deceptive sales practices specifically use of plastic wrap to hide spoilage of fresh meat and produce at local corner stores it meat was wrapped and rewrapped and rewrapped on top of that it was like the wrapping was taking away from you getting a chance to see the clarity of the actual meat because there was so much wrapping on it adaptive strategies data analysis revealed that women adopted several strategies to manage or change these environmental barriers we grouped emergent themes into four categories optimizing settling being proactive and advocating we discuss each category below optimizingwhen resources such as time and transportation allowed women optimized to get the foods they wanted seeking the highest quality products at the lowest prices in desirable stores women engaged in two optimizing strategies shopping at multiple retailers and traveling for it first on average women shopped at 43 different food retailers ranging from 2 to 9 stores in their use of multiple retailers women employed one of two general approaches in one approach women described frequenting a different store on each shopping trip with store selection dependent on which store had the lowest prices that week based on sales or other promotions in a second approach women routinely purchased some kinds of foods at one store and other kinds at a different store a typical pattern was purchasing lower priced canned and packaged goods at discount grocers and buying fresh meat and produce at supermarkets or specialty stores which were perceived as having better selection and quality while some women traveled from store to store in a single shopping trip others spread out visits to these distinct stores over a set period of time traveling for it was a second optimizing strategy with many women journeying to other neighborhoods and sometimes to the suburbs to obtain foods at the price or quality they wanted and in an acceptable environment on average stores frequented by the women in the sample were 23 miles from their home whereas half the women frequented at least one store within 05 mile of their home onethird traveled more than five miles to reach at least one store where they shopped some observed that the variety and quality of foods was better in predominately white neighborhoods even among stores of the same type you go all the way out to the suburbs where the white people live at and you find everything in the thrift stores out there its even a better variety in discount grocers and supermarkets when you go to their stores theres a difference so i will go out farther to travel and get better quality and stuff yes settlingwhen they lacked resources some women settled to get foods they needed when they did not have transportation or time to reach preferred stores some felt they had no choice but to shop at local convenience or corner stores this often meant paying higher prices or selecting other foods such as junk food when healthy foods were preferred one participant explained at that particular time it might be late and i dont feel like cooking so i might settle for what they local stores have at that particular point in time other than that if i dont have to settle i dont…i have to travel out of my way to get certain kinds of foods that are healthy for me and my son when forced to shop at stores of questionable quality another way women settled was to purchase packaged items women avoided purchasing fresh meat and produce and limited their shopping to canned goods bottled drinks and snacks according to one participant if it aint canned up or bottled up i dont want it another described the shelves are dirty the items that are on the shelves are dusty ive had a situation onetime when i bought some of that instant oatmeal and there were worms in the package that was some years ago…so i dont buy anything like that out of there the most i will buy out of there is a pop a juice or something i dont have to eat being proactiveto avoid or minimize problems participants engaged in several proactive strategies changing the timing of shopping modifying their demeanor while shopping and leaving or refusing to shop at stores as a first proactive tactic some women adjusted their shopping timing some would only shop at local stores during daylight due to safety concerns me i wouldnt go late at night the latest i would go would be seven oclock… there are weird people out and a lot of drunks and theyre babbling and people have to kick them out of the stores then ive got two kids and i would have to carry them with me because her son was tempted by unhealthy food items placed in the front of the store one woman limited shopping to times while her son was in school another shopped during the day when stores were staffed by older employees in order to get better customer service others timed their shopping to avoid busy times of the month when people received food assistance benefits second women modified their demeanor to avoid problems when anticipating safety concerns women got in and out of stores quickly going straight to what they were looking for and not stopping to look around some described staying alert and paying attention to their surroundings some women sought good customer service by being aware of how they carried themselves and purposefully respecting store employees leaving or refusing to shop at stores if they had a bad experience was a third proactive strategy this strategy was frequently in response to lack of cleanliness long lines rude service and poor quality foods some women felt strongly that they would not spend their hardearned money at nasty stores i walked in the store and it was just like nasty it was cockroaches running on the floor and as soon as i saw that i called my mama on the phone like look ma were not fixing to get nothing from up out of here because theyve got roaches and the floor is filthy dirty im gone advocatingwomen also engaged in advocacy seeking to bring about changes related to the store environment and food products women most commonly reported problems or concerns directly to store owners or employees but some contacted regulatory agencies such as the local health department with respect to the store environment women advocated for enhanced upkeep and safety with respect to food products women advocated to increase availability of food products they wanted and especially to improve food quality or safety one participant found the mere threat of contacting regulatory agencies brought about desired change related to food quality i ran into a problem where there was a fly in my ground beef…and then i had bought some turkey tails before and it had mold on it so that was two different complaints he had from me and i said im going to call the health department but because of me he had bought all new coolers and i was happy he remodeled that store when he really was scared he thought i was going to health department for real which i actually did but i never got through to them their advocacy efforts were not always successful in bringing about desired changes in the store environment or food products according to one participant in response to her complaints about safety a store owner explained that he had tried to address safety issues around stores but could not get the cooperation of the local police department discussion our findings yield new insights into food acquisition practices among lowincome africanamerican women residing in a community with few food resources as found in prior quantitative and qualitative studies on the food environment these lowincome women desired a wide selection of reasonably priced foods though not just healthy foods in a pleasing environment yet they perceived multiple environmental barriers to obtaining food extending beyond the types of stores and food options nearby to the physical and social environments of stores in the face of these challenges women adopted multiple strategies to acquire food sometimes adjusting their tactics depending on resources available at the time environmental barriers economic and material threats related to store availability and food product characteristics have been the most commonly reported environmental barriers in previous qualitative studies with africanamericans as well as other populations these factors are the focus of most quantitative studies and the most common targets of environmental intervention efforts to date our findings are consistent with prior qualitative studies in which participants identified lack of a supermarket limited variety of foods poor food quality and high food prices particularly at small neighborhood stores as environmental barriers to food acquisition and healthy eating one striking similarity to a study with africanamericans in new york city was reports of deceptive food packaging to hide poor food quality yet much less commonly identified in previous studies we found that the challenges women identified in the neighborhood food environment extended to the store physical and social environments like cummins and colleagues in scotland we found that poor upkeep was a material concern related to the physical environment of stores women also identified multiple negative socialinteractional features of stores that hindered food acquisition of the socialinteractional features we identified crowding and poor customer service have been identified as concerns in prior studies on the food environment however less attention has focused on safety and unfair treatment in research on the food environment interestingly in an australian study participants mentioned trafficrelated safety concerns when walking to stores whereas crimerelated safety concerns were described by participants in our study crimerelated safety was a particular problem for our participants because children often accompanied them to the store while a study on shopping experiences of africanamericans in new york city and philadelphia found that participants were more likely to report poor treatment at stores in white neighborhoods than in africanamerican neighborhoods women in our sample identified unfair treatment as a problem at stores owned by individuals of a different raceethnicity both inside and outside their neighborhood both poor upkeep and socialinteractional concerns were frequently discussed in connection with the raceethnicity of the store owner or employees highlighting previously documented tensions between white and immigrant owners and employees and local africanamerican clientele the implications of widespread ownership of food stores by nonafricanamericans for food acquisition practices and health outcomes of africanamericans could be explored in more depth in future studies overall our findings underscore the relevance of not only economic and material obstacles that are frequently reported in previous qualitative and quantitative studies but also physical and social environmental impediments to food acquisition in lowincome african american neighborhoods future observational and intervention research on the neighborhood food environment should consider these elements as well adaptive strategies confronted with a restricted food environment women in our sample adopted several tactics to cope with unsupportive food environments our findings highlight the fluidity of their approach depending on the resources available to them at the time when they had sufficient resources women optimized to obtain foods they wanted by shopping at multiple retailers and traveling outside the neighborhood in two previous us studiesone with an africanamerican sample in new york city and another with a majority latino sample in austin texasparticipants mentioned similar strategies nonetheless when resources were lacking women in our sample settled for what they needed at local stores in a qualitative study with a predominately latina sample women also described frequenting local stores only in emergencies and for everyday items taken together these findings challenge the assumption apparent in most quantitative studies on that lowincome racialethnic minority persons are confined to food sources in their residential neighborhood nonetheless as illustrated in prior studies especially among those without reliable transportation additional and prolonged efforts to reach food sources outside the neighborhood comes with costs including time money limited flexibility in scheduling compromised food choices feelings of uncertainty and lack of control and missed opportunities thus ensuring that lowincome africanamerican neighborhoods have supportive food environments could alleviate these burdens women in the sample adopted proactive strategies to cope with environmental threats in addition to changing the timing of their shopping to avoid particularly crowded times as also found by clifton women also adjusted when they shopped to feel safe enhance the likelihood of receiving good customer service and minimize childrens exposure to marketing of unhealthy food products and unsafe situations intense and targeted marketing of foods high in fat and sugar to children may negatively impact childrens dietary quality and body weight and may be especially pronounced in africanamerican and lowincome neighborhoods other proactive strategies included being attentive to how they carried themselves and going out of their way to respect store employees to obtain good service these strategies reflect those identified in a study of food shopping by lee in a sample of urban africanamericans lee found that participants consciously wore their class including dressing up carrying expensive accessories and using certain mannerisms and speech to show that they belonged at stores and to avoid negative treatment similar to lee we also found that some women avoided stores where they had bad experiences finally women advocated for improvements in the food environment in a prior study an africanamerican female participant described lobbying her local food store for organic products without success in this study women identified multiple targets of advocacy efforts not only changes in product mix but also food quality and store sanitation and safety as found by munozplaza women felt compelled to take these actions incensed by what they perceived as a socially unjust food environment implications for health our findings suggest multiple pathways by which environmental barriers and adaptive strategies may affect the health of africanamerican women and their children living in lowincome neighborhoods first drawing on empirical evidence in prior studies lack of availability high prices and poor quality of healthy foods in the neighborhood may negatively impact dietary quality and increase obesity risk among women and their children obesity is a public health crisis with particularly high rates among africanamerican women and children children who are obese are more likely to become obese adults poor diet and obesity are major risk factors for developing type 2 diabetes cardiovascular disease and some cancers second our findings highlight several sources of chronic psychosocial stress in the food environment such as unfair treatment deteriorated conditions and lack of safety at stores chronic stress may contribute to obesity especially viscerally through alternations in the hypothalamicpituitaryadrenal axis functioning and triggering highfat highsugar food intake chronic stress also contributes to mental distress and depressive symptoms third confronted with multiple environmental barriers many women engaged in prolonged and higheffort coping to obtain food which may lead to hypertension and generally more wear and tear on the body systems this may be particularly true for those with few socioeconomic resources fourth safety concerns around stores may make it especially difficult for older children who may be going to the store alone to obtain food finally because it can lead to business closures and further divestment the extent to which barriers in the local food environment force women to shop outside the neighborhood further weakens economic conditions in the neighborhood with negative repercussions for the social and physical environment implications for intervention our findings have several implications for interventions to support food acquisition among residents in underresourced neighborhoods first the findings suggest the need to eliminate environmental barriers through environmental change such as attracting supermarkets enhancing existing local stores and supporting local food production attracting supermarkets and increasing healthy foods at existing stores in lowincome communities is a strategy that is gaining traction in the us through programs such as fresh food financing initiative however as illustrated by our findings these strategies may not be successful in improving nutrition among residents of lowincome neighborhoods if not accompanied by efforts to make foods more affordable further promoting local ownership and employment at stores may be important to enhance local residents treatment and comfort efforts aimed at transforming existing local stores should not only address food supply characteristics but also the broader store social and physical environment including upkeep safety and customer service that few women primarily selected stores based on the availability of healthy food products substantiates the importance of addressing these other aspects of the food environment investment in local food production including urban agriculture and community gardens may also improve the food environment in underresourced communities second intervention efforts could facilitate adaptive strategies among local residents through economic development in lowincome communities to increase income economic subsidies for healthy food options to make them more affordable and enhanced transportation options to help residents reach food sources outside the communities implications for future research the consistency of our findings on environmental barriers and adaptive strategies with constructs of stress and coping suggests that studying the food acquisition through a stress process lens may assist in advancing understanding of food acquisition practices in neighborhoods with restricted food resources identifying health consequences and pinpointing multiple points for intervention as suggested earlier psychosocial stress and higheffort coping are understudied pathways by which the food environment may affect the health of residents in lowincome neighborhoods we recommend developing and testing stress process models for food acquisition limitations this study has limitations first our sample was restricted to 30 participants enhancing the credibility of our findings we did achieve saturation of our codes reaching a point in the analysis in which no new codes or new information regarding our codes emerged nonetheless it is possible that a larger sample may have yielded new concepts had we financial resources to increase our sample size beyond 30 participants second we focused only on food procurement at stores though also important components of the food environment and food acquisition we did not consider restaurants or purchase of prepared foods respectively third while embedded in some of our findings our study may not adequately reflect the complex interplay between person factors and environmental factors in shaping food acquisition due to our interview guides environmental emphasis despite these limitations this study provides important new insights into perceptions of the food environment and strategies used to obtain food among africanamerican women in a lowincome community with restricted food resources engagement of health center partners who work with the population of interest during all phases of the research augments the credibility of our findings conclusion although there is strong interest in identifying social inequities in neighborhood food environments and their implications for health disparities few studies have focused on understanding the perspectives of persons who live in neighborhoods with few food resources our data from 30 urban lowincome africanamerican women show that women faced with restricted neighborhood food environments identified multiple environmental barriersmaterial economic and socialinteractionalto obtaining food yet they were resourceful and had developed a multitude of adaptive strategies to cope with these challenges while environmental change as part of a multilevel approach is needed to enhance the likelihood that these efforts are successful it is important that we first gain a deeper appreciation of food acquisition practices and factors that influence it in supporting womens food acquisition our findings suggest that addressing stores physical and social environments may be a necessary accompaniment to improvements in the food supply

this qualitative study sought to understand food acquisition behaviors and environmental factors that influence those behaviors among women in a lowincome african american community with limited food resources we drew upon indepth interviews with 30 women ages 21 to 45 recruited from a community health center in chicago illinois data were analyzed using qualitative content analysis emergent themes revealed that women identified multiple environmental barriersmaterial economic and socialinteractionalto acquiring food in an acceptable setting in response they engaged in several adaptive strategies to manage or alter these challenges including optimizing settling being proactive and advocating these findings indicate that efforts to improve neighborhood food environments should address not only food availability and prices but also the physical and social environments of stores as well

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introduction by july 2022 the covid19 pandemic had infected over 88 million people in the united states and caused over a million deaths 1 the lancets covid19 commission on mental health task force concluded that there was clear evidence that psychological distress increased during the early months of covid19 and that the pandemic was harming mental health 2 vahratian and colleagues at the national center for health statistics at the cdc using crosssectional surveys from almost 80000 respondents documented a 14 increase in the number of us adults experiencing symptoms of anxiety or depression in the seven days prior to its surveys 3 however the existing research has not convincingly identified the distinct pathways through which covidinduced stressors trigger mental distress nor disentangled the causal relationships among them most research has treated the pandemic as an undifferentiated whole showing for example that indicators of mental distress were higher in locations 4 or at times with higher infection rates 5 6 7 or among specific groups of people such as healthcare professionals 8 while this type of research demonstrates that the pandemic was associated with increases in mental distress it rarely differentiates distinct stressors associated with the pandemic and how they influence mental distress a small number of studies have attempted to differentiate the influence of distinct stressors associated with the pandemic such as risks of disease and death unemployment and loss of income and social isolation resulting from stayathome policies and individual choices and even fewer have attempted to examine the impact of these stressors simultaneously we are aware only of recent research by ka ¨mpfen et al 9 who used a large national probability survey of us adults conducted for three weeks in march 2020 to examine the extent to which disease and financial or social stressors predicted changes in symptoms of anxiety and depression the stressors respectively were respondents perceived risk of getting infected and dying from covid19 their concerns that they would run out of money and selfreported reductions in their social activities they found that all three of these stressors predicted worse anxiety and depression outcomes as measured by higher phq4 scores 10 after controlling for relevant demographic variables including sex age educational race and marital status alimoradi et al 11 found that sleep problems appear to have been common during the covid19 pandemic and were associated with higher levels of psychological distress among the general population healthcare professionals and covid19 patients although an excellent start this research has important limitations that undercut the conclusion that these stressors cause increases in anxiety and depression perhaps the most important are the related problems of endogeneity common method bias and reverse causation both the stressors and the mental health outcome were measured via respondents selfreports therefore it is plausible that people who had higher levels of generalized anxiety and depression also perceived greater risk and had greater anxiety from the specific stressors the survey targeted that is respondents generalized mental distress may have led them to perceive delphigithubiodelphiepidataapicovidcasthtml these data come from multiple sources with data licensing handled separately for each source the deidentified survey data are available to researchers associated with universities or nonprofit organizations researchers who want access to the survey data should submit an information request on facebooks covid19 symptom survey request for data access page higher risks independent of their objective risk similarly those with higher levels of generalized anxiety and depression may have been more likely to practice social distancing the main substantive goal of our research is to examine the causal impact of distinct pandemicrelated stressors on mental health we examine the disease financial and social stressors identified by ka ¨mpfen et al 9 our methodological goal is to reduce threats to causal interpretation by combining evidence of objective pandemicrelated stressors with selfreported survey data and using mediation analysis to examine the extent to which the objective stressors influence mental health by influencing individual respondents behavior and fears in contrast to most previous research we examine the relationship between changes in pandemicrelated stressors and mental health not just at the beginning of the pandemic but over a long 8month period and collect populationweighted data from over 115 million us adult respondents a simplified path model is presented in fig 1 summarizing our hypotheses about how objective communitylevel stressors predicted mental distress mediated by individual respondents social isolation and worries about disease and finances we hypothesize that the pandemic could plausibly harm mental health through three distinct routes first the pandemic could increase mental distress by increasing fears of getting the disease 12 second pandemicinduced social distancing a result of both public health recommendations and individual decisions to limit exposure could influence mental distress in a more complicated way on the one hand the hypothesis that social distancing would increase mental distress is based on decades of research demonstrating that social contact is associated with better physical and mental health and that loneliness and social isolation are associated with increased depression and mortality 13 14 15 on the other hand social distancing could also reduce peoples exposure to disease which in turn could reduce their fears about getting ill and their overall mental distress in addition social distancing could also reduce employment opportunities for some people such as restaurant workers but increase employment for other occupations such as warehouse workers or delivery drivers or lower commuting and other workrelated expenses for others such as white collar workers thus to better understand the impact of social distancing policies and norms we hypothesize that countylevel social distancing can also influence mental distress by influencing personal social contact illness worries and financial worries third the pandemic could lead to financial hardships and fears about them caused by economic slowdowns which in turn could cause mental distress 16 the solid lines labeled a represent the degree to which countylevel distancing and stressors influence respondents social contact and their individual worries and the solid lines labeled b represent the association between respondents social contact and their individual worries and their mental distress the dotted lines labeled c represent the direct pathway between the countylevel stressors and respondents mental distress the product of a and b represents indirect effects of the countylevel stressors on distress which are mediated by their effects on respondents social contact and their individual worries about the illness and household finances methods study design and data collection we used timeseries data from the covid19 trends and impact survey 17 a collaborative project between facebook and academics to support covid19 research each day facebook invited a random sample of users in the united states at least 18 years old to take a survey designed and collected by carnegie mellon universitys delphi group by placing a notification at the top of their news feed the survey was anonymous and did not collect any personally identifiable information the current paper relies on 11974779 survey responses from 239 crosssectional samples gathered daily from april 6 to november 30 2020 although some respondents may have taken the survey more than once because of the anonymous nature of the data collection we cannot identify surveys completed by the same person and we therefore treat them as independent each survey response was weighted to adjust for nonresponse and coverage biases so that the distribution of age gender and county of residence in the survey samples were representative of the general population of the united states the demographic characteristics of the weighted sample closely matches data from the 2019 american community survey except for an overrepresentation of highly educated respondents the survey asked respondents questions about covid19 symptoms they and other household members had it also asked questions about the depression anxiety inperson social contact and covidrelated stressors respondents were experiencing the focus of this paper respondents also described their demographic characteristics including their household composition their gender and their approximate age the survey data included respondents federal information processing system county code which allowed responses to be joined with countylevel data from multiple sources describing daily and cumulative infection rates of covid19 in the county 17 unemployment rates 18 and the time county residents spent outside of the household as estimated from mobile devices 19 we also estimated from the survey data daily countylevel worries about illness and finances and countylevel social contact by first removing the respondents data and then calculating the 2week moving average surrounding the respondents survey date these countylevel variables are treated as potential causes that could influence mental distress directly or indirectly by influencing the respondentlevel predictors of interest including social contact and worries about disease and finances measures table 1 below describes the measures of all variables used in the analyses analysis logic we used structural equation modeling done with the stata sem package 20 to implement the mediation analysis represented in fig 1s path diagram the maximum likelihood estimation was used in the analysis the mediation analysis examines the potential causal pathways through which daytoday variation in objective countylevel disease threat financial threat and social distancing could influence respondents mental distress either directly or mediated by respondents individual social contact and worries about disease and finances to control for static characteristics of respondents locations we first centered each variable by the countyidentification fips code which removes all fixed effects associated with that geographic area such as its size economic prosperity demographics and other unmeasured static differences what remains is the daytoday variability in respondents mental distress disease and financial worries and countylevel stressors the use of both respondentlevel variables collected via the survey and countylevel ones from multiple sources reduces many threats to assessing causation from observational data because the variation in countylevel stressors and social distancing are outside of any single respondents control we can treat them as exogenous variables that can directly influence respondentlevel variables but not be caused by them eliminating possibilities of reverse causation for example changes in countylevel disease threat and financial threat are exogenous variables that could influence respondents mental distress directly or indirectly through their worries about getting ill or their concerns about household finances similarly changes in the time residents of a county spent outside their home reflecting both government regulations and evolving local norms are exogenous variables that could influence a respondents mental distress both directly or indirectly through its effect on their social distancing behavior and their worries about disease and finances the multiple levels of analysis reduce the likelihood that unobservable variables like respondents socioeconomic status workstatus or disability jointly influence their social contact and their mental distress the multiple levels of analysis also reduce commonmethod bias in which associations are inflated because potential causes and consequence are measured using similar measures from a single source 21 results tables 2 and3 below show descriptive statistics and correlations among the variables fig 2 shows how selfreported mental distress countylevel predictors and mediators varied over time in addition to these timevarying variables analyses reported below included several static covariates respondents selfreported gender approximate age and whether the respondent lived alone or with others in the household table 4 and fig 3 summarize the mediation analysis showing how countylevel social distancing and disease and financial threats predict respondents mental distress both directly and indirectly through their influence on respondents social contacts with people outside their household and the worries they report having about getting ill and household finances finances the three coefficients on the dotted lines respectively represent the total effect the direct effect and the indirect effect of countylevel variables on mental distress note all coefficients in fig 3 are highly significantly different from zero with all pvalues 0001 effects of covariates women younger respondents and respondents living alone reported greater mental distress compared to men older respondents and those living with others respectively the associations of mental distress with these demographic characteristics are all consistent with prior research for example salk et als metaanalysis revealed that women are substantially more likely to be diagnosed with depression and show depressive symptoms across multiple cultures 24 abundant research also demonstrates the links between social integration and both physical and mental health 25 for example people who live alone are almost twice as likely to report symptoms of depression compared to those who live with others in their household 26 although not the focus of the current project survey findings showing less mental distress among respondents in households with other adults or children are consistent with one of our core hypotheses social contact is a preventative for mental distress however because household composition is something that people choose and people who are predisposed to mental distress may be more likely to choose to live alone the association of household composition and mental distress is not itself strong evidence of a causal relationship between social contact and mental health in contrast an association of social distancing at the county level with mental distress is stronger causal evidence of the role of social contact because it is unlikely that respondents with greater than average mental distress choose to live in a county during a period in which social distancing is greater than average effects of disease threat social distancing and financial threat on respondents mental health disease threat the mediation analysis in table 4 shows that overall greater threat of disease in an area is associated with more mental distress because the countylevel disease threat is associated with individual respondents worries that they or a family member would get ill from the disease and these worries about the disease are associated with their mental distress nearly 65 of the total effect of countylevel disease threat is mediated by individual worries about disease 013 this mediation result suggests that objective risks of illness have their effects on mental distress to a large extent by elevating individual worries about becoming ill social distancing overall social distancing at the county level is associated with increased mental distress because countylevel social distancing is associated with individual respondents having less social contact outside the home more disease worries and more financial worries and because these individual level behaviors and worries are associated with mental distress the mediation analysis suggests that social distancing in a county affects respondents mental distress to a large extent by reducing their contact with others outside their homes as well as increasing their worries about disease and finances approximately 63 of the total effect of countylevel social mobility on mental distress is indirect and mediated by respondents selfreported reductions in social contact outside of their households and disease and financial worries 011 628 the total effect of countylevel social distancing on mental distress is small but practically important because it is a policy lever at the disposal of government authorities and because of the many millions of people whose mental health might be affected by social distancing policies and norms the small effect size may be the result of other factors that influence respondents social mobility besides objective social distancing policies and norms such as whether they are employed outside the home their gender or their household composition which can also influence their mental distress in addition lockdown orders and other reductions in opportunities for social contact outside the household may cause people to spend more time interacting with others in their household and thus compensate for the impact of social distancing on mental health that is for people who live with others the greater social contact they have within the home may compensate for reductions in social contacts outside it to examine this possibility we tested whether the mental health benefits of greater countylevel social mobility were greater for respondents living alone than for those living with another in their household we added an interaction term between social distancing and live with someone to the sem model s2 table shows the results as a reminder 76 of respondents lived with at least another adult or a child and 24 lived alone the lack of a statistical interaction between countylevel social distancing and living with others suggests that social distancing was not more harmful in terms of increasing mental distress among people who live alone the marginal analysis shows that a standard deviation increase in countylevel social distancing was associated with a 0044 standard deviation increase in mental distress both among those who lived alone and those living with another person financial threat overall financial threat at the county level was associated with more mental distress this result is consistent with witteveen and velthorsts findings in six european countries showing a positive relationship between instantaneous economic hardships during the covid19 lockdown and expressing feelings of depression and health anxiety 16 a systematic review of research on covid19related fear and anxiety and jobrelated outcomes also shows that fear of covid19 was associated with increased future career anxiety decreased job satisfaction and perceived job insecurity 27 because countylevel financial threats were associated with respondents worrying more about household finances and respondentlevel financial worries are in turn associated with greater mental distress the mediation analysis suggests that countylevel financial threat affects respondents mental distress partially by increasing their personal worry about household finances surprisingly though the direct effect of countylevel financial threats was to reduce mental distress to rule out the possibilities of multicollinearity due to a correlation between social distancing and countylevel financial threats we conducted an additional analysis excluding social mobility the result shows a robust negative effect of countylevel financial threats on mental distress if countylevel financial threats raised personal financial concerns which in turn increased mental distress why was the direct effect of countylevel financial threats to reduce mental distress it may be that even though unemployment and concerns about finances in the county exacerbated mental distress by raising personal worries about finances the 2020 coronavirus aid relief and economic security act and other government stimulus programs reduced the actual financial pain associated with the pandemic but these effects of government stimulus programs were not reflected in the countylevel employment data we had available moreover considering the overrepresentation of adults with higher education in the survey samples those highly educated individuals might have been in white collar occupations less subject to the economic hardships caused by the pandemic discussion this research provides evidence consistent with the thesis that the covid19 pandemic harmed the mental wellbeing of adults in the united states and identifies specific stressors associated with the pandemic that seem responsible for increasing mental distress the current study distinguished objective stressors from respondents perceptions of stress thereby reducing common method biases that have inflated the associations between stressors and mental distress in earlier research note that mental distress correlates ten times more highly with these measures of disease and finances worries and social contact all of which were measured by selfreport at the respondent level than with parallel measures of disease and financial threat and social distancing measured at the county level this substantial difference in strength of association is consistent with the speculation that ka ¨mpfen et als results 9 were inflated by common method variance the analyses show that objective disease stressors outside of respondents control as measured by countylevel covid19 infection rates and the likelihood of other county residents knowing someone with covid symptoms and being worried about getting ill increased individuals mental distress in part by increasing their own worries that they or other family members would get ill overall objective financial stressors as measured by countylevel unemployment rates and countylevel perceptions that the pandemic was harming household finances were associated with greater mental distress and these effects were mediated by the extent to which these financial stressors caused respondents to become worried about harm to their own households finances however the direct effect of the financial stressors seemed to be to lower mental distress future research is needed to examine the mechanism for this direct effect for example did federal government stimulus programs reduce the actual financial pain and associated mental distress during times of high unemployment and what role did sociodemographic variables play the reduction in social contact caused by the pandemic is especially interesting reductions in social contact outside of the household which were partially caused by official lockdown orders and informal norms in a county were associated with greater mental distress authorities issued shutdowns and stayathome orders and people voluntarily reduced outside social contact to reduce their risk of becoming infected with the disease and to the extent that these actions reduced peoples worries about getting covid they also reduced mental distress however to the extent that these efforts also reduced peoples social contact outside the home they had the undesirable side effect of increasing mental distress surprisingly the harmful effects of social distancing policies and behavioral norms in increasing mental distress applied equally to those who lived alone and those who lived with others this latter result is consistent with previous research showing benefits from social interaction with coworkers acquaintances and other weak ties even among people who have greater than average strongtie interactions 28 and benefits from social interactions in social spaces outside the home 29 we believe one can balance the benefits of reduced social contact to slow the spread of disease with the mental health harms to social isolation for example having social interactions online through text chats emails phone calls and video sessions may successfully substitute for inperson social interactions very little research has examined the impact that modality of communication has on mental wellbeing 30 this study has several methodological limitations that should be considered when interpreting the findings respondents mental distress was measured by two questions assessing depression and anxiety followup research should use more robust and clinically validated measures of psychological distress while the survey data were representative of us adults in terms of age gender and region there was a sampling bias associated with education the survey respondents were more educated than average us citizens additionally followup research should examine how communitylevel predictors like poverty and social inequality and individuallevel ones like occupational status moderate the stresses associated with the pandemic despite these limitations this research allows us to make stronger causal claims than possible with more conventional respondentlevel survey research about the impact of covidrelated stressors on mental health because it examines pathways through which pandemicrelated reductions in social mobility and increases in disease and financial stressors measured at the county level and therefore out of respondents control influence respondentlevel social contacts and worries which in turn lead to increases in mental distress although the focus of this research was to understand how pandemicrelated stressors were influencing mental health during the covid19 pandemic it also extends our theoretical understanding of how social support works decades of research have provided strong and consistent evidence that social ties and social support improve many aspects of personal health including allcause mortality 3132 physical health 3334 and mental health 35 but the mechanisms are still murky 25 it is unclear whether the component of support that is most valuable is the perception that support will be available when needed the explicit exchange of support during times of stress especially from strong ties or merely the accumulation of everyday social interactions 25 36 37 38 results of the current research are consistent with the thesis that mundane social interactions can lead to wellbeing weektoweek changes in the frequency of social contacts in the community seem to lead to changes in respondents mental distress suggesting that to some extent it is social interactions that people actually engage in outside the home that confer benefits rather than slowertochange perceived social support while our data show that people who are living with others have less mental distress they also show that social contact outside of the household and presumably with less intimate ties also confers benefits over and above social contact within the home data sharing most of the data reported in this paper are publicly available in the epidata api maintained by the delphi research group at carnegie mellon university and available through r and python clients these data come from multiple sources with data licensing handled separately for each source the deidentified survey data are available to researchers associated with universities or nonprofit organizations researchers who want access to the survey data should submit an information request on facebooks covid19 symptom surveyrequest for data access page 39 most of the data reported in this paper are publicly available at a github repository maintained by the delphi research group at carnegie mellon university and available through r and python apis conclusion this research provides evidence consistent with the thesis that the covid19 pandemic harmed the mental wellbeing of adults in the united states and identifies specific stressors associated with the pandemic that are responsible for increasing mental distress to collect the data kraut had no role in data collection and as part of the datause agreement was not allowed direct access to the data ethics statement the carnegie mellon university institutional review board reviewed the research plan and granted approval under exempt review on 7102020 characteristics of the study sample compared to 2019 american community survey supplemental estimates supporting information s1 table s2 table mediation analysis predicting mental distress from countylevel and respondentlevel variables including the interaction between social distancing and live with someone

although research shows that the covid19 pandemic has led to declines in mental health the existing research has not identified the pathways through which this decline happensthe current study identifies the distinct pathways through which covidinduced stressors ie social distancing disease risk and financial stressors trigger mental distress and examines the causal impact of these stressors on mental distresswe combined evidence of objective pandemicrelated stressors collected at the county level eg lack of social contact infection rates and unemployment rates with selfreported survey data from over 115 million adult respondents in the united states collected daily for eight months we used mediation analysis to examine the extent to which the objective stressors influenced mental health by influencing individual respondents behavior and fearscountylevel daytoday social distancing predicted significantly greater mental distress both directly and indirectly through its effects on individual social contacts worries about getting ill and concerns about finances economic hardships were indirectly linked to increased mental distress by elevating peoples concerns about their households finances disease threats were both directly linked to mental distress and indirectly through its effects on individual worries about getting ill although one might expect that social distancing from people outside the home would have a greater influence on people who live alone subanalyses based on household composition do not support this expectation

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background urban ai adolescent girls reported greater sexual risk behaviors other risk behaviors and pregnancy compared to reservation ais and other racial groups rutman et al concluded that urban ai adolescent girls were at a twofold increased risk for sexual risk behavior as well as for violence at school drug use rape assault and pregnancy and a threefold increased risk of suicide feeling unsafe at school and involvement in fights that required medical care similarly gruber et al found that urbanbased ais particularly girls were more likely to engage in risk behavior including substance use physical violence and early initiation of sexual behavior compared to their black white and reservation based ai counterparts in addition of the studies conducted with urban ai adolescents that focus on sexual risk behavior few were guided by a culturally informed theoretical model american indians are not just different racially but also politically and historically and this can affect the research perspective although multiple theoretical models have been developed for ais by health researchers these theories tend to focus on a specific tribe adult populations reservation based ais and make assumptions about previous life experiences this diversity highlights the need for a culturally specific theory to frame research with the urban ai adolescent girl population the purpose of this grounded theory study was to explore how individual family environmental community tribal and national factors and processes influence urban adolescent ai girls sexual risk behavior theoretical guide glasers grounded theory methodology guided this study in addition symbolic interactionism and bronfenbrenners ecological model shaped the project design including the guides for the talking circles interviews and event history calendars symbolic interactionism provided focus on the social interactions of the adolescents in the context of the larger society bronfenbrenners ecological model facilitated exploration of the ai adolescent girls sexual risk behavior by examining the social contexts of the sexual risk behaviors and interactions of ai adolescent girls method sample and setting access for this study was granted by the director of an american indian health and community center and approval by the university institutional review board a certificate of confidentiality was obtained from the national institute of nursing research twenty 1519 year old participants were primarily recruited from the ai health and community center located in a large metropolitan area in the midwestern united states participants primarily self referred after seeing flyers posted throughout the center although many were referred from the youth group and by the medical staff those living outside of the service area were referred by staff in their own community who received notification about the project from the pi and the staff adolescent girls were eligible to participate in the study if they were between 1519 years of age selfidentified as urban ai had parental permission to participate in the research study and were able to speak read and write english the twenty ai girls in this study ranged in age from 15 to 19 years old most were full time students lived with either one or two parents were eligible for subsidized lunch and were on medicaid nine of the participants denied any history of sexual activity and 11 reported oral sex vaginal sex or both participants were able to identify multiple tribal affiliations and reported connections with tribes from across the us with most participants having representation in tribes from the upper midwest all participants currently lived in nonreservation areas within a large urban or suburban area data collection and recording informed consentassent was received from the participants and the parents of minors participating in the study participants were given a gift card to a local store for participating in the initial study and follow up interviews the girls and their family members were also offered a full meal during the study family members and participants were invited to eat and socialize while consentassent was obtained and prior to data collection beginning data collection included completion of demographic information an event history calendar and talking circle or individual interview participation prior to beginning the talking circle or individual interview adolescents individually completed a demographic form and an ehc in an area that provided privacy and confidentiality the ehc is based upon previous life history calendar research with adolescents as well as themes that martyn and colleagues derived qualitatively the ehc helped prepare the adolescent for the talking circles and interviews by providing an opportunity to chronicle their life events over a three year period and reflect on the interaction between life events relationships living situation sexual activity and other risk behaviors the ehc also provides a column for a fourth year so that adolescents can note future goals or plans the current study also utilized the ehc to gain valuable historical contextual information from the adolescents that was not revealed in the talking circles or individual interviews after completion of the ehc the girls participated in a talking circle or individual interview that explored the psychosocial and contextual factors that influenced ai adolescent girl sexual behavior talking circle and interview questions were developed using bronfenbrenners ecological model and symbolic interactionism as a guide questions were developed and reviewed by an ai advisor and experienced researcher after initial approval the questions were reviewed by the staff at the data collection site for appropriateness and cultural sensitivity questions were revised after feedback from the recruitment site initially talking circles were planned as the primary data collection method however based upon the requests of the ai girls in the community individual interviews were added to respect each individuals right to confidentiality talking circles are a traditional method of group communication in ai society that allows all participants to speak and to be heard this culturally appropriate method of conducting focus groups has been successfully used in other urban and reservation ai research projects during the talking circle everyone was given the opportunity to talk and share their story unlike focus groups the interaction between participants is not as important as allowing each member to share their personal experience on the topic in talking circles each persons voice is equal and each member has equal opportunity to address the question an object is used during talking circles to show which person currently is given the right to share their story in this study a shell was passed from one participant to the next and the person with the shell was the person who had the floor to talk once the participant finished speaking they passed the shell to the next person in the circle the talking circles and interviews were audiorecorded a professional transcriptionist transcribed all the talking circle and interview data yielding 478 pages of data for analysis immediately following the talking circles and interviews the researcher debriefed with a colleague experienced in the grounded theory method and recorded memos of impressions and observations in addition to enhance cultural sensitivity in data analysis an ai research assistant reviewed the transcripts and offered impressions of influences on sexual risk behavior that were incorporated into memos seventy four pages of memos from the primary author and ai research assistant supplemented the data transcripts data analysis the constant comparative method of data analysis was used simultaneously with data collection to enhance validity the ehcs transcripts and memos were analyzed using three levels of coding open coding of the data involved line by line analysis of the ehcs and transcribed data from the talking circles and individual interviews in order to identify processes and contextual factors in the data relevant to urban ai adolescent girls perceptions of sexual risk behavior during the research project these processescontextual factors or substantive codes were compared with other data including the memos by the pi and research assistant and assigned to categories the categories were compared to other categories to ensure that they were mutually exclusive reduction of the number of categories occurred in order to identify the primary social processes or core variables that explained the social scene conceptualization of the relationship among the three levels of codes occurred through development of the more theoretical level iii codes results ten girls participated in three talking circle groups of those four were sexually active the other ten participants opted to participate in individual interviews recruitment ended when data saturation was reached eight participants were selected to return for a follow up interview for member checking clarification and further exploration of data and for peer validation of the data analysis the eight participants who returned for follow up interviews were selected because they expressed interest in their initial interview to meet again with the pi andor the ideas and themes they discussed in the initial meeting resonated with the preliminary research results using the methods described above the generated theory framing sexual risk behavior emerged framing sexual risk behavior a grounded theory two assumptions underlie the developed grounded theory model the first assumption is that reciprocal interactions between the systems of the model influence how each urban ai adolescent girl views sexual risk behavior the second assumption is the form content and strength of the processes affecting the urban ai adolescent varies depending on individual factors and environmental surroundings american indian girls sexual risk behavior in this study was most influenced by the groups and organizations in their environment in this study the basic social process for the urban ai adolescent girls regardless of their social economic or tribal status focuses on the exposure to messages about sexual behavior from both social and structural influences these are positive and negative messages that influence how the adolescent reacts to and negotiates her own sexual behavior in addition for the urban ai girls in this study the strength and content of the messages they receive effects their perceptions about sexual risk behavior the generated theory framing sexual risk behavior emerged and was consistent with bronfenbrenners ecological model microsystem the urban ai adolescent girls sexual risk behavior was influenced by her social and structural systems the microsystem including long term goals identification of being a normal teenager and cultural identity helped the participants determine who they are and influenced them to abstain from sex have safe sex or have unsafe sex being normalparticipants believed that they were normal adolescents who lived lives similar to other urban dwelling adolescents all the participants had friends who were not ai and most had family members who were not ai yet despite the interracial company the girls kept they could not see a difference between themselves and adolescents from these other racial and ethnic groups the girls felt that their day to day lives were no different than others nor were their decisions about sexual behavior however although ai adolescents felt normal they also had a sense of what it meant to be an ai woman the girls in this study remarked on their intentions to become strong native women the idea of being strong resonated with many of the girls particularly those who were not sexually active these girls in particular spoke of making their people proud by pursuing their goals particularly finishing college and becoming a role model for other ai youth having goalsthe significance of having long term goals emerged from the girls event history calendars interviews and talking circles the girls who specified long term goals reported less risky sexual behaviors and had a clear plan to complete their goals in addition the goals of those reporting fewer risk behaviors tended to be more academic girls in this study saw the consequences of sexual risk behavior particularly early childbearing as an impediment to achievement of their goals and future success they were aware of the negative effects early child bearing could have on goals from observing their parents aunts sisters and friends some were children of teen parents and as an 18 year old who was not sexually active said my mom had me at a young age and it was hard for her to take care of us not having an education and not having a good job she was graduating from high school and had already been accepted into four different colleges she explained i will be like the first on my moms side to go to college…so i dont want to take the risk of having sex and getting pregnant i want to finish college those with future plans felt they were extremely important in how each identified herself when participants spoke of their goals they spoke of their life the meaning of the goals and the rationale for their goals even those who had unrealistic goals spoke of their goals as imperative to their life story cultural identitycultural identity emerged as a critical component in how participants defined or described themselves this identity formation helped the girls in this study determine who they were and what they wanted to be subsequently this identity influenced their decisions about sexual behavior those who identified strongly with being ai reported less sexual risk behavior than those who were not connected to their culture the majority of participants stated that they were of mixed racial and ethnic heritage however most described being ai as integral to who they were as individuals a 17 year old participant said its really weird because i feel like really connected to my native culture but im not necessarily a part of it so i dont know why i feel so connected another participant age 16 said i say im native because i think thats basically what i am i know some languages and some other culture and stuff girls felt that their ai heritage was a key part of their identity mesosystem six components of the mesosystem were identified by participants as influencing sexual behavior the mesosystem particularly family and friends emerged as powerful influences on the adolescents in this study adolescents are aware of the various messages both positive and negative from social and structural systems surrounding them these messages are interpreted by the adolescent in the context of their life and influence their sexual behavior familyfamily was an important influence on ai adolescent girls sexual behavior and knowledge about safe sex girls in this study cited the family as the most important influence on their sexual behavior three important themes emerged related to family influence 1 networks of family influences 2 talking about sex with at least one family member usually another female and 3 mixed messages about sexual behavior from different family members including those who discouraged and those who encouraged sex girls in this study described a network of family members that included mothers fathers grandmothers sisters aunts and cousins who influenced their sexual behavior for example one 15 year old participant identified her cousins as her primary sources of sexual information while an 18 year old identified her father and grandmother as people who influenced her decision to abstain from sexual activity in addition to having a wide network of family members available who influenced sexual behavior all of the participants in this study reported at least one female family member that they could openly discuss sex with these family members included mom aunts grandmothers sisters and cousins however even though girls reported having family members available to discuss sex they often received mixed messages about sex girls in this study were more likely to receive messages discouraging sex from their elders and messages encouraging sex from those family members close to their own age one participant age 17 said i did it because all my sisters were doing it now its just like i have already done it when i was younger i guess i just wanted to be like my sisters overall girls in this study felt that their family regardless of the messages they received from them were highly influential in their sexual behavior friendsin this study the influence of friends on sexual behavior was most commonly identified after family influence three important themes emerged related to friend influence 1 friends discourage sexual risk behavior 2 friends encourage sex and 3 friends are often family members many participants in this study particularly those who were not sexually active cited their friends as an important influence for avoiding sexual risk behavior having friends who were not engaging in sexual activity helped participants feel comfortable with their own decision to abstain a 16 year old who was not sexually active stated my friends dont have sex however friends also encouraged sexual behaviors many girls felt pressure to have sex to fit in with their friends or for acceptance from their partners or boys in school multiple participants also reflected on how their decision to initiate sex in early adolescence was shaped by friend influence an 18 year old with four sexual partners over a three year period stated that friends were a primary influence in her decision to have sex she said i made a lot of bad decisions like who i chose to hang around…i just gave into all the peer pressure when i was younger finally although participants identified friends from school and their neighborhood many of the girls in this study reported considerable overlap between their friendship groups and their family many participants identified their sisters and cousins as their friends and therefore the influence of friends and family were not mutually exclusive this lack of exclusiveness blurs the lines between where the sphere of family influence ends and where the friend influence begins therefore it is important to consider the two in tandem rather than separately neighborhoodin this grounded theory study neighborhood was noted as an influence on sexual behavior by participants although participants described family and friends as more influential the majority saw some connection between their sexual behavior and their neighborhood those who grew up in suburban neighborhoods felt that this influenced them to abstain from sexual activity participants residing in suburban regions who were sexually active felt that their actions conflicted with the values of their community or neighborhood those who lived in innercity areas responded in two distinct ways regarding sexual behavior one reaction by participants was to follow the normative sexual behaviors of the community to fit in and feel accepted the second reaction was to ignore common sexual behaviors and make decisions based upon a desire to exit the neighborhood and lifestyle when girls accepted the neighborhoods values as their own the girls felt that they were part of the neighborhood and therefore protected those who chose to ignore the normative behavior of others in their neighborhood used their desire for better opportunities as their reason to abstain from sex or have safe sex many participants pointed to their siblings and cousins who had babies as teenagers and were now stuck in their neighborhood one participant age 17 said i dont want to live in the hood and all that…my sisters are stuck there because they had babies that isnt gonna happen to me schoolschool emerged as an influence similar to that of the neighborhood three major themes emerged related to school 1 belief that most teens in schools are having sex 2 sex education courses are not enough for an adolescents understanding of sexual risk behavior and 3 out of school organized youth groups are needed to supplement school based sex education programs in this study participants overwhelmingly cited the school as a place where sexual behavior was on display and where introductory learning about reproduction sexual consequences contraception and abstinence occurred one nonsexually active 16 year old felt that school was a major factor that influenced sexual behavior and said i think its school got a big influence no matter what school you go to poor or rich…its the same in every school peer pressure about sex and everyone is having it in addition many of the girls believed that the school environment helped influence their own decisions about sexual behavior although most stated that their sexual education was inadequate for example a 15 year old who was sexually active said that her official sex education course had just started two months prior to the interview she had already been sexually active for a year when her school based sex education course took place mass mediaone issue that arose from the school and neighborhood questions was the influence of the mass media and popular culture on sexual behavior the girls in this study believed that media particularly tv shows influence ai adolescent sexual behavior current shows such as 16 and pregnant jersey shore and teen mom arose in the interviews and talking circles as media that teens watched regularly the majority of participants admitted to watching reality shows and felt that tv was one way that they learned about sexual behavior one participant age 18 who was sexually active and was pregnant at the follow up interview felt that tv shows were a significant influence on sexual behavior in adolescents shows like teen mom sent messages to adolescents about the acceptability of sexual behavior she explained because you see all these teen moms having babies and it looks like theyre doing okay so that influence you to have sex health carehealth care emerged as an influence on sexual behavior this study revealed two themes for urban adolescent ais with regards to health care 1 trusting the health care providers and 2 access to health care services the majority of participants trusted their health care provider and the larger medical system participants felt that health care providers had their best interests in mind and believed that the girls safety was of utmost importance in addition all participants said that health care access was important for receiving health care information and practicing safe sex girls in this study believed that health care access was necessary for good sexual health a 17 year old sexually active participant said having access to health care makes it easier to have safe sex…they the doctors could help me teach me have the doctors tell how to practice safe sex another 17 year old who was also sexually active believed that having low cost accessible services was a necessity for good health macrosystem although federal policy drives support for many ai services and the environment in which they lived adolescents did not identify a link between policy and their own personal lives within the ecological model it is logical to conceptualize that them acrosystem would influence the other systems surrounding the adolescent federal and state policies towards ais trickle down to the individual in a number of forms such as health care and government assistance given the age and development of the participants the connections between government policy and their daily lives may not be immediately obvious or relevant for them discussion and recommendations framing sexual risk behavior the theoretical model that evolved from the study data has the potential to assist both clinicians and researchers understanding of sexual behavior in urban adolescent ai girls similar to other racialethnic groups factors that influence the urban ai adolescent populations sexual risk behaviors are consistent with bronfenbrenners ecological model other findings from this study are consistent with research with urban adolescent girls that indicates parental communication and sexual risk behaviors have an inverse relationship emphasizing the importance of family in modifying sexual risk behavior in adolescents the urban ai adolescent girls described many similarities with other racialethnic groups such as the high value placed on family and peer opinion and relationships the role of parental expectations in their decision to abstain from sex or practice safe sex and the influence of messages about sexual behavior received from their family members and friends distinct differences emerged between ai urban families and nonai urban families including the importance of the large network of family members and openness to talking about sex with at least one female family member in addition contrary to previous literature with ai populations this study revealed that urban adolescent ai girls trusted their health care provider and believed that health care access was imperative to their personal wellbeing according to shafii and burstein adolescence is a critical time to support patients sexual health health care providers are uniquely positioned to provide resources and education to adolescents about safe sexual practices in a safe confidential setting the similarities between factors that influence the sexual behavior of ai adolescent girls and nonai adolescent girls can be used by both clinicians and researchers to develop interventions and clinical plans for ai adolescent girls the unique culture of urban adolescent ai girls offers clinicians the opportunity to develop with the community culturally aware interventions to reduce sexual risk behavior these interventions should consider including a female family member into the health care visitor identifying cultural health care beliefs that could enhance treatment or adherence clinicians should also consider formulating personal goals with each patient and taking time to review how health promoting behavior and healthy sexual choices will help the patient meet their longterm and shortterm goals additionally because there are many similarities between urban ai youth and those nonai youth living in urban areas previous interventions that focused on reducing unintended pregnancies and stis with nonai urban dwelling adolescents should be considered for modification adaptation implementation and evaluation however it would be important for researchers modifying interventions for the urban ai population to consider the differences among the various tribes in urban populations and ensure that the modifications meet the needs of a diverse group of urban ai adolescents strategies clinicians can consider include attending culturally responsive training as well as taking time to learn about ai culture particularly the history of tribes in their local area in addition clinicians should be experts not only on clinical care but also on connecting urban ai adolescent girls to community based programs that emphasize the importance of culture and sexual health clinicians must build relationships with other providers who can collaborate with one another to provide community based interventions to reduce sexual risk behaviors these health care collaborations should be in association with the larger ai community and involve both ai elders and ai community leaders future research recommendations the grounded theory developed from the findings of this study provides direction for future research the current literature on urban ai adolescent sexual risk behavior is limited therefore using the framing sexual risk behavior model to investigate known influences on sexual risk behavior could be important to the health of the urban ai adolescent girl population future research should also focus on the male adolescent as well as comparison of urban ai adolescents to reservation ai adolescents replication of the current study on reservations could confirm any similarities or differences between the two groups similarly replicating the study with male adolescents could provide valuable insight into how adolescent ai boys regard sexual behavior and what they believe to be the primary influences on sexual behavior framing sexual risk behavior can be used to guide future research and efforts to reduce sexual risk behaviors among urban ai adolescent girls understanding ai culture and heritage as well as recognizing the urban ai girls unique influences described by the girls in this study is necessary for reducing teenage pregnancy among ai adolescents interview questions variables topic one knowledge and influences 1 tell me what you know about having sex 2 tell me how you feel about having sex 3 tell me what influences you havingnot having sex 4 tell me who influences you to havenot have sex

purposeamerican indian ai adolescent girls have higher rates of sexual activity births and stis compared to the national average the purpose of this study was to explore factors that influence urban adolescent ai girls sexual risk behavior srb designa qualitative study was conducted using grounded theory methodology to reveal factors and processes that influence srb methodstalking circles individual interviews and event history calendars were used with 20 urban ai 1519 year old girls to explore influences on their sexual behavior findingsthe generated theory framing sexual risk behavior describes both social and structural factors and processes that influenced the girls sexual behaviors the theory extends bronfenbrenners ecological model by identifying microsystem mesosystem and macrosystem influences on sexual behavior including microsystem being normal native and having

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introduction according to ministry of unification 1 in 2018 an estimated 32476 north korean refugees had settled in south korea about 40 of which were children and young adults aged 10 to 29 scholarly interest in nkrs has increased along with their growing numbers during the past 10 years but there is scant research on them particularly north korean refugee youths nkrs are likely to have had traumatic experiences such as compulsory confinement arrests and detainments witnessing people die of starvation witnessing public executions or accidents or being deported to north korea 2 nkrys have reported a variety of traumatic experiences while they were in north korea and on their way to south korea 3 nkrys often feel a sense of guilt and loss about family members that were separated from them during their escape and they have fears about others knowledge of them as refugees 34 nkrys often suffer from posttraumatic stress disorder depression or anxiety because of these traumatic events 5 in particular depression which is a psychological symptom of maladjustment is a key indicator used to assess the mental health of immigrants and refugees 6 and it is one of the most common maladjustment problems of nkrs 7 because childhood depression might cause psychosocial and other problems in adulthood it might be associated with a huge social cost 8 therefore it is important to relieve the depression experienced by nkrys and prevent their childhood problems from affecting their adult lives adolescence is usually a vulnerable stage in the life course when physical interpersonal cognitive environmental and stress problems can negatively influence mental health 9 nkrys are particularly vulnerable to internal problems such as anxiety and depression and their depression is likely to increase over time after they arrive in south korea 210 however resilience theory proposes that the developmental outcomes of adolescents who spent their childhoods in stressful environments such as poverty or abuse or those who experienced adverse events are not necessarily negative 11 12 13 14 consequently researchers also consider protective factors protective factors are expected to reduce the likelihood of dysfunction or illness after life experiences that might cause vulnerability andor stress 15 adolescent developmental protective factors 16 17 18 are classified as personal characteristics and internal factors positive responses to others and cognitive factors social supporters or adults who warmly care for and supervise youths and adult support systems social supports adult role models and service institutions that link youths to their communities therefore clarifying the personal and environmental factors associated with change in depression is important to realizing effective interventions many studies on nkrys mental health have focused on psychopathology such as suicidal ideation depression anxiety and ptsd and the associated risk factors however little research has been conducted on the protective factors such as positive mental health character strength and social support adaptation to a new culture in south korea places constant demands on every aspect of nkrys lives and because their lives are dynamic it is important to conduct longitudinal analyses to examine changes in mental health based on the previous studies about these youths and their mental health this study examined changes in depression levels and the related protective factors and risk factors in a sample of nkrys to obtain insight for effective interventions in accordance with the results of the current study materials and methods variables and measurement sociodemographic characteristics gender age birthplace parental education level and type of household were the personal characteristics used in the studys analysis potential risk of depression the center for epidemiologic studies depression scale was developed to measure depressive symptoms in the general population 19 it has four positive items and sixteen negative items the response options are on a fourpoint scale where 0 rarely or none of the time 1 some or a little of the time 2 occasionally or a moderate amount of time and 3 most or all of the time the four positive items were reversecoded and then the responses were summed the total scores ranged from zero to 60 16 through 25 points was classified as mild depression and more than 25 points was classified as clinically significant major depression 20 this classification was based on the usual 16point cutoff used in primary care 21 for the analysis depression levels were low zero to 15 and high 16 or higher psychological characteristics three psychological characteristics were measured the brief resilience scale measured resilience defined as the process of or capacity for successful adaptation after exposure to trauma or severe stress 2223 the scale has three positive items and three negative items the response options are on a fivepoint scale where 1 strongly disagree through 5 strongly agree the negative items were reversecoded and the scores were then summed for a composite score which ranged from six to 30 with higher scores indicating more resilience the emotion regulation questionnaire measured cognitive reappraisal and expressive suppression which are two emotional regulation strategies 24 the response options were on a fivepoint scale where 1 strongly disagree through 5 strongly agree higher scores indicated that the use of more strategies to control emotions by changing their thoughts or suppressing emotions the rosenberg selfesteem scale was used to assess selfesteem 25 it has six positive items and four negative items the response options were on a fivepoint scale where 1 strongly disagree through 5 strongly agree the responses were summed after reversecoding the negative items total scores ranged from 10 to 50 with higher scores indicating higher selfesteem social support two items were used to measure social support as psychological or practical support received from others psychological support was measured by responses to the question how much psychological support do you currently receive from your family relatives friends and others around you practical support was measured by responses to the question how much practical support do you currently receive from your family relatives friends and others around you both items response options were on a 10point scale where 1 none at all through 10 enough statistical analyses first descriptive statistics were generated on all the variables we then compared the two groups to see if their baseline scores differed a multinomial logistic regression analysis was performed to identify the variables significantly related to change in depression by comparing t2 to t1 data odds ratios and 95 confidence intervals were calculated using the group factor as the outcome variable and sociodemographic personal and psychological variables were predictors the outcome variable was based on the cesd cutoff score of 16 depression change was categorized using the cesd scores at t1 and t2 stable low alleviated deteriorated and prolonged all statistical analyses were performed using spss 200 and the statistical significance cutoff level was p 005 results the sample comprised 66 female and 42 male nkrys aged 13 to 26 years old with a mean age of 1784 table 1 presents the descriptive statistics twelve of the 66 respondents who scored high on depression symptoms at t1 had lower scores at t2 fiftyfour of the 66 respondents who scored high on depressive symptoms at t1 also had high depression scores at t2 and 20 of the 42 respondents with low depression scores at t1 had higher scores at t2 there was no significant difference in sociodemographic variables in the four depression change groups when comparing baseline scores between the followup group and the group without followups there was a significant difference in mean age there was no significant difference in gender there were no significant differences in baseline scores on the cesd brs rses or erq there was no significant difference in psychological support but there was a significant difference in practical support table 2 presents the results of the multinomial logistic regression analysis of the predictors of change in depression the alleviated depression group had significantly higher odds than the stable low depression group regarding expressive suppression and tended to have low selfesteem at t1 the deteriorated depression group was more likely than the stable low depression group to have low resilience and low cognitive reappraisal at t1 the respondents with prolonged depression were more likely than the stable low group to have low resilience low selfesteem and perceive low practical support at t1 the stable low depression group was treated as the reference aor adjusted odds ratio adjusting for all variables in table 2 ci confidence interval discussion this study investigated factors related to change in the potential risk of depression among nkrys focusing on the progression maintenance and alleviation of depression the nkrys whose depression was alleviated between t1 and t2 had significantly higher t1 expressive suppression scores and tended to have lower t1 selfesteem scores than those in the stable low group low selfesteem and expressive suppression are two features of depression 24 26 27 28 therefore the relatively low selfesteem and relatively high expressive suppression scores of the respondents in the alleviated depression group seem to reflect their high baseline depression scores rather than that these factors alleviated their depression these results imply that programs to promote selfesteem and emotional expression might be effective interventions for depressed nkrys the respondents in the deteriorated depression group had significantly lower resilience and lower cognitive reappraisal scores at t1 than those who were in the stable low group resilience is a protective factor previously associated with subjective health status and low depression and anxiety among nkrys 29 resilience theory proposes that personal characteristics and internal factors classified as protective factors reduce the likelihood of dysfunction among those with life experiences that could cause vulnerability or stress 15 the ways that nkrys perceive interpret and accept traumatic experiences or acculturation stress seems to be important considered together low resilience and low cognitive reappraisal seemed to create a propensity to be vulnerable that increased the risk of depression among the respondents which implies that depression prevention programs for nkrys should focus on promoting resilience and enhancing healthy emotional regulation strategies this studys prolonged depression group had significantly lower resilience practical social support and selfesteem scores at t1 than those in the stable low group in addition to low resilience and selfesteem which are historically considered central factors in depression 26 27 28 lack of practical social support seemed to have a significant role in depression maintenance the relationships between depression and low selfesteem and social support could be bidirectional individuals with depression may be more likely to have low selfesteem 30 and feel socially isolated and as though they have a lack of social support 31 these feelings of low selfesteem and insufficient social support in turn may be a risk factor for developing more severe depression 26 27 28 30 31 32 the psychological and practical support received from family members friends and others were previously associated with nkrys mental health 3334 these are protective factors in resilience theory because through social support individuals obtain knowledge and advice that helps them to adapt to their environment improve their adaptability skills and cope with change and stress 35 in particular practical support functions to adequately provide resources and services necessary for youths thereby improving mental health by reducing stress and helping with environmental adaptation 33 34 35 however a previous study indicated that the average number per nkrys of individuals providing practical informational and emotional assistance was 21 per person and about 12 of the youth had no social supporters 33 those who lack social support are expected to be relatively vulnerable to mental health problems caused by stress to the best our knowledge this is the first longitudinal study on change in the potential risk of depression among nkrys the findings provide insights into the variation in depression among nkrys first relatively low resilience at t1 related to increased depression at t2 suggesting that resilience is a risk factor for deteriorated depression second because selfesteem was significantly lower in the t1 high depression group low selfesteem seems to be important to the initial state of depression third low practical social support seems to be a factor that contributes to maintaining a high level of depression these results will help develop programs to improve mental health among nkrys and inform experts on depression further studies are needed on larger and representative samples and the protective effects of family characteristics should be analyzed to verify our results despite this studys important findings it has several limitations first the sample was small with only 12 to 50 people per depression change group which might have influenced the external validity of the results second social support was measured with two single items further research is needed that uses a validated scale to distinguish among social supports received from family members friends and others third we did not collect any information on treatment for depression which could have affected changes in depression during the followup period finally this study revealed factors associated with change in depression among nkrys but it did not explore the ways that these factors might relate to alleviation deterioration or maintenance of depression longitudinal studies of longer duration with more followups and that use statistical analyses such as temporal mediation or moderation would help to reveal the relevant mechanisms conclusions this study examined the factors associated with change in the potential risk of depression and those that affect the progression maintenance and alleviation of depression among nkrys twelve of the 66 respondents who scored high on depression symptoms at t1 had lower scores at t2 a total of 54 participants scored high on depressive symptoms at t12 author contributions conceptualization sp methodology jyj and sp formal analysis esl investigation sp and jyj writingoriginal draft preparation sp syk and esl writingreview and editing syk and sp funding acquisition sp

this study investigated change in depression and revealed factors related to change using oneyear followup data a sample of 108 north korean refugee youths nkrys aged 13 to 26 years 66 females was recruited from two alternative schools for nkrys in south korea based on the center for epidemiologic studies depression scale cutoff score of 16 respondents were grouped based on change in depression score after one year as stable low alleviated deteriorated or prolonged multinomial logistic regression assessed the influence of baseline psychological scores resilience emotional regulation strategy and selfesteem and reported social support psychologicalpractical on the odds of group classification with the stable low group as the reference category those with alleviated depression at time 2 had significantly higher odds of expressive suppression and tended to have lower selfesteem at time 1 the deteriorated depression group was more likely than the stable low group to have lower resilience and cognitive appraisal scores those with prolonged high depression were more likely than the stable low group to have lower resilience less practical social support and lower selfesteem psychological interventions particularly those focused on increasing selfesteem and resilience could be helpful for nkrys with potential risk of depression in addition practical support should be provided on an asneeded basis to prevent chronic depression among nkrys

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november 2023 employ a variety of mechanisms such as questionnaires interviews diaries field notes and reflections over some time the process of research always encompasses feedback to improve the situation and bring about some changes modifications or redefinitions action research is all about researching own practice or the people involved together rather than people out there it is participatory and emergent it can also be useful for real problemsolving it is situationbased and theorybuilding from the practice moreover it deals with individuals or groups of people who have a common purpose to improve their practice involving analysis evaluation and reflection action research processes many studies have given various stagesprocedures for the participatory action research method of research particularly it is known as a cyclicalspiral process in which a complete cycle completes and is repeated time and again one cycle has four stages the planning stage the acting stage the developing stage and the reflection stage figure 1 stages of action research action research involves recurring stages of planning observation action and reflection along with the evaluation these stages are recursive in almost all the action research process the influence of lewins original ideas continues to organize action research works in the spiral of stages that comprises observation reflection action evaluation and modification these cyclical stages are recurring even in another cycle reviewing many research and research reports through an action research approach reports a common framework for participatory action research that undergoes a cyclical process of factfinding action reflection leading to further inquiry and action for change the contributory writers on participatory action research kemmis and mcgaraat also emphasized the recursive steps in par such as plan act observe and reflect and repeat the same process of plan act observe and reflect until the situation is improved likewise kelly suggests that the beginning of action research is followed by collaboration with the community partners in three cycles planning acting and reviewing in the same line valsa koshy suggested a list of stages to be followed in the conduction of participatory action research these states are identification of topic and context setting review of related literature emphasizing the topic research question or hypothesis careful planning of the activities collecting required data analyzing the data and fixing the problems implementing the plan reflecting on the results and reporting the changes in the literature on action research many action researchers often mention the basic common four phases involved in action research assessment planning action and reflection among the processes mentioned and suggested by the previous studies clark et al provided clear steps for conducting action research in the educational setting these steps are almost similar to many other scholars such as topic identification in a particular educational context literature review revision of the topic construction of research questions planning of research activities collecting data analysing them doing real action reflection reporting sharing and documenting these processes can be useful for conducting action research in the classroom setting as well aligning these steps of action research to the rigorous process of educational research these steps can help the researchers participatory action research as a research methodology pain et al provided the participatory action research toolkit for conducting par as an approach to learning research and action they have defined it as collaborative research education and action used to gather information to use for change on social or environmental issues it involves people who are concerned about or affected by an issue taking a leading role in producing and using knowledge about it par is different from other traditional research approaches in the sense that it is initiated by participants at workplaces rather than an outsider funders or academicians moreover it offers a democratic and practical model of producing taking ownership and using the knowledge produced themselves it is collaborative at every stage in nature that involves discussions reflections and applications intending to bring about changes or improvements in the issues researched since par is a research approach to explore and improve the practices with a set of principles and practices for identifying issues designing plans conducting activities analyzing and acting it can also be used as a research methodology it is not a single method but an integration of multiple methods such as group discussion interviews observations videos diagramming and photography it has a typical and cyclical stage of action and reflection from the beginning to the end of any par project in the toolkit offered by pain et al it is said to include a set of questions at every stage of par for example they said to include various questions for collaboration knowledge power ethicalities theory generation vol vi november 2023 the findings of the research who is involved in the meaningmaking process and what does that mean what outputs will we expect from the research taking action and researchers wellbeing and emotions is the topic of the research relevant on which the people care passionately or directly affects their wellbeing how will we make sure that our workplace is comfortable and hospitable for participants how can we manage the negative emotions of the participants in the meetings how might the results of the research affect the outsiders in the participatory action research do we have alternative strategies to overcome such problems that arise during the implementation of the research results these toolkits could be utilized to guide the research methodology through par lewin stated you cannot understand a system until you try to change it as expressed by lewin only the talk exploration and discussion may not be possible to bring about changes in the existing situation par as a research methodology can be an alternative qualitative approach to improvesolve practical problems the main aim of qualitative research is to describe and understand the phenomena rather than to predict and control them par is considered a subset of action research which is the systematic collection and analysis of data to take action and make change by generating practical knowledge action research embeds myriads of other terminologies such as participatory action research participatory research communitybased participatory research participatory inquiry practitioners research and classroombased research which might be confusing for novice researchers to distinguish and conduct action research the common purpose of all research is to bring social change with a specific action as the ultimate goal by involving researchers and community members who desire to improve their situation action research often opts for social change the philosophical underpinning of participatory action research is the changeoriented action that is valueladen and morally committed therefore participatory action researchers try to understand themselves and the phenomena being intervened concerning other individuals in social contexts along with the epistemological assumptions underlying action participatory action research also aims to create knowledge as an active process knowledge being uncertain and the object of the enquiry action researchers believe that the philosophical underpinnings of participatory action research are similar to postmodern tradition that embraces a dialectical of shifting understandings whereas objectivity is almost impossible and multiple or shared realities exist the philosophy of par embodies the idea that the people in the community must have the right to determine their development and participate meaningfully in the process of analyzing the results or solutions by recognizing the needs of local people for sustainable development in participatory action research the role of participants remains the coresearchers since they engage in the research process from the beginning to the end for coconstructing the knowledge guiding principles for action research the theory of participatory action research is guided by two reasons the first one is that it is an effective way of imparting knowledge acquired from the experience of participants in the workplace mctaggart further states that the guiding principles are descriptive as well as prescriptive whereas in the second reason the recipients should perform an educative function lewinian approach to cyclic action research emphasizes the need for an action plan to be flexible and responsive two works were substantive in lewins work group decisions and commitment to improvement participation means taking ownership of the knowledge tandon identified many determinants of actual participation in research these determinants were listed as participants active role in setting the agenda of research their participation in the process of data collection and analysis and their dominance over the utilization of the results and the entire research process it is visible from the literature that par engages participants from the academic fields and workplace with unique relationships participatory action research is democratic equitable liberating and lifeenhancing because it selects the participants based on the criteria given with equal access to them and helps them to transform through action mctaggart outlined 16 tenets of par such as the active approach to improve social practices real participation of the individuals collaborative selfreflective learning communities and involvement of practitioners for theory building recordkeeping making critical analysis political initiated from small cycles and groups likewise de oliveira identified seven components that characterize participatory action research such as originating from the problem in the community oriented to a drastic change of social reality and improvements in the lives of participants full and active participation of the community engagement of a range of powerless groups of individuals creating greater awareness in individuals and mobilizing them for selfreliant development and making selfdetermined participants initiators facilitators and learners during the process participatory action research shapes the identity of the individual and groups through the collective project which improves their work and the way it is understood furthermore it increases the collaboration with the individuals within their institution and beyond for understanding the situation solving the problems and developing their own professional space it attempts not only to change the individuals but also the culture of the groups institutions and societies where they belong bringing changes in the ongoing discourses practices and organizational context from the perspective of the distribution of power unifying the intellectuals and the project engaging the politics of research and action strengths of action research the par always identifies and values the people as social beings within the broader social political and economic context it also seeks to address the issue of significance concerning humans and their communities in participatory action research participants are not only treated as the subject of study rather they are treated as active participants and contributors to the research it attempts to rebuild the participants capacity as creative actors in the world engage them in the decisionmaking process and empower them by being involved in the research process since it as a collective inquiry develops the ownership of the participants in the research and its outcomes moreover it empowers oppressed individuals to partner the social change it also provides the opportunity to collaborate the individuals with diverse knowledge skills and expertise during the process of research in this research design individuals learn by doing the process in par is transformative empowering liberating and consciousnessraising for its participants furthermore it provides critical understanding and selfreflection to the researcher and participants par enhances the collective consciousness and the democratization of the participants applications and benefits of action research action research has been useful in understanding the problem and improving it directly being involved in it since it is the systematic inquiry into ones practice in the field of education it is the process which supports teachers to study their classrooms and improve the quality or effectiveness of teachinglearning mertler provided six ways of making par and teacher inquiry critical in any profession they are constructing teachers knowledge base developing skills enhancing journal of nelta gandaki vol vi november 2023 teachers agency teacher empowerment improvement of educational practices and professional growth among them vaughan and mertler highlighted teacher empowerment the improvement of educational practice and professional growth as the important ones the first application of action research is directly concerned to lead to the improvement of educational practices because the researchers or educators study their practice by critically examining and reflecting on their problems related to their contexts the action researchers identify their problems collect the data and finally engage in the process of data informed and practical decisionmaking professionals teachers and teacher educators get the solutions to their presenting issues at the workplaces and solve them through the process of action research similarly through action research or teacher inquiry teachers can grow themselves successfully in their profession the application of action research has become the alternative to professional grown for many teachers and teacher educators acton research has been considered one of the major means of inservice teachers professional development in education for example in school education in nepal the provision of granting one mark for one action research each year has been made just for promotion in this regard oliver contended that inservice teachers benefit from action research as a key component of professional development since it promotes the culture of posing questions and findings solutions to solve their immediate problems action research and teacher research can be highly effective tools for teachers empowerment when teachers engage themselves in the process of researchidentifying issues collecting data by using various tools making subsequent decisions based on the data and taking necessary interventions for the action and change they experience get knowledge and empowerment that also helps them to innovate create and apply to their education contexts the whole process becomes truly empowering themselves the studies suggested various benefits of participatory action research in education such as empowerment collaboration engagement change professional community building and emancipation there are various advantages to using action research as a method of research macdonald provides five characteristicsbenefits of action research first it is open to all the competing possibilities in the educational context because it rejects the positivistic notion of objectivity rationality and truth second it invites the practitioners reflective and interpretive subjectivity and develops localized theory and pedagogy third it provides opportunities for educators to selfrealize and understand their practices by exploring and analysing the existing situation fourth it links reflection and action encouraging the educators or researchers to overcome the problems for pedagogical changes through the systematic exploration into the educational context finally it involves deep consideration of theory and practice and also demonstrates critically reflective action by developing and organizing knowledge with the practice sample studies on action research many dissertations and articles through participatory action research are available online and offline repositories journals such as the journal of teacher action research action research and educational action research publish articles based on participatory action research for example one recent study on action research exploring the teaching of english and academic writing as a social practice in a british malaysian university by alison abraham at the college of education victoria university melbourne australia in 2016 followed the par as research methodology the purpose of that study was to analyze and improve english for academic purposes in the malaysian university setting taking an academic literacies perspective the study attempted to capture the complexities of teaching and learning academic writing within a tertiary classroom the researcher used postmethod pedagogy to guide a teacher while implementing the action plans the researcher used action research with 117 voluntary students in six cycles over two years and collected data from various sources such as teacher diaries interviews with colleagues and students students letters email exchanges and assignments in the study the researchers journey of becoming a critically reflective teacher alongside the students growth as academic writers has presented the findings the study reports the findings that power mismatches can be reduced through negotiated interactions students autonomy was increased after the knowledge gained from the study and students were engaged in learning after ensuring the relevance of social and cultural context the researcher engaged in teaching the students for two years long time and kept records of all the documents analyzed and presented in the form of a dissertation the analysis of the power conditions knowledge conditions and sociocultural conditions have been developed as the main themesresults of the study in the narrative form it shows that action research can be applied along with narrative inquiry many studies have also applied participatory action research as a research methodology for completing their formal university degrees campbells study uses par methods for the professional learning community to investigate traumainformed practices with six coresearchers also used participatory action research as a method to explore the experiences of bilingual teachers at an elementary school in the professional learning community the study found that the participants in the professional learning community enjoyed the safest spaces for learning group work and reflection participatory action research methods in the field of social sciences and education were found for the participants engagement knowledge construction and immediate use of the research findings in the practice misconceptions and criticisms of participatory action research participatory action research is not what academics and workers normally think about it is more systematic and collaborative in gathering the data on which to base the reflection and plan change it is not only problemsolving it is also problem posing where it finds the values and plans realized by the work in reallife situations it is oriented by the quest to improve and understand the problems by getting involved in it and making some changes par is not research conducted by outsiders but research by practitioners on their practices it treats the people as independent responsible change agents who can solve their problems themselves make their histories and construct knowledge it never makes the people subject of study but encourages them to engage in the research and improve the existing situation it is also not the method or technique for policy analysis and implementation because it never accepts the truths created by outsiders moreover it is not the scientific method of any social work because it does not test hypotheses using hard data it further works in the natural setting it is systematically evolving a living process changing through living dialectics of researcher and research kemmis and mcgarrat illustrated four types of myths misinterpretations and mistakes in critical participatory action research they grouped them into four clusters … exaggerated assumptions about how empowerment might be achieved through action research confusions about the role of those helping others to learn how to conduct action research the problem of facilitation and the illusion of neutrality the falsity of a supposed researchactivism dualism with research seen as dispassionate informed and rationales and with activities seen as passionate intuitive and weakly theorized an understatement of the role of collective and journal of nelta gandaki vol vi november 2023 how it might be conceptualized in conducting the research and in formulating action in the project and its engagement with the public spare in all facets of institutional and social life similarly clark et al stated three criticisms commonly occurred in action research practices the major criticisms they discussed were the lack of rigour and trustworthiness in comparison to other research methodologies the generalizability of the findings to other contexts and the deficit model as its basis as they explained in the article these criticisms can be minimized by maintaining rigor throughout the research process from selecting issues to collecting and reporting challenges in doing participatory action research there are several challenges for example diversity in meanings of par and interchangeable use of terms such as action research participatory action research practitioners research and novice researchers might get confused since there is a lack of a comprehensive and balanced way to learn about the diverse origins theories methods motives and problems associated with the related field the researchers may remain in dilemmas about whether to follow par as a research methodology another challenge can be the inclusion of community members in the research team because they may have problems maintaining commitment throughout the research since par requires time knowledge and sensitivities on the part of researchers to participants agenda moreover there may be a divergence of perspectives values and abilities among the members the next challenge can be the balance of power and establishing the relationship in par issues of power imbalances and the establishment of egalitarian relationships must be addressed before initiating par research there may be misunderstanding among the people involved lack of agreement wrong perceptions directions and questions resulting in irrelevant data while using par as a methodology the researchers need to be sensitive because the researchers may have to prove its legitimacy to others those conventional researchers who are not used to openended research designs might criticize it the most criticized aspect of par from a scientific perspective is that it is a soft method of research therefore other researchers might challenge it for employing as a research methodology as it emphasizes voice and everyday experiences and not hard data conclusion and implications participatory action research as it aims to transform the existing situation and emancipate the research participants has been widely applied in the field of social sciences and education for exploring workplace issues and overcoming them through collaboration participation and action its cyclical and transformative nature has also fascinated many emerging researchers to adapt it in their research as a methodology moreover the critical review of its origin features and practices shows that participatory action research can bridge the gap between theory and practice as it is always oriented to generate practical knowledge and also to practice the knowledge created in the local context furthermore participatory action research engages the community people in the process of research and takes ownership of the knowledge or change that occurs although it is often criticized for being loosely designed and not systematicallyscientifically conducted to produce true scholarship scholars have suggested ethical considerations and quality standards for its rigour its popularity has tremendously increased as the qualitative approach to coping with local issues and theorizing the knowledge produced by the practitioners this paper might be helpful to understand and apply participatory action research in the field of social sciences and education as a research methodology moreover this can be insightful to the teachers researchers and policy makers for taking into practice

participatory action research as other qualitative methods like phenomenology ethnography narrative inquiry autoethnography and case studies has emerged as a distinct field of study and established itself as a research design in the field of social sciences and education this methodological conceptual paper presents a review of participatory action research papers highlighting their meaning purpose and use in research along with their definitions the process of conducting research through participatory action research as a methodology its guiding principles strengths weaknesses and challenges applications misconceptions and analysis of previous studies through participatory action research in various disciplines and contexts this paper also highlights how participatory action research elevates the marginalized communities involved in the research process solves their workplace problems and transforms their identities throughout the research by reviewing a few sample studies through participatory action research the findings show that participatory action research has been immensely used in the social sciences and educational research for creating new knowledge as well as improving the existing situation this paper might provide some significant insights into understanding and employing participatory action research to the teachers teacher educators and researchers who opt for using research as part of their academic degrees

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introduction the amazon rainforest colloquially called the lungs of the earth is an ecosystem of incalculable global ecological value this unique ecosystem is threatened by various human activities most notably traditional and industrial mining both legal and illegal the growing mining expansion in the amazon region is of grave concern mainly due to the potential harm to surrounding communities and the sustainability of this fragile ecosystem this situation mirrors critical challenges in sustainable development and environmental justice when attempting to implement landuse change policies the inherent ecological fragility of the amazon region poses significant challenges historically land use planning and zoning decisions have favoured economic gains over environmental and social welfare in these delicate ecosystems while industrialisation may spur economic development it also carries severe environmental and social repercussions that must be understood from various perspectives this study aims to explore and understand the ramifications of gold mining on communities near extraction sites specifically it focuses on the daily life of communities near areas where illegal gold mining is practised following years of legal exploitation with government permits within the framework of sustainable development anticipating the legacy that mining will leave in communities after its closure is vital as it constitutes a crucial element of its planning the goal is to provide key insights that aid in planning land transformation and crafting policies for sustainable land use the community of yutzupino in the napo province of ecuador serves as the focal point of this research through exploring the experiences of this community we aspire to amplify our comprehension of the socioeconomic interplay and challenges they face in the aftermath of official mining activities notably this study posits the creation of a new category within spatial planning explicitly tailored for territories previously subjected to mining a qualitative methodology encompassing comprehensive interviews and observational studies was employed to fulfil this objective the findings of this article contribute theoretical empirical and practical insights relevant to territorial planners policymakers and local communities in addition the study provides an essential understanding of the needs challenges and goals of the communities impacted by mining which can inform and steer both sustainable development strategies and initiatives led by the community itself the articles structure unfolds as follows section 2 provides the studys theoretical framework focusing on the aftermath of mining following the termination of concession contracts section 3 outlines the methodology and approaches used in the research the results and their corresponding analysis are presented in section 4 divided into five subsections the paper ends with a set of concluding remarks derived from the study theoretical background one of the main threats facing the amazonian ecosystem is industrial and traditional mining activities the expansion of mining poses concerns about the potential destruction of surrounding communities and the sustainability of particularly fragile ecosystems worldwide this sustainability in debate brasília v 14 n3 p 219233 dez2023 issne 21799067 theoretical review explores the socioenvironmental implications of gold mining in the amazon and its consequences for local communities land use zoning is a tool for regulating activities in a specific geographical area it allows authorities to categorise lands for various purposes such as agriculture conservation infrastructure and industrial development in the amazon case zoning favouring industrial mining has prioritised economic gains over environmental and social welfare the expansion of industrial mining brings with it the destruction of forests and loss of habitats impacting communities that depend on these resources for their livelihood and cultural identity thereby exacerbating inequality and social conflicts concurrently the release of toxic chemicals into water bodies such as mercury and cyanide threatens biological diversity and disrupts the natural cycles of the ecosystem this negatively affects flora fauna and vital ecosystem services such as climate regulation water purification and food provision the interconnection of the different ecosystem components like rivers forests and soils requires a holistic approach to land use management deforestation frequently spanning across borders often results from clearing forests to accommodate mining activities this leads directly to extensive habitat loss and biodiversity displacement also the extraction of minerals and the associated infrastructure construction disrupt natural hydrological cycles resulting in notable changes in water availability heightened incidence of flooding and exacerbated soil erosion much like other mining activities gold mining plays a substantial role in the amazons environmental degradation celi sangurima and velasteguimontoya et al underscore the connection between gold mining and forest loss changes in land cover and use patterns and decreasing biodiversity also pérez et al scrutinise the detrimental effects on water quality and likewise link gold mining with longterm biodiversity loss furthermore by its very nature gold mining requires substantial displacement of soil and rock a factor that invariably instigates soil erosion this erosion affects slope stability undermines soil fertility and hinders the ecosystems innate regenerative abilities comprehensive research such as the study conducted by balaka opiyo et al in kenya demonstrates that gold mining precipitates the degradation of vegetation cover and the depletion of fertile soil posing substantial threats to agricultural productivity the impact on surrounding communities driven by the rising global demand the amazon has seen a surge in gold mining leading to significant land cover changes swenson et al highlighted how this increased gold demand local resource utilisation and growing populations in communities around the mines have reshaped the peruvian amazons environment this demographic growth in mining areas pushes forests to be converted into agricultural land lópez and maldonado emphasise that while this land cover transition does not always spike overall deforestation rates it notably diminishes successional forests and exacerbates water quality issues the health consequences of gold mining for amazonian communities are notably alarming the employment of hazardous substances like mercury and cyanide in gold extraction processes severely threatens human wellbeing specifically mercury contamination of fish and water sources has been associated with neurological and developmental disorders among communities along the brazilian amazons riverbanks social disruptions are also of primary concern the social impact of mining projects in amazon communities is complex marked by anticipation and conflict during various stages of mining operations in early phases companies must obtain social consent to operate leading to high expectations and sometimes resistance or division within communities attempts to secure local consent may involve harmful practices such as coopting leaders and corruption once mining is underway challenges include mismatches between expectations and reality inequalities dependency on the company social changes and erosion of trust in public institutions these dynamics along with land rights conflicts underscore the multifaceted social impacts of mining in the region the literature has broadly examined the environmental and health consequences faced by communities surrounding gold mining territories in the amazon much of this focus has been directed towards concession contracts for industrial exploitation particularly emphasising the stages prior to and during the concession phases however a noticeable gap persists in understanding the social conflicts that arise postconcession this underexplored area highlights a need for further investigation to comprehensively address the full spectrum of social impacts associated with gold mining in the region emerging approaches to mining concessions addressing the destructive consequences of mining in the amazon requires a fundamental shift in land use zoning and resource management strategies this includes encouraging responsible mining practices utilising cleaner technologies and enforcing stringent environmental regulations to reduce the ecological footprint of mining operations moreover facilitating the temporal coexistence of legally concessioned mining by industrial means with traditional mining practices has been identified as an approach to decrease social conflict between concessioned firms and local communities this idea supported by loor and evans and roy illustrates the ongoing interaction between formal and informal spheres in the global south highlighting the potential for sustainable solutions that balance ecological integrity and social harmony managing the challenges of mining concessions in the amazon may also be addressed through strategic incentives barroso and campos emphasise the crucial role of economic incentives such as certification schemes and fairtrade initiatives in promoting responsible gold mining practices by offering financial rewards tied to sustainability these incentives not only encourage miners to employ environmentally friendly techniques but also actively promote the restoration of areas that have been degraded land tenure regularisation is another approach to tackle the challenge according to bernal dávalos unrestrained mining exploitation in bolivia has been driven by the separation of indigenous communities from their ancestral territories leading to new mining settlements and consequent land ownership disputes for indigenous peoples land is more than a physical entity it is a vital part of their cultural identity providing wealth comfort security and stability regularising land tenure and establishing clear ownership and rights can be a protective measure this approach could help prevent illegal mining activities create a legal framework for sustainable land use and preserve the delicate balance between economic growth and the conservation of culture and the environment recognising and empowering indigenous communities in decisionmaking related to mining is also crucial indigenous territorial organisation and selfmanagement play a vital role in conserving amazonian ecosystems and protecting indigenous rights martin et al emphasise the importance of land rights and indigenous management practices for achieving conservation and social goals indigenous communities possess traditional knowledge associated with sustainable practices that can help mitigate the negative impacts of gold mining and promote alternative livelihoods based on traditional resource use and cultural preservation based on the literature review a discernible gap in research has been identified in understanding the social conflicts that arise postconcession of gold mines this unexplored aspect necessitates further investigation to provide a comprehensive understanding of the impacts of gold mining in the region moreover little attention has been paid to understanding what it is like to live and subsist daily while economically depending on nearby gold mining a comprehensive insight into these subtleties can pave the way for targeted solutions that balance economic growth with environmental stewardship methodology and methods what is the social context of communities proximal to gold deposits which are still subject to traditional and illegal mining operations in the amazon after the end of official concessions to tackle this research question this study employs a qualitative and descriptive case study approach the study aims for evidencebased insights into how the transition of gold mining concessions unfolds emphasising the complex interplay between traditional mining practices and illegal operations the community of yutzupino located near tena city in napo province within the ecuadorian amazon region is the case selected for this study yutzupino is of interest because it encompasses various intersecting factors within this community the interplay between traditional mining practices industrial mining companies and indigenous land connections forms a complex landscape this combination yields unique challenges and insights into how mining influences the inhabitants their lifestyles and the surrounding environment the specific circumstances in yutzupino contribute to a broader understanding of the complex issues related to mining in the amazon marking it as an invaluable area for exploration as part of this research primary data were collected through detailed interviews and onsite observations while secondary data were derived from recent censuses conducted by the risk secretariat of ecuador and relevant media content the subsequent sections delineate the cases characteristics and the data collection and analysis methods the case the community of yutzupino situated 14 kilometers away from the parish of puerto napo and nestled in the heart of the ecuadorian amazon in napo province is today home to 327 kichwaspeaking residents living in 65 dwellings and families despite its modest size the community showcases a substantial demographic variety with pregnant women persons with disabilities and older adults the houses are entwined with this biodiverse regions vibrant flora and fauna at first glance it may seem idyllic yet yutzupino faces a series of challenges threatening the life and safety of its inhabitants homes in yutzupino traditionally constructed are perpetually endangered due to their proximity to the jatunyacu river a tributary of the napo river meaning big river these houses are in a high floodrisk area constantly threatening the safety and lives of their inhabitants land tenure issues and the scarcity of relocation alternatives limit residents options to move away from this hazard zone the communitys economy is rooted in agriculture with crops like cassava banana and cacao as staples however the people have also turned to traditional mining as a vital supplement to their income supporting their local economy the simple yet effective act of miners shaking pans in the water to extract gold has become a symbol of daily life in yutzupino reflecting both their ingenuity and their connection to the land over the last two decades the landscape of yutzupino has been profoundly transformed by the concession of mining rights to private firms for industrial gold extraction the ecuadorian government these concessions have transformed the everyday life of local miners who perform the extraction while dodging heavy machinery and excavators a perilous reality that has woven itself into their routine as the situation moved into the postconcession phase it has further deteriorated the blend of illegal industrial extraction outsider traditional miners and local traditional miners has ignited tensions and social conflicts this mix has accelerated environmental degradation heightened community vulnerability and added complexity and risk to the mining practice data collection and analysis the primary data collection process unfolded as follows between april and may 2023 indepth interviews were conducted with 18 heads of households focusing on those involved in traditional gold mining these hourlong interviews took place in the participants homes detailing their everyday lives challenges and relationships with illegal mining ethical considerations were paramount with informed consent sought for all interviews and observations the selection of participants was carried out randomly during onsite observations between november 2022 and may 2023 initially triggered by the interest of the municipality of tena the capital city of napo province to address the presence of illegal minersa situation that escalated to become the subject of a hearing in the ecuadorian national assemblythe observations evolved in scope and focus the research began with unsystematic observations to map the area and the communities affected by mining later moving to a more structured approach this focused on the houses materials that sustain everyday life and travel patterns to everyday places photographs were taken and a diary was maintained to capture these observations analysing the data involved content analysis and handcoding indepth interviews were transcribed and organised by key themes and categories forming the backbone for a narrative description of the communitys daily experiences this qualitative data was then linked to observations and secondary sources allowing for triangulation and a more nuanced understanding of the areas complex often tense social dynamics the researchers were mindful of the dangers and tensions in this area arising from the intersecting interests of locals outsiders and newcomers involved with illegal mining findings and discussion the findings unfold an unsettling reality faced by the indigenous amazonian community of yutzupino historically engaged in rudimentary practices of gold mining as one of their diverse sources of income these inhabitants now find themselves at a complex intersection of challenges their struggle to preserve their traditional way of life increasingly clashes with the need for conservation and personal safety the current context presents a web of socioeconomic environmental and security challenges that weave together demanding immediate and effective intervention to untangle and resolve the following paragraphs are organised into five subsections the end of mining concessions affecting the study area is reported in the first subsection revealing their impact on the local community the second subsection delves into traditional gold mining elucidating its practices and significance within the community next the focus shifts to the living conditions in the third subsection where a portrayal of the houses and limited access to essential services is given the fourth subsection uncovers the physical vulnerabilities of yutzupinos inhabitants highlighting the prominent risks and challenges the fifth section identifies governmental initiatives aiming to address the main issues the end of mining concessions during the mining concessions active period a balance of exploitation was forged between the concession beneficiary particularly terraearth resources and yutzupinos local traditional miners the community members coincide that this balance allowed a harmonious coexistence with the company often employing local miners on a daily wage basis for various gold extraction tasks including machinery maintenance however this cooperative relationship abruptly ended with the concessions suspension in october 2020 in the aftermath of the suspension illegal miners unfamiliar with the community rapidly invaded the area wielding heavy machinery and aggressively competing with local miners this dramatic shift has disrupted the previously established dynamics creating tensions for yutzupinos mining practices yutzupino is now among the areas most severely impacted by rampant illegal gold mining as reported in may 2021 by a technical analyst from the ecuadorian institute of geological and energy research citizen groups napo loves life and napo resists exposed unlicensed gold extraction by four backhoes on the jatunyacu rivers beaches in november 2021 this illegal mining has been conducted using industrial machinery and without compliance with basic environmental standards a report from the andean amazon monitoring project further confirmed this highlighting the illegal miners swift takeover of the area maap issued its initial alarm report in october 2021 identifying less than one hectare of affected land shockingly by december this damage had ballooned to 61 hectares according to a journalism report ecociencia spokespersons who participated in maaps analysis pointed out that 875 of the illegal mining expansion occurred in december by january 2022 the devastated area had expanded another six hectares this alarming rate of mining activity expansion underscores the urgent need for intervention traditional mining in the community of yutzupino traditional mining is viewed as a secondary activity supplemental to their primary occupation of farming and selling local products like cassava banana and cocoa in interviews yutzupino miners explained that gold mining typically occurs at night continuing until about 3 in the morning community members including men women and young people embark on a 30minute walk along a gravel road to reach the gold extraction area there heavy machinery is observed excavating and forming embankments describing their handson process miners shared how they collect material from the base of the embankment using shovels after removing larger rocks they wash the material with gentle pan movements leaving only small sediments at the pans bottom these sediments may or may not contain gold they emphasised that the success of this endeavour depends on the miners skill with each load taking approximately 5 minutes to process the miners also described an adaptation of traditional gold mining techniques through a less conventional tool a homemade version of a washing machine commonly used in smallscale mining as explained by the miners the device consists of a wooden ramp covered with a piece of cloth and a metal grid the process begins with the miners pouring material onto the ramp with a shovel and then the socioenvironmental aftermath of gold mining in the amazon the case of yutzupino in napoecuador 226 sustainability in debate brasília v 14 n3 p 219233 dez2023 issne 21799067 adding water to filter the material through the cloth and grid after all the material has been filtered they remove the cloth and in the centre sediments remain where gold may be present these descriptions vividly show how traditional methods are being fused with innovative techniques to maximise their gold extraction efforts figure 1 offers a visual representation of a miner using the pan in yutzupino traditional mining practices occur in dark and hazardous areas where machinery operators dig the poor visibility increases the risk of traditional miners being struck by excavators furthermore the communitys digging activities at the base of the embankment undermine its stability leading to frequent collapses that pose serious dangers to those working below yutzupino miners have also voiced concerns about pollution and the authorities responses to gold mining in the area recent military operations to combat illegal mining have led to the confiscation of their traditional mining tools and gold further igniting dissatisfaction within the community one resident emotionally reflected at least the chinese miners gave us work we had breakfast lunch and dinner for our children recalling a time when the concession was still active concerning pollution they describe the pollutants in nearby bodies of water they often find deposits of oils fats and metallic waste formerly components of the mining machinery they have observed that the bodies of water near the community are contaminated with sediments which decreases water quality exterminates aquatic life and affects peoples health these issues aligning with martin et al are viewed as an affront to indigenous land rights however the impact of gold mining in yutzupino extends beyond environmental degradation the lure of gold has attracted outside miners leading to clandestine businesses and tolerance zones this influx has fostered an environment marked by excessive alcohol consumption and occasional aggression disrupting community peace additionally reports of prostitution and violence during protests further underline the negative social consequences of mining within the community the problems the yutzupino community is facing are complex involving their traditional way of living taking care of the environment and getting along with each other what is happening in yutzupino might not be unique to just their community the experiences and concerns shared by the people there show that we must look deeper into these issues more research is needed to see if similar things are happening in other places where gold mining occurs especially after the official permissions for mining end this will help us understand the broader effects of mining on local communities and their environment housing houses of yutzupino erected on wooden pillars and chains without formal technical design also symbolise the precarious living conditions and the ongoing struggle for survival faced by their inhabitants the durability of the wood elements is particularly poor making them highly vulnerable to the extreme weather conditions common to the amazon region the walls of these houses are made of vertically arranged wooden planks occasionally cement blocks can be observed denoting an attempt to incorporate more durable materials but it also highlights inequality in resource access as a result the structures require frequent maintenance and reinforcement to ensure their integrity and to provide enough protection for those who live within them the roofs of the houses are made of zinc sheets while these roofs are lightweight and resistant to heavy rain they create a hot and overwhelming internal environment that is hardly conducive to the wellbeing of its inhabitants often covered with plastic sheets windows provide an ephemeral barrier against the exterior environment and lack the security and durability of a conventional window figure 2 displays two houses with typical features of the community the socioenvironmental aftermath of gold mining in the amazon the case of yutzupino in napo ecuador the poverty situation in yutzupino is further reflected in the shortcomings of its essential public services and facilities access to clean water is persistently challenging largely due to the complexities of land subdivision an administrative and legal process that divides properties into smaller lots with individual registration this practice vital for clarifying land use rights and maximising property value is hampered by the need for proper land tenure regularisation to prevent misuses such as illegal mining as hänggli et al emphasised in addition to water issues the community faces problems with electricity access though available throughout yutzupino the electricity supply is often unreliable and insufficient to meet everyday needs education in yutzupino is limited to a basic level the daily commute to puerto napo necessary for young people aspiring to obtain a high school education is emblematic of the broader challenges faced by the community this burden not only hinders their academic development but is a manifestation of the systemic weaknesses in the area which adds to the unreliable utilities and the need for frequent housing maintenance figure 3 illustrates the daily route students use between yutzupino and puerto napo a visual representation of the interconnected challenges that obstruct educational advancement and overall progress within the community in yutzupino the precarious state of housing coupled with the lack of dependable utilities and constrained access to education creates a vivid portrait of the challenges endemic to this amazonian community this complex situation does not merely reflect material hardship it underscores a broader narrative of poverty and vulnerability it is a call to action emphasising the need for thoughtful intervention and support to address these multifaceted issues and empower the community the physical vulnerabilities of yutzupino inhabitants yutzupino is close to the river which defines the areas appearance but also makes it vulnerable the people there enjoy the rich natural resources but face constant threats to their safety because of the location flooding is common especially when it rains heavily the residents recall times when the floods were so strong that they washed away weak homes on the riverbanks destroying important belongings and crops the people believe that gold mining is making things worse changing the rivers flow and washing away the banks this makes flooding more likely and puts the homes near the river in danger in addition to flooding residents of yutzupino mention feeling small earthquakes at least once a month while they have become accustomed to these lowmagnitude tremors the experience is always unsettling and scary these regular quakes have revealed cracks in the houses and throughout the community adding to ongoing concerns for the inhabitants safety the inability of the structures to withstand even these minor quakes underscores the precariousness of living conditions in the area and keeps the fear of a more significant disaster yutzupino susceptibility to house fires also stands out as a critical concern the residents identify poor electrical installations and the use of highly flammable construction materials like wood as the primary causes such conditions allow fires to ignite and spread rapidly posing an everpresent danger to both life and property the community also fears the force of strong winds a common occurrence in the area these windstorms have the power to tear off roofs and damage crops causing chaos in the populations livelihoods and essential infrastructure in the face of these environmental challenges yutzupino finds itself in a ceaseless battle with nature the combined threats of flooding earthquakes fires and windstorms weave a tapestry of physical vulnerability exacerbated by a lack of resources and proper planning this precarious situation perpetuates a cycle of poverty and exposure to environmental risks underscoring the imperative need to mitigate these threats government interventions in addition to the vulnerabilities mentioned above yutzupino faces land regularisation and tenure security challenges here 89 plots are dangerously located within the risk zone of the jatunyacu river and do not qualify for regularisation the tena municipal government has played a crucial role in responding to these challenges it has been confirmed that the lands belong to the heirs or relatives of the original owners recognised by regulatory institutions such as the national institute of agrarian development and the ecuadorian institute of agrarian reform and colonization however instability persists due to the environmental risk that constantly imposes the threat of relocation to counteract these challenges the municipality has acquired 235 hectares of land in the upper part of the community to relocate the endangered residents the area was subsequently parcelled and the parcel plan was approved and legalised it fell to the community to take the final step to secure ownership of the individualised lands registering them in their name at the tena property registry however a lack of management and resources has thwarted this process leaving the residents in an even deeper situation of vulnerability and uncertainty in these plans yutzupino is categorised as a forest conservation area with minimal agricultural uses destined for sustainable forest utilisation however according to the map of conservation areas of the tena canton yutzupino is not classified under any conservation category on the contrary it is identified as a metal extraction zone on the mining types mining concessions map which aligns with the mining concession granted to terraearth resources sa company to explore and exploit a vast territory including the community area this evidences a conflict in the classification of land use in the canton conclusion this research sought to investigate the socioenvironmental consequences of gold mining in amazonian communities particularly after the ending of official mining concessions the core question revolved around the effects of mining activities specifically how the cessation of formal concessions gave rise to an upsurge in illicit mining activities and its impact on local communities and their environment this studys theoretical contribution lies in a nuanced understanding of the dynamics of mining exploitation in amazonian communities during the active lifespan of a mining concession a delicate equilibrium is observed to coexist between traditional and industrial exploitation where environmental degradation occurs gradually however this equilibrium can be disrupted at the end of the official mining concession marking a shift towards an anarchic state in this phase illegal exploitation encompassing both traditional means and heavy machinery overexploits resources leading to exponential degradation this understanding constitutes significant insights into the transitional phases of mining activity and their impact on social and environmental stability providing a theoretical foundation for future territorial planning and industrial policy implementation in terms of empirical and practical implications the study offers a rich exploration of overexploitation in mining empirically it paints a vivid picture of how illegal mining practices can dramatically alter the socioenvironmental context of local communities practically these insights shed light on better land use planning in amazonian mining sites the research delivers tangible elements for developing sustainable mining policies particularly on avoiding undesirable aftermaths of gold mining by analysing the specific impacts and complex dynamics at play the study equips policymakers and planners with the evidencebased understanding needed to navigate the challenges of postconcession mining activities thus offering a robust foundation for planning and policy future research in this field should focus on exploring potential measures to prevent overexploitation post the lifespan of mining concessions a promising avenue of investigation is to evaluate the efficacy of various zoning policies that act as mitigating strategies against rampant exploitation furthermore studies examining successful interventions in other regions could provide valuable insights and potential frameworks to guide policies and practices the findings of such research would contribute significantly to devising and implementing sustainable mining policies that prioritise not just economic gain but also social welfare and environmental protection

this study addresses the social and environmental repercussions on amazonian communities due to gold mining following the conclusion of official concessions framed within the literature on natural resource extraction sustainability and social impacts in developing countries the work employs qualitative methods including interviews with residents and field observations in the community of yutzupino in the ecuadorian amazon it reveals that postconcession mining often informal and illegal sharply triggers social and environmental degradation the research emphasises the need to incorporate sustainability principles into mining concessions to prevent such effects this analysis enhances understanding of the complex socioecological aftermath of mining in vulnerable environments it proposes recommendations for mitigation underlining the importance of dialogue between communities governments and mining companies

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introduction access to microfinance is a vital but problematic issue for persons with disabilities who wish to pursue their own businesses in uganda microfinance is a strategy that is increasingly being used in the fight against poverty unfortunately persons with disabilities are faced with challenges while learning about and engaging with microfinance this is despite the existence of the communitybased rehabilitation guidelines of 2010 and the united nations convention on the rights of people with disabilities that advocate inclusiveness similarly the good policies that exist in uganda are not matched by good practices katureebes exemplary case has been selected because it provides rich experiences of his learning and insights into many of the barriers that people with visual impairments face while learning about microfinance and the strategies to address them understanding the case of a person with disabilitys learning experiences and the challenges he faces while learning about microfinance can provide insight into the complexity of the interplay between disability and adult learning and provide a basis for improving education provision for people with visual disabilities the case also provides a glimpse of the complex relationships between adult education disability and microfinance the purpose of this article is to illuminate the barriers that a person with a visual impairment encountered while learning about microfinance and the strategies that he developed to overcome them it provides an understanding of the interplay between unfavourable physical and psychological factors learning environment and inadequate finances we start with the research context and then frame the study within relevant literature and theory this is followed by an explanation of the methodology employed a profile of katureebe and the presentation of results focusing on adult learning practices the barriers encountered and strategies adopted we discuss the findings in relation to the social model of disability we conclude with some reflections on the implications regarding adults with disabilities learning and microfinance background research context the world report on disability estimates that 153 of the world population is disabled and is likely to have lower educational and employment opportunities who confirms that in uganda as in many developing countries persons with disabilities have low literacy levels while the net enrolment in primary education stands at 811 only 15 of children with disabilities are able to access education 5 through inclusive schools and 10 through special schools this limits persons with disabilities acquisition of what who calls foundation skills including those required to successfully run a business lwangantale confirms that in uganda many persons with disabilities are of low formal education levels and hardly have any formal employment opportunities for those who wish to start or improve their own businesses accessing microfinance loans requires literacy skills such as filling in loan application forms calculating interest on loans and keeping records persons with disabilities access to education may therefore enhance their access to microfinance services conversely lack of education may limit access it is likely that the income situation of persons with disabilities would change if they had access to microfinance loans and appropriate adult learning opportunities the need to provide educational opportunities for such a large and deprived group cannot be ignored unfortunately in uganda as in many african countries persons with disabilities hardly benefit from adult education provision despite the challenges some persons with disabilities including those who are semiliterate do access microfinance services however the way they acquire the knowledge and skills to improve their livelihood is largely unknown and undocumented the microfinance services in this study were those provided by savings and credit cooperative organisations according to the executive director microfinance centre saccos are memberowned membermanaged and memberused community based and much closer to the poor than mainstream mfis our addition micro finance institutions unfortunately the field of adult education and disability in african contexts is underresearched and especially how disability affects impacts andor constrains the adult learning context this is reflected in subsaharan countries recommendation 28 for the international conference in adult education vi that all adult learning and education programmes should take into consideration the special needs of disabled learners objectives this article builds on nuwagabas study by engaging in more indepth analysis to bring out the complexities of the barriers experienced by a person with visual disabilities during learning processes and the strategies employed to overcome them literature review understanding the unique characteristics of adult learners with disabilities while adult learners with disabilities engage holistically in adult learning processes like learners without disabilities they are a minority group whose voices are often silenced their selfidentity and how they are viewed by society play a much bigger negative role in their learning than for those without disabilities because society often regards them as inadequate some of them have internalised their oppression and as freire argues those who get to this stage believe their situation cannot be changed on the other hand there is evidence that some adult learners with disabilities have a strong motivation to learn rule modipa investigated the attitudes of adult learners with disabilities regarding education in a nongovernmental organisation setting in south africa they found that they had negative childhood experiences of education and suffered stigmatisation as adults however they had a strong desire to learn and attempted to affirm their position in society as people with potential just like anyone else in addition to the social barriers that exclude them from microfinance services adult learners with disabilities may also be hindered by lack of selfesteem and selfconfidence themselves internalised consequences of social barriers their families or own expectations of an entitlement to charity may reinforce this exclusion additionally adult learners especially those who have faced discrimination and inequality have strong emotions which can either support or hinder learning in his study on distance learners zembylas describes attitudes that arise out of inequality and discrimination as us versus them adult learners with disabilities may fit this description as they face discrimination and marginalisation for such learners who may feel persecuted and defensive learning with learners without disabilities can be problematic unless society takes explicit measures to accommodate them open access adult education literature recognises the uniqueness of adult learners with disabilities clark identifies such learners as individuals with unique or special needs that can be addressed through provision of sign language interpretation notetaking services assistive technology and separate andor extra time for exams services that can be provided by society although clarks conceptualisation relates to formal learning it is apart from examinations relevant to nonformal adult learning relevant content and the use of facilitators who are able to recognise the characteristics of adult learners with disabilities and employ appropriate methodologies can also help to address their learning needs framing the study in theory the social model of disability the social model of disability was developed as a reaction and alternative to the medical model which defined disability in medical terms and located it as a problem of the patient according to the social model economic cultural attitudinal physical and social barriers stop people with impairments from participating fully in society and so create disabilities society is viewed as the problem not the person with impairment the social model fits in well with the agenda of the disability movement in uganda which advocates for the removal of barriers to the participation of persons with disabilities in all spheres of life ugandas national policy on disability understands disability as permanent and substantial functional limitation of daily life activities caused by physical mental or sensory impairment and environmental barriers resulting in limited participation this definition focuses on the disabling environment although the impairment is not ignored however the social model is criticised for downplaying the role of impairment and personal experiences the social model of disability resonates well with the critical research paradigm which was adopted in this study and which can be used to understand and contribute to reshaping oppressive structures and processes in society such as those experienced by persons with disabilities research method and design the study adopted a qualitative case study approach within the critical research paradigm this paradigm was adopted as an appropriate theoretical frame because the study investigated the marginalisation of a person with visual disabilities involved in nonformal and informal adult learning and the strategies he employed to transform this situation the transformation focused on redressing discrimination inequalities barriers and social structures and systems which according to oliver truman and ndeezi prevent people with impairments from full social participation in this way the critical research paradigm and the social model of disability complement each other a case study was adopted because with its focus on the specific case it can provide a rich description of a particular instance examining the complex relations within the case and in relation to its context as well as yield insights into the relation between the case and what it is a case of walter also affirms that case studies can be used to provide insight into educational issues and processes in this instance the adult learning practices of a person with visual disability in addition case study research can apply and develop theory such as in this study the social model of disability the sampling approach used in the study combined purposive and snowball sampling purposive sampling was used to identify the saccos serving the persons with disabilities in the western ugandan district of bushenyi because according to uca the district had vibrant saccos as saccos do not easily release information about their clients snowball sampling was used to identify katureebe a leader of persons with disabilities was contacted and she helped identify some persons with disabilities involved in saccos and these in turn identified others including katureebe katureebe was selected due to his long involvement in saccos and his role as a leader among persons with disabilities using microfinance we do not view his experiences as representative of or generalisable to all persons with disabilities involved in microfinance as we indicate in our discussion section nevertheless this case provides valuable insights into the social model of disability in relation to disability adult learning and microfinance data collection involved the use of loosely structured interviews and observations katureebe was interviewed three times between 2012 and 2013 and each time the interview lasted about one and a half hours the interview questions focused on type and degree of impairment and their effect on learning and engagement with saccos the challenges faced during learning processes and the conduciveness of the learning venues the interviews were conducted in the local language and taperecorded they were then transcribed and translated into english by the open access researcher and a research assistant to improve accuracy and reduce bias the observations focused on the conduciveness of learning venues at sacco and administrative buildings for data analysis the adult learning practices of katureebe constituted the case and the unit of analysis open coding and axial coding were employed to generate categories and themes the transcribed data were read many times and four key themes namely learning methods barriers and strategies were identified as axial codes for analysis under learning what katureebe learnt such as knowledge and skills in savings borrowing and attitudes were analysed in the theme on methods we analysed how he learned and this included touchfeelrecognise and questioning as for barriers the hindrances to his learning and engagement with saccos were analysed and these included inaccessible teaching and communication approaches unfavourable physical and psychological environment and economic and mobility barriers the analysis of strategies focused on the coping strategies and the support katureebe received to address the barriers the data analysis process was dialectical and involved assembling and disassembling of data to discover connections and relationships we as authors do not have impairments but identify with persons with disabilities struggles against marginalisation and discrimination the first author has a sister with a disability and both authors have previously conducted participatory research on disability although oliver proposes that persons with disability should conduct their own research barness counter proposal is that a researcher does not necessarily need to have an impairment in order to do it as katureebe was a person with visual impairment a category considered vulnerable particular care was taken to ensure that he was treated with respect and in a manner that was intended not to psychologically stress or humiliate him the checklist suggested by mcniff lomax and whitehead which includes participants right to withdraw researcher trustworthiness and keeping promises was adhered to ethical considerations informed consent informed consent was sought and obtained from the research participant orally in his local language before doing the observations or indepth interviews but after he was informed of his rights the uncst guidelines accept oral consent anonymity although respect for anonymity is a good ethical practice katureebe insisted we use his real name he argued that as he had told us the truth there was no need to hide his identity we agreed with him because of nuwagaba and rules argument that going against his wish would signify that his views were not being respected because of his impairment profile of mr katureebe mr katureebe desired to learn how to read and write braille but was constrained by lack of learning opportunities and the costs involved he has had many challenges in life he was forced to abandon his job with a shoe company because of his impairment and his emotions are evident as he tells his story he acknowledges that disability has made it difficult for him to realise his full potential yet the responsibility of maintaining the family rests with him as man because he lives in a patriarchal society the same society bestows on him control over family resources katureebe faced barriers such as inaccessible teaching and communication approaches unfavourable physical and psychological environment and lack of finances that limited his learning and engagement with microfinance he strove to overcome these barriers with support from fellow persons with disabilities saccos family and community members results katureebe was found to have participated in two types of adult learning about microfinance informal and nonformal rogers notes that informal learning occurs as a result of interaction between adults as they engage in activities in their everyday lives nonformal learning on the other hand is structured in terms of learning objectives learning time or learning support and is intentional from the learners perspective what katureebe learnt and how he learnt it katureebe learnt a wide range of skills knowledge and attitudes including farming identifying currency getting feedback during communication leadership roles use of mobile phones and strategies to address barriers to participation and utilisation of microfinance services the focus of this article is on the learning related to his engagement with microfinance how katureebe learnt the various ways through which katureebe learnt depended on the interaction between his impairment the environment and what he was learning touchfeelrecognise a strategy of touchfeelrecognise was used in learning how to manage money as described by mr katureebe i feel the sizes of the notes with my fingers after arranging them on my palm and distinguish them by size to determine their value i know the notes are in the values of shs 1000 2000 5000 10000 20000 and 50000 and the sizes of the notes correspond to the values of the notes the shs 500 coin has the shortest circumference is thickest and has an embossed picture of the head of a bird the shs 200 coin is somehow thin with a medium circumference and has an embossed picture of a fish and the shs 100 coin has the longest circumference is thinnest and has an embossed picture of a cow this explanation indicates a process involving touching followed by feeling and then recognising which nuwagaba coined as the touchfeelrecognise method of learning this method served katureebe well in identifying ugandan currency notes which have no embossed features it is noteworthy that while size distinguishes the notes thickness distinguishes the coins he acknowledged that this method could only be used when one had all the notes and the amount involved was not large questioning as a learner katureebe used questioning as a strategy of seeking feedback while communicating with those conducting the training and fellow learners during the learning process he mentioned that having become blind later in life he was aware that people often show they are following a discussion through nonverbal cues which blind people do not pick up his strategy was to constantly ask ummmhhh aaaahhh eeee tukwe onyine he often did not complete the words or sentences and encouraged the listener to complete them by asking ummmhhh he then used that response as feedback to gauge whether someone was following the discussion or not practice katureebe intimated that the leadership skills he exhibited as leader of their rosca were acquired through practising the skills acquired from the cbr training he received in 1990 saying when cbr was introduced from bushenyi they educated us … we made groups and from there we who got into leadership positions started practicing leadership skills the skills he mentioned included chairing meetings making decisions regarding admission of members communicating on behalf of their group representing their group in leadership training and other meetings among others barriers to leaning and engagement with sacco services the barriers that katureebe faced included inaccessible teaching and communication approaches unfavourable physical and psychological learning environment and lack of finances which limited his participation as follows inaccessible teaching and communication approaches katureebe could neither see facilitators demonstrations during the learning process nor effectively participate in learning about microfinance services because the facilitators were using inaccessible teaching and communication approaches this restricted his participation in learning he noted but for someone who is blind when your arm is up they will point to you and say you but you will not rise to contribute katureebe noted that barriers went beyond the teaching and learning encounter and included obstructions caused by societys practice of queuing for food at training events he lamented but it pains you when they say that you should all stand to join a line not so you smell the scent of the food others have already started eating and they are swallowing and for you you are swallowing saliva put yourself in that situation by the time you get the food the food will no longer be tasty because your appetite will have already been taken by others ummmh the interconnectedness of physical affective and social elements is evident here society by using a system of lining up for food creates a physical barrier which stops him from collecting the food himself leading to loss of confidence which is an affective barrier and conditions that do not allow him to stand in the line with others create a social distance between him and the others each of the barriers independently as well as the combination of the barriers affected his preparedness to learn unfavourable physical and psychological learning environment the area where katureebe lived was very hilly and very slippery during the rainy seasons the buildings where microfinance training took place had accessibility and usability issues many had entrance steps andor were located in steepslanting landscapes and inside there were steps and cemented or tiled floors which made use of walking sticks on them problematic i will not go there said karureebe of learning events in inaccessible venues because that place is not friendly to me the psychological environment was evaluated as favourable at certain times and unfavourable at other times the psychological conditions he described as favourable included those that put him at ease with himself and with the facilitator katureebe experienced a sense of inferiority and fear which hindered or prevented his participation in learning he added that some community members and development workers took people with impairments to be of low status which limited their participation in learning and utilisation of sacco services he remarked persons with disabilities who think that their potential and abilities are inferior fear to mix with others and this hinders cooperation in learning sessions we see here the phenomenon of persons with disabilities internalising the attitudes of the ablebodied towards them which in turn disables them as participants this reveals that social attitudes have affective consequences katureebe added that persons with disabilities were afraid of getting loans saying we fear to get the money for a loan and then you fail to manage the project i want to show you an example like me i have a pig which i all along thought was pregnant if i could see i would have known that it is not pregnant and taken it where to a male for servicing … when they chicken were attacked by a diseasecoccidiosis you are supposed to tell this disease by the sight of their droppings now if you dont have an active person at home they will be attacked by disease and die … because i might put money in a project and i fail to manage it and i find myself in a loss why should i ask for a loan for what … you decide to die in poverty instead of being taken to prison for failure to pay back a loan are you following me there were occasions when the physical environment influenced katureebes affective state as explained above lining up for food in a crowded room that in addition had steps negatively affected his mood for learning an unfavourable physical and psychological environment was therefore a hindrance to the learning process the absence of mobility systems or support accentuated the environments hindrances again here we see the creation of disabling social barriers to learning with accompanying psychological and affective dimensions which hinder participation financial barriers katureebe noted that because of limited income he could not afford to pay membership fees of groups transport costs to learning venues or buy batteries for his radio all the time and so he missed saccorelated messages he could not open access afford mobility assistive devices such as white canes or a guide and all these combined negatively affected learning about and utilisation of sacco services he explained that because of their impairments and unfavourable environment persons with disabilities spent more to access services which they could not often afford he argued as a blind person … on top of his blindness he needs a guide eeh now life becomes double expensive in addition katureebe was aware that lack of funds denied persons with disabilities sureties when they were applying for loans because wouldbe guarantors were afraid that persons with disabilities lacked the resources to pay back loans findings suggest that while mobility was a barrier in its own right it was also linked to economic barriers all these difficulties however did not deter katureebe as his philosophy was that disability is not inability and that through hard work one can maintain oneself strategies to address the barriers the strategies that katureebe developed to overcome barriers such as the touchfeelrecognise method questioning and practicing were explained in the section on how he learnt other strategies which we now turn to included engaging in advocacy having his daughter assist him in learning sessions and sitting close to people who knew he had visual impairment and would assist him when the need arose he said in a learning session when i put my hand up to contribute some community members help attract the attention of the facilitator to give me an opportunity they pull my shirt or pinch my ribs to alert me that the facilitator wants me to make a contribution katureebe mentioned that he relied on assistance from his daughter who listened in and observed demonstrations and posters during learning sessions and later explained them to him he added she helps me put a pen on the right spot which made it possible for me to sign in an appropriate place katureebe because of his success in engaging with saccos was a role model in sensitising saccos on how to improve access to microfinance by persons with disabilities he was an example of how reducing discrimination against persons with disabilities can make them successful as a result of this and efforts from disabled peoples organisations saccos had started to provide faster services to persons with disabilities and together with family and community members provided personal services to katureebe to address mobility and communication barriers to overcome financial barriers the government had introduced disability grants national agricultural advisory services and other initiatives it is therefore evident that katureebe overcame some of the barriers on his own and with others he was supported by saccos family community members and the government he also helped other people with disabilities to overcome barriers the principle of interdependence emerges from these strategies as important in overcoming barriers on the whole the data do not seem to show any difference in learning approach barriers to learning or strategies to overcome the barriers whether katureebe was learning informally or nonformally discussion our discussion begins with the issue of a case study and generalisability particularly regarding a case study of a single subject it then follows three lines of argument barriers to learning and microfinance existed for a person with visual disability in uganda the social model of disability sheds light on such barriers and the barriers can be overcome through active engagement and interdependence a limitation of case study findings that is frequently cited is their lack of generalisability however case study experts have countered that statistical generalisation is not the point of case study as yin argues a case study can generate analytical generalisations in which generalisations are made to theoretical propositions rather than populations in this paper the findings regarding the social factors that constrained katureebes learning confirm the theoretical template of the social model of disability as a way of understanding the experiences of adult learners with disabilities regarding microfinance as we show below besides testing existing theory a case study even the rich and detailed account of a single subject as in this paper can generate new insights into a phenomenon for example katureebes experiences point to the importance of psychological responses to constraining social conditions as a key factor that impacts on learning of the individual person with a disability applying this finding more widely could happen through a process of what thomas calls abduction and phronesis here the focus is on generating practical wisdom from a case study which readers can then apply to related cases and make discerning judgements about appropriateness this paper sheds light on the experiences of a single participant with a visual impairment regarding learning and microfinance as such the findings yield insights through discerning application into the nexus of disability microfinance and adult learning without succumbing to the claim that katureebe is a representative of all adults with disabilities involved in microfinance or that his experiences can be generalised to theirs results show that katureebe learnt to engage with livelihood microfinance and other activities through various methods such as touchfeelrecognise questioning and practice however despite his motivation capacities and a wealth of experience katureebe faced a range of barriers such as open access inaccessible teaching and communication approaches unfavourable physical and psychological environment and limited finances these barriers were interconnected and impacted on each other as they influenced katureebes mobility and learning activities the first category of barriers that hindered his learning was identified as negative attitudes of community members who regarded persons with disabilities as inferior this is consistent with naamis findings in ghana regarding societys negative attitudes towards persons with disabilities doubts about their capacities and discrimination against them stone argues that some people view persons with disabilities as people who need to be pitied and yet they do not like it and prefer to be viewed as any other person when they are pitied it affects their motivation and consequently their learning potential may be compromised who identifies negative attitudes of families and communities as some of the most damaging barriers it is likely that such negative attitudes may create negative feelings that may inhibit learning the second category was the unfavourable environment in which he learnt and engaged with microfinance these included steep landscapes and inaccessible buildings the kinds of barriers that stone identified as natural and artificial the third category was financial barriers katureebe raised collateral with great difficulty and could not access messages about microfinance and other opportunities because often he could not afford dry cells for his radio inaccessible information about learning and microfinance opportunities constrained his participation in saccos thus compounding his financial barriers indeed economic factors limit many persons with disabilities participation in educational and other development activities these three categories of barriers are clearly a societal creation as explained by the social model viewing the barriers through the social model of disability oliver reveals that persons with disabilities were discriminated against by ablebodied society the study confirms that despite good legislation barriers still existed in practice in uganda similar results had been found earlier in uganda and in ghana the study confirms olivers argument that economic cultural attitudinal physical and social barriers disable persons with impairments the fact that katureebes learning about sacco services was possible with support from his family saccos and community members is testimony that society which erects barriers is capable of removing them this could be performed for example through supporting the person with impairment and providing a disabilityfriendly learning environment thus enabling persons with disabilities access to services and empowering them this strengthens the social models explanation of disability as a social phenomenon and the holistic approach to cbr as proposed by the convention on the rights of people with disabilities of 2006 however watson criticises the social model for presenting an incomplete picture of disability for example it cannot explain katureebes personal limitations and impairment and how they affected his learning he notes that socialisation of disability shifts the focus to commonalities thus underplaying the complexity and diversity of each persons lived experiences the fourth category katureebes negative attitudes indicates an interplay between the social and the personal social barriers may have psychological consequences including loss of confidence and withdrawal from activities katureebes negative attitude towards himself and feeling of inferiority sometimes made him exclude himself from community activities including learning a study in ghana revealed that some barriers such as low levels of selfconfidence negative reaction to societal attitudes and ignorance about their own potential were personal rather than societal here we argue that the social and the personal are closely related this is because the societal barriers as well as katureebes personal barriers influenced each other and affected his learning the societal and personal factors coupled with an unfavourable learning context further constrained his learning fear as a result of vulnerability has been identified elsewhere as an inherent barrier in the context of disability and hiv aids a combination of negative attitudes inferiority and fear within a sometimes excluding and discriminating social context contributed to katureebes emotional disposition zembylas established that emotional experiences regarding injustices can sometimes inhibit learning and this can also result in the internalisation of oppression viewing katureebe inherent barriers and those erected by society through the social model and critical theory indicates that these barriers combined to marginalise oppress and discriminate against katureebe as an adult learner in katureebes case his positive psychological disposition motivated him to learn in this process some of the societal barriers were removed by the society that had erected them thus further enhancing his participation in learning the study also reveals that despite the favourable disability policies the reality shows that persons with disabilities are still faced with barriers open access limitations of the study although we had planned to observe katureebes involvement in nonformal learning sessions that was not possible as none occurred during the period of data collection the data regarding learning processes may therefore have inadequacies as they are based on opinions about the process although the physical layout and accessibility of training venues were observed there could be differences between katureebes views on the processes and the actual learning processes in addition one participant and his experiences cannot be generalised to represent all persons with disabilities experiences of microfinance in uganda nevertheless his story yields insights into some of the ways in which disability and adult learning interface with microfinance in uganda and as simons notes the case study helps understand the case itself rather than generalise to a whole population as discussed above conclusions katureebe as a person with visual disability successfully engaged with learning and microfinance however he faced barriers to learning and engagement in livelihood and sacco activities the barriers were actually experienced in a combined manner but were categorised to facilitate analysis the barriers were theorised using the social model of disability katureebe developed coping strategies through which he changed the conception of barriers from permanent obstacles that obstructed persons with disabilities to hurdles to be overcome he helped others and also received help from fellow persons with and those without disabilities and this interdependence a key feature of the social model of disability helped reduce the barriers interdependence unlike dependence empowers as each person has something to offer and to gain also unlike the independence of autonomous individuals it shows the connectivity and relationality of persons with disabilities in an african context this interdependence has the potential to enhance persons with disabilities learning and engagement with microfinance for katureebe therefore many of the barriers he faced were surmountable although some of the barriers could be removed the impairments remain meaning he still remains with some challenges such as not being able to see during learning and engagement with saccos katureebes case provides evidence to confirm that the social model of disability can be extended to encompass the psychological consequences of social barriers through a more interactional understanding of biological psychological and social factors recommendations although our case was exploratory and based on a single case of one participant findings can be used to suggest that adult education programmes for persons with disabilities should aim at addressing the unique learning challenges of persons with visual and other disabilities this is because the challenges are not homogenous to all categories of disabilities but relate to disability type also the persons with disabilities as well as the communities in which they live and work and their agencies that provide services should be sensitised about disability each side has a role in addressing the barriers faced by persons with visual and other disabilities

background despite ugandas progress in promoting affirmative action for persons with disabilities and its strategy of using microfinance to fight poverty access to microfinance services by persons with disabilities is still problematic due to barriers characterised by discrepancies between policies and practices regarding education the affirmative action in favour of learners with disabilities has not translated into actual learning opportunities due to personal and environmental barriersthe study on which this article is based investigated the nonformal and informal adult learning practices regarding microfinance that persons with disabilities engaged in this article seeks to illuminate the barriers that a person with a visual impairment encountered while learning about and engaging with microfinance and the strategies that he developed to overcome themthis was a case study framed within the social model of disability and critical research paradigm data were collected through indepth interviews of a person with visual impairment and observations of the environment in which adult learning and engagement with savings and credit cooperative organisations saccos occurredfindings indicate that the person with a visual disability faced barriers to learning about microfinance services he experienced barriers in an integrated manner and developed strategies to overcome these barriers the barriers and strategies are theorised using the social model of disabilitythe case of a person with visual impairment suggests that persons with disabilities face multiple barriers regarding microfinance including social psychological and educational however his own agency and attitudes were also of importance as they influenced his learning viewing these barriers as blockades can lead to nonparticipation in learning and engagement with microfinance whereas viewing them as surmountable hurdles can potentially motivate participants to succeed in learning about and engaging with microfinance

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introduction brazil is among the 30 countries globally with a high tuberculosis burden according to the world health organization in brazil approximately 104 million people were estimated to have tb in 2016 1 in brazil around 73000 new cases of tb are reported annually with 4577 deaths in 2013 in the state of espírito santo 15225 new cases of tuberculosis were reported from 2001 to 2012 9356 of which occurred in the metropolitan area of vitória 2 the stop tb plan recommended that using 1990 as the baseline prevalence and death rates should have decreased by 50 by 2015 the post2015 end tb strategy aims to eliminate tb as a public health problem by 2050 1 the strategy is based on increasing access to diagnosis and effective lowcost treatment and reducing tb incidence and the associated mortality rates 3 in brazil tb incidence has decreased in the past decade although not at a pace that will allow future targets to be met the tb incidence rate in brazil decreased from 353 cases per 100000 inhabitants in 2013 to 338 cases per 100000 inhabitants in 2014 the cure rate was 74 for the new cases in 2013 4 however the maintenance of tuberculosis indicators at the levels described above is partially associated with social determinants despite efforts targeting their reduction these determinants identified through research in different countries including brazil were as follows lack of social protection low income lack of access to health care services poorly ventilated residences and a high average number of inhabitants per household 5 6 7 8 in addition to individual care the strategy used to identify those susceptible to or suffering from the disease requires a comprehensive approach with the reduction of the number of determinants of tb incidence in these populations 9 two previous studies were conducted in this area the first was a 4year retrospective territorybased surveillance study of all new pulmonary tb cases conducted in vitoria between 2002 and 2006 wherein spatial patterns of disease incidence were compared using spatial clustering statistics a total of 651 cases of tb were reported across 78 neighborhoods with incidence ranging from 0 to 129 cases per 100000 population and a strong spatial autocorrelation was observed for the incidence furthermore tb incidence and socioeconomic status had a significant curvilinear relationship 10 in the second study 503 isolates were genotyped by is6110 restriction fragment length polymorphism and spoligotyping of these the proportion associated with recent transmission was 342 the largest rflp clusters and families showed that they colocalized in space distance analysis confirmed these results and indicated unique strain patterns randomly distributed in space these results indicated that tb transmission in vitoria is spatially determined and that recent transmission most frequently occurs among young age adults and those with a low index of quality of urban municipality 11 due to considerable heterogeneity in tb incidence throughout the city and the importance of understanding disease distribution especially in low incidence areas in order to highlight if this area had no transmission or if the low number of cases was due to subnotification the aim of this study was to analyze social factors associated with spatial distribution in the underreporting of tuberculosis incidence in the city of vitória espírito santo state brazil methods type of study this is an ecological study of the reported cases of tuberculosis according to census tracts in the city of vitória espírito santo state between 2009 and 2011 in 2010 the city of vitória had a population of 327801 inhabitants distributed among 577 census tracts 12 data sources diseaserelated data were obtained from the notifiable diseases information system sistema de informação de agravos de notificação and maps of the census tracts in vitória data related to socioeconomic variables were taken from the 2010 census available from the brazilian geography and statistics institute instituto brasileiro de geografia e estatística website he outcome measure was the tuberculosis incidence for the study period calculated as the average number of cases per year in the study period divided by the reference population per 100000 inhabitants we defined the following exposure variables based on reports by different authors 13 14 15 16 17 18 19 20 literacy inhabitants with income up to ½ minimum monthly wage and inhabitants associated with the sewerage system or with access to safe drinking water per census tract the variables for the fully bayesian approach were selected according to the literature 13 14 15 16 17 18 19 20 on tb in the state of es according to census tracts we collected 21 socioeconomic and demographic variables from brazils atlas of human development and analyzed them using pearsons correlation and a scattering matrix in order to minimize the redundancy of data produced by the high degree of correlation between variables ending up with 15 variables three of these 15 variables were selected from the 2010 census according to the census tracts and the scientific literature on tb data analysis spatial statistics spatial analysis of the tuberculosis risk per census tract was performed by smoothing the overall rate using empirical bayes estimation proposed by marshal and defined as where eb i is the estimated value or i the overall rate for tract i and lr the local empirical bayes rate that considers the rates of neighboring tracts the local empirical bayesian is allows for spatial smoothing of the rate which reduces the instability in the measurement of the risk rate thus facilitatin the interpretation and correlation of the tb event with other factors in space the results are presented in the form of scatter plots and maps zeroinflated model in this model we used a zeroinflated process the zeroinflated negative binomial and as there was overdispersion of the data the explanatory model was selected based on the akaike information criterion a way of modeling the problem is to assume that the random variable y i can be represented by a negative binomial random variable in this case the expression in is written as follows the explanatory model was based on the aic the statistics of which are the result of adjusting the model and the number of parameters used to calculate it 21 the § is one of the most widely used model selection measures and is based on the difference between the values observed and those estimated by the model in question with the model that generates the lowest aic value deemed the best fit sampling zeros occur when conditions are conducive to cases whereas structural zeros are observed when cases do not occur data were analyzed using satscan software 22 table 1 indicators selected to compile municipal profiles 21 indicators results spatial analysis a total of 588 cases of tb were reported in vitória from 2009 to 2011 distributed among 223 census tracts while 354 tracts showed zero cases figure 1a shows a significant fluctuation in the overall rate particularly in census tracts with smaller populations by contrast figure 1b indicates a considerable decline in overall rate fluctuation for estimates generated by the local empirical bayes estimator in tracts with smaller populations a funnel effect can be seen in figure 2a which is not apparent in figure 2b the figure 2 confirms the above the map based on empirical bayes estimates of tb incidence figure 2b exhibits a welldefined spatial pattern incidence smoothing during the period and more evident tb risk areas in the municipality of vitória particularly in the southwest on vitória bay as well as in the center and southeast regions risk factors model for excess zeros table 2 shows the modeling results considering the effect of excess zeros the adjusted models and aic values for each model it is important to underscore that there were 4 census tracts in our database without information on the selected variables in these cases a zero value was attributed to the variables and a 1 was attributed to the population in order to perform the analyses in the negative binomial model estimates for the parameters of the model in table 2 considered the best fit were where the mean value of p i was 093 that is there is a mean probability of 093 that a zero observed is a false zero from the best model adjusted according to the lowest aic value it can be concluded that the logarithm of the average number of cases of tb decreases linearly with the increase of the percentage of literate people moreover an increase in the percentage of individuals with income exceeding ½ mmw reduced the probability of false zeros discussion in the municipality of vitoria 588 cases of tuberculosis were recorded between 2009 and 2011 with 614 of census tracts exhibiting zero cases which justifies the application of a model for excess zeros the variables of social determinant found in this study using the better adjusted model were illiterate inhabitants and an income up to ½ mmw several areas with a case count of zero were observed according to the study results 93 of zeros were false zeros possibly due to underreporting this finding may be because the occurrence of zero cases in socially deprived areas is rare in an endemic country consequently in such census tracts where zero cases occurred the likelihood of the cases being false zeros is higher these areas have in general limited infrastructure for health services including less epidemiological surveillance lack of reporting may lead to these figures distorting the epidemiological scenario reported to the public officials in spatial analysis the distribution of tuberculosis cases in vitória is not homogeneous over time some census tracts display a high risk of tb transmission while others show low risk high risk areas should be prioritized not only for disease prevention but for the early detection of cases and adequate treatment for those affected in order to break the disease transmission cycle as in our study two other studies 10 11 observed that the southwest and northwest regions of the city of vitória presented a higher incidence and high probability of clusters these regions are characterized by population agglomeration and low socioeconomic status next to these regions is the central region of the municipality which despite not having a high probability of clusters showed an increase in the number of census tracts with a high incidence compared to the results in the study from 2002 to 2006 10 this region is mainly inhabited by individuals with a higher socioeconomic status accordingly we considered an average distance of 2000 meters reported in the study 11 and apart from the social determinants there is a need to understand tb transmission as an increase in tb incidence has been reported in areas with a higher socioeconomic status in the over the last few years there is also a need to include such areas for tuberculosis control and prevention due to changes in the spatial epidemiological scenario over time to our knowledge the use of the zinb model is recent and the zinb model has not been used to analyze tb in the city of vitória our findings corroborate with those reported by other research groups 71023 that is individuals with a low socioeconomic status were at a greater risk of tb infection however a significant portion of this risk may be the result of limited access to health services it is not only in vitória that tb is associated with issues such as poverty social inequality and unequal income distribution a study performed in ribeirão preto 24 observed a direct association between tb income and education level two other studies in ribeirão preto and spain reported an association between the disease and education level 25 26 and tb was associated with the income of the individuals in a study in hong kong 27 priority should be given to areas with a large population of illiterate inhabitants and those earning less than the minimum monthly wage since these factors influence the occurrence of tb in the municipality of vitória the zeroinflated model such as the zinb may therefore be an important tool for public health managers as it identifies the percentage of false zeros by census tracts generating a more realistic estimate of tb case distribution thereby enabling more effective action to be taken to control the disease

introduction this study aimed to analyze social factors involved in the spatial distribution and underreporting of tuberculosis tb in the city of vitória espírito santo state brazil methods this was an ecological study of the reported cases of tb between 2009 and 2011 according to census tracts the outcome was tb incidence for the study period and the variables of exposure were proportions of literacy inhabitants with an income of up to half the minimum monthly wage mmw and inhabitants associated with sewer mains or with access to safe drinking water we used a zeroinflated process zeroinflated negative binomial regression zinb and selected an explanatory model based on the akaike information criterion aic results a total of 588 cases of tuberculosis were reported in vitória during the study period distributed among 223 census tracts 386 with 354 614 tracts presenting zero cases in the zinb model the mean value of p i was 093 indicating that there is a 93 chance that an observed false zero could be due to subnotification conclusions it is important to prioritize areas exhibiting determinants that influence the occurrence of tb in the municipality of vitória the zeroinflated model can be useful to the public health sector since it identifies the percentage of false zeros generating an estimate of the real epidemiological condition of tb in vitória

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introduction attitudes and behaviours of nursing staff towards patients are an essential aspect of quality of care in healthsettings treatment of elderly patients is particularly important in longterm care settings because of their prolonged stay and health problems elderly residents in longterm care are extremely vulnerable and find themselves in an asymmetrical relationship with the nursing staff this is especially true for elderly residents with cognitive disorders such as dementia several studies have shown the importance of 2 theoretical background krackhardt and hanson define communication networks as the informal networks of employees who talk about workrelated matters on a regular basis ties between nursing staff and relatives and acquaintances of residents cross the boundary of the organization in line with reagans and zuckerman we name these ties boundaryspanning or boundarycrossing networks because they place employees in direct contact with third parties outside the organization networks are often described by the density of interpersonal ties of its members where density is seen as a measure of social cohesion since seashores classical study there have been multiple studies that link cohesion of networks to group outcomes yet results remain inconclusive partly because conceptualizations of social cohesion differ greatly festinger first proposed that social cohesion should be seen as the causal system that determines individuals membership attitudes and behaviours in this manner conditions at the grouplevel can be seen as antecedents of attitudes and behaviour of groupmembers at the individual level over the years several mechanisms are named through which networks influence behaviour of groupmembers first density of networks is believed to enable information exchange between actors granovetter first identified the strength of weak ties low density networks of socially distant actors are more effective in information exchange and innovation than high density networks of closely knit actors burt argued that a network in which a person has contacts with few others who provide unique information is more productive than a network in which one has contacts with many others who provide the same information low density networks seem to be especially efficient for information exchange in more competitive worksettings tasks that depend on cooperation on the other hand seem to profit from networks with a high density second cohesive networks are deemed to affect trust between actors buskens and raub name two aspects through which socially embedded relations affect trust earlier experiences with actors and possibilities to sanction untrustworthy actors control in a social network can be the result of direct sanctioning between actors but can also be the result of sanctioning by third parties and may even lead to social isolation if untrustworthy behaviour is detected research of control has mainly focused on its positive effects however flache and macy also name a negative effect of social cohesion or as they name it a weakness of strong ties they argue that relations between two groupmembers evolve more rapidly than exchanges between all groupmembers in a group when strong ties between two actors are established social control is aimed at the maintenance of these interpersonal relationships instead of compliance with group obligations which may decrease group effectiveness third cohesive networks enhance social support closeknit networks exchange more affective and instrumental support which in turn is related to individual wellbeing in studies social support has also been associated with lower levels of work stress and work strain although overall results remain inconclusive fourth networks provide a sense of social identity according to the social identity theory a persons selfimage is connected to the image of the group to which he or she belongs individuals define themselves in terms of their groupmembership and ascribe typical characteristics of the group to themselves for social identification to occur groupmembership has to be made salient especially closed and cohesive networks are deemed to facilitate social identity social identity theory forms the basis for organizational identification which is related to feelings of attachment and loyalty to the organization several studies have investigated the relationship between social networks and organizational identification focusing on individuals networks bartels et al found that determinants of identification with the organization as a whole differ from the determinants of employees identification with lower organizational levels the climate of internal communication was especially important for the identification with the lower levels of the organization perceived external prestige appeared more important for employees identification with the overall organization how are these mechanisms of social networks related to the treatment of residents with dementia in longterm care we expect social networks to be related to behaviour of nursing staff both directly and indirectly first we expect that the existence of boundarycrossing ties between nursing staff and relatives acquaintances of residents will affect behaviour of nursing staff towards residents directly because these contacts provide information on the background and habits of residents information about elderly residents that those residents cannot provide themselves due to their dementia in addition we argue that boundarycrossing ties will also guide the appropriate treatment of residents because they enhance trust we will explain this reasoning through the concept of embeddedness as described by granovetter and uzzi uzzi noted that socially embedded ties in exchange networks are often formed through referrals by thirdparties or previous personal relationships trust is seen as a primary feature of these embedded ties and described by uzzi as the belief that an exchange partner would not act in selfinterest at anothers expense when untrustworthy behaviour is detected this not only affects further exchanges between two actors but information about untrustworthy behaviour will also spread to others in the extended network that is shared by actors increasing the chances of punishment boundarycrossing ties of nursing staff with relatives or acquaintances of residents represent the manner in which staff members and residents are embedded in the community outside the organization if these ties exist we expect that staff members will be less likely to act in selfinterest at the expense of the resident for instance by treating residents poorly or by rushing aspects of care to be able to spend time chatting to colleagues furthermore when a boundarycrossing tie exists untrustworthy behaviour of staff members will not only affect the relationship with the resident it will also influence the relationship between the staff member and familyacquaintances of this resident outside the longterm care facility giving these third parties opportunities to sanction unwanted behaviour notably an important distinction from the original exchanges described by uzzi and granovetter is that there exists no equal exchange relationship between staff members and residents with dementia making residents with dementia extremely vulnerable for this reason we expect that the possibilities of control by third parties become even more important in this setting based on these expectations we define the following general hypothesis h1 on dementia units with more boundarycrossing networks residents are given a better treatment second we expect that boundarycrossing and communication networks will indirectly influence behaviour through staff members identification with the organization we specify our expectations on the level of individual staff members and at unitlevel first we expect that boundarycrossing ties will increase identification with the organization as third parties will regard staff members as representatives of the facility making staffs membership to the facility salient thus we expect a relationship between boundarycrossing ties and organizational identification at the level of individual nursing staff we believe that for nursing staff identification with the facility is especially important as public opinion on quality of longterm care in the netherlands has been mainly based on media attention to adverse events in facilities less attention has been paid to the quality of care of individual units or holdings to which facilities may belong in addition we expect that staff members organizational identification is also influenced by the density of staffs communication networks as interpersonal relations affect a persons attitudes about the attractiveness of the group and their orientation towards groupmembership following bartels et al we expect that boundarycrossing ties are especially important for organizational identification as they are related to the reputation of staff members in the community when no boundarycrossing tie exists we expect that the density of internal communication networks becomes more important for organizational identification consequently we hypothesize an interaction effect of boundarycrossing ties at the individual level and density of communication networks at unitlevel where density of communication networks becomes more important when no boundarycrossing ties exist h2 boundarycrossing ties increase staff members identification with the facility h3 dense communication networks of nursing staff increase staff members identification with the facility particularly when no boundarycrossing ties exist organizational identification motivates groupmembers to work in the groups interest we expect that organizational identification is positively related to work motivation which results in a better treatment of residents in dementia units work motivation is deemed to be especially important for nursing staff as they often seem to choose their jobs on intrinsic values such as recognition contacts with residents and task content over instrumental rewards such as salary we hypothesize that this relationship between organizational identification work motivation and behaviour exists at the level of individual staff members but will affect the treatment of all residents of the unit h4 organizational identification results in higher work motivation h5 residents are given better treatment on dementia units with more motivated nursing staff in summary this study investigates social networks of nursing staff and attitudes and behaviour of nursing staff at individual and grouplevel it can best be described using the micromacro scheme that was introduced by coleman and is often used in sociology the structure of the theoretical framework and our hypotheses are presented in fig 1 at the macrolevel we study the relationship between social networks of nursing staff and the treatment of residents to understand this macrorelationship we investigate how social networks affect organizational identification and work motivation on the microlevel and study how work motivation is related to the treatment of residents of the unit on macrolevel methods design and ethical considerations the study was guided by a crosssectional design data were collected between october 2002 and june 2003 in 37 longterm care dementia units in the netherlands each unit was visited by two researchers during three days during these days questionnaires were distributed among nursing staff of the units and the behaviour towards residents was systematically observed according to dutch regulation no approval of an ethics committee for this study was necessary as no intervention was investigated and data were not directly collected from residents written informed consent from legal representatives of residents was obtained in addition client setting in the netherlands longterm dementia care is provided in psychogeriatric units in nursing homes and residential homes residents who live in these psychogeriatric units receive multidisciplinary care and often share bedrooms in addition residential homes provide dementia care in psychogeriatric group projects these group projects also provide multidisciplinary care and aim to delay or prevent admission of residents to a nursing home residents who attend group projects live in their own apartments in the facility but spend most of their day in a small group setting for this study a convenience sample of facilities was recruited in four regions in the netherlands data were collected in one unit in each facility participating units consisted of 26 psychogeriatric units 16 units in nursing homes and 10 units in residential homes in addition 11 group projects in residential homes also took part group projects provided care to an average of 12 residents compared to 28 residents on psychogeriatric units in nursing homes analyses showed that the 37 units in the study did not differ from psychogeriatric units in general in the netherlands in terms of the psychosocial and somatic care requirements of residents social networks of nursing staff we individualized the questionnaires for each unit by presenting the names of all staff to measure communication networks we asked the following question please report for each colleague how often you speak to him or her about your work or things that happen at work frequency of contacts was presented in five categories ranging from a few times a day to less than two times a monthnever communication networks were analyzed with the ucinet software package first responses of individual members of nursing staff were symmetrized coding a tie between two members of nursing staff when at least one indicated a relation with the other second the answers were dichotomized into at least once a week and rare third density was computed as a measure of the general level of cohesion of the network for boundarycrossing networks we were interested in the ties between nursing staff and relatives or acquaintances of residents in the community we collected information on these networks with a question based upon the work of milgram known as the small world problem that later became popularly known as the six degrees of separation experiment figure 1 individual staff members were asked if they knew residents of their units through others and how many ties existed between them and this resident we asked the following question please think randomly of a resident of this unit for instance by choosing a resident whose surname starts with the same capital letter as yours how many intervening steps of people you know are necessary to arrive at this resident two examples were provided to clarify the question example 1 i did not know resident y before she was admitted to this unit however i went to school with her daughter example 2 my father knew resident x when they were younger they played billiards together resident x visited my parents once in a while in both examples there is one intervening step between the resident and the member of nursing staff for this study the presence of boundarycrossing ties between residents and nursing staff was important the number of intervening steps was less important for this reason answers were dichotomized for each member of nursing staff with a score of one representing a boundarycrossing tie and a score of zero representing no boundarycrossing ties with residents organizational identification and motivation organizational identification was measured in two ways identification with the dementia unit and identification with the facility identification with the unit was measured by an adaptation of the dutch version of mael and ashforths organizational identification scale this scale consists of six items answers are scored from 1 to 5 for this study the name of the unit was inserted into each item examples of items are when someone criticizes i feel personally offended im very interested about others opinion of for the total score scores of all items were summed and then divided by six the higher the score the more nursing staff identified with the unit cronbachs alpha of the scale in this study was 069 in addition to these questions for the unit nursing staff were asked with one overall question if the answers applied in the same way for the facility the unit belonged to answers on this item were scored on a scale from 1 to 5 the score of this last question was used as the main variable for identification with the organization in our analyses intrinsic work motivation was measured with six items derived from a scale developed by warr et al examples of items are i feel a sense of personal satisfaction when i do my job well and my opinion of myself decreases when i do this job badly answers are scored from 1 to 5 for the total score scores of all items were summed and then divided by six a higher score representing a higher work motivation cronbachs alpha of the scale in this study was 071 treatment of residents by nursing staff for the observations an observationlist of 32 items was used that focused on different aspects of care for residents the observationlist was derived from a list that was based on the aspects of quality of care defined by rantz et al each item was scored on a fivepoint scale with 5 representing the most positive score six items of the observationlist were related to the behaviour of nursing staff towards residents starting a friendly conversation with residents taking sufficient time for residents calling residents by their name treating residents with respect actively caring for residents and residents and nursing staff smiling at each other and seeming at ease with each other the observationlist was completed at three times one observation on each day of datacollection observationtimes represented three important moments of care morning dinnertime and the afternoon the times of observation were not known to the units in advance after an observationperiod of twenty to thirty minutes both researchers individually completed the list and afterwards discussed their findings a total of 15 researchers carried out the observations on the 37 units one researcher observed all the observationmoments each time accompanied by one of the 14 other researchers a score for each item was computed based on the average score of the two researchers over all three observationmoments interobserver reliability of the separate items varied between 065 and 078 with a mean of 074 cronbachs alpha of the six items was 084 data analysis to test the hypotheses data were analyzed in several steps distinguishing between analyses on macrolevel and microlevel first the correlation between boundarycrossing networks of nursing staff and the treatment of residents at the level of units was studied second we looked at the relationship between social networks of nursing staff organizational identification and work motivation the existence of boundarycrossing ties organizational identification and motivation were all measured at the individual level density of communication networks was measured at unitlevel for this reason we carried out multilevel analyses in mlwin in which individual and unit variables could be combined in addition multilevel analyses show how much variance in outcomes can be ascribed to the unit and to individual staff members two separate models were analyzed each with two levels units and nursing staff on these units in model 1 the relationship between boundarycrossing networks density of communication networks and organizational identification was studied model 2 investigated the relation between organizational identification and work motivation in the multilevel analyses it was first investigated how organizational identification was influenced by characteristics of nursing staff and structural aspects of the units second boundarycrossing and communication networks were entered into the model boundarycrossing networks were first entered into the analyses on the level of individual staff members density of communication networks measured on unit level was then entered into the model as a crosslevel interaction as it was expected that communication networks among nursing staff become more important when no boundarycrossing ties exist for work motivation the analyses were repeated in addition organizational identification was added to the model finally we studied the relationship between work motivation and the treatment of residents at unitlevel a total of 474 nursing staff completed the questionnaire of this study this was 55 of all 861 nursing staff in the units the majority of nursing staff consisted of women with an average age of 38 years nursing staff mostly worked parttime and the vast majority held a permanent position the question on communication networks was answered by 380 staff members two units were excluded for analyses due to a response rate of less than 15 the response percentage on the remaining 35 units varied between 18 and 100 per unit with an average response rate of 53 in psychogeriatric units in nursing homes and residential homes the average response rate was 45 in group projects the average response rate was 71 response rates were negatively related to the size of the units on units with more nursing staff response rates on communication networks were lower the average density of the communication networks was 052 varying between 022 and 10 for the participating units density of communication networks was also significantly related to the number of nursing staff in the unit when we controlled for the average response on the social network questions the relationship between the number of nursing staff and the density of communication networks of the units remained significant the question on boundary crossing networks was answered by 391 nursing staff in the 37 units a boundary crossing tie was mentioned by 44 of the nursing staff varying between 0 and 100 of nursing staff on the units on average 35 of nursing staff in psychogeriatric units in nursing homes mentioned a boundary crossing tie for psychogeriatric units in residential homes this was 48 for group projects it was 53 h1 direct relationship between boundarycrossing networks of nursing staff and treatment of residents table 1 gives an overview of the correlations between boundarycrossing networks of nursing staff and the observed treatment of residents in the 37 units in units with more boundarycrossing ties nursing staff treated residents with more respect and nursing staff and residents seemed more at ease with each other furthermore boundarycrossing ties were related to the number of times nursing staff started a friendly conversation with residents and the amount of time they actively cared for residents the different items to measure treatment of residents were also positively related to each other for instance on units where nursing staff more frequently started a friendly conversation with residents they also took more time for residents and treated residents with more respect the results support hypothesis 1 h2 and h3 relationship between social networks and organizational identification of nursing staff next the relationship between boundarycrossing networks density of communication networks and nursing staffs organizational identification was studied average identification with the facility was 30 on a scale from 1 to 5 table 2 presents the relationship between characteristics of nursing staff structural aspects of the units social networks and identification with the facility for nursing staff of 35 units identification with the facility varied significantly between staff members there was also significant variance between units of the variance 16 could be ascribed to differences on the level of the units identification with the facility was not related to characteristics of the nursing staff in our sample however it was related to structural aspects of the units on larger units nursing staff identified less with the facility this relationship between size of the units and identification ceased to exist when results table 1 table 2 table 3 boundarycrossing networks and communication networks were entered into the model no main effect for boundarycrossing networks was found yet we did find an interaction effect of boundarycrossing networks and communication networks when there were no boundarycrossing ties the density of communication networks of staff in the unit was positively related to identification with the facility the results do not support hypothesis 2 we found no main effect for boundarycrossing networks and identification with the facility yet we found a crosslevel interaction effect of boundarycrossing ties and communication networks for organizational identification the results support hypothesis 3 h4 relationship between organizational identification and work motivation of nursing staff average work motivation was 40 on a scale from 1 to 5 table 3 shows that motivation varied significantly between individual members of nursing staff no significant variation between the units was found for work motivation 4 of the variance could be ascribed to differences on the level of the units identical to the analyses for organizational identification it was first investigated how motivation was influenced by characteristics of nursing staff and structural aspects of the units we found that older nursing staff was more motivated work motivation was not related to structural aspects of the units or the social networks of nursing staff however nursing staff that identified more with the facility were more motivated to provide better care the results thus support hypothesis 4 table 4 h5 relationship between work motivation and treatment of residents finally scores of work motivation were aggregated to the unitlevel to investigate whether motivation was related to the treatment of residents of the units for this the percentage of nursing staff that scored higher than average on the scale for work motivation was assessed these percentages of nursing staff with a high work motivation varied between 25 and 100 between the units with an average of 58 the percentage of highly motivated nursing staff related positively to the treatment of residents in the units in units with more motivated nursing staff nursing staff smiled at residents more often and seemed more at ease with residents and more often started a friendly conversation with residents the results support hypothesis 5 discussion this study is the first to examine the relationship between social networks of nursing staff and behaviour of nursing staff towards elderly residents with dementia on units where nursing staff reported more contacts with relatives and acquaintances of residents nursing staff treated residents more often with respect and approached residents in a friendly manner both by being at ease and by starting friendly conversations with residents social networks also indirectly affected the treatment of residents communication networks of nursing staff were positively related to staffs identification with the facility when no boundarycrossing ties existed organizational identification in turn was related to work motivation of nursing staff which aggregated to unitlevel proved to be positively related to the treatment of residents of the unit these results largely supported our hypotheses several characteristics of nursing staff and characteristics of the units that could influence the relationship between social networks and organizational identification and work motivation were taken into account only one characteristic of nursing staff was found to be related to the dependent variables older nursing staff was more motivated to provide good care more nursing staff on the unit was found to be negatively related to identification with the facility however this relationship between size of the unit and identification ceased to exist when social networks were entered into the model the results of this study should be interpreted with caution first the response rates on the social network measures were limited the question regarding communication networks had a response rate of 53 after we excluded two units with very poor response we found that response rates were lower in units with more nursing staff evidently it is easier to answer questions for a limited group of colleagues than for a larger group kossinets argues that nonresponse in social network surveys can be partially balanced out by reciprocal nominations of actors if a does not fill in the network questionnaire but b and c of the same network describe their interactions with a information about the social network of a is still available in the analyses data were symmetrized coding a tie between members of nursing staff when at least one staff member indicated a tie with this colleague through this information was gained on the communication networks of those who did not complete the questionnaire furthermore when low response rate leads to smaller numbers the empirical bayes estimation used in the multilevel analyses shrinks the estimates to the general mean which results in a conservative approach the question on boundarycrossing networks was answered by 44 of nursing staff it is not known whether the remaining nursing staff had no boundarycrossing tie or if they did not understand the question due to how it was constructed the question used to obtain boundarycrossing information was relatively complex not only asking after the presence of a boundarycrossing tie but also asking after the number of intervening steps perhaps response rates would be higher if the latter part of the question was omitted as it would make the question easier to understand dementia care in the netherlands is provided by an educationally diverse nursing staff and due to the growing number of older people that need extensive care often staff with a low education level is employed as this is the first study to address networks between nursing staff and family and acquaintances of residents in longterm care it is impossible to compare our findings or response rates to other studies to address our response problem we performed additional analyses in which all missing values were recoded into value 0 the findings of these analyses did not differ from the results that are presented in this article nevertheless the limited response on both social network questions is an important limitation of this study further studies should focus on methods to obtain more complete social network data of nursing staff second the study was guided by a crosssectional design in which several outcomes were used overall reliability of the scales used for organizational identification intrinsic work motivation and behaviour towards residents with dementia was sufficient yet several limitations can be identified organizational identification was measured in two ways identification with the dementia unit and identification with the facility the score of this last item that measured deviations from the identification with the unit was used as the main variable for identification with the organization in our analyses this measure has to our knowledge not been used before further research is needed to see if similar results may be obtained in other settings cronbachs alpha for intrinsic work motivation was 071 although not very high this is comparable to other studies in the netherlands in which the scale was used for instance janssen et al reported a cronbachs alpha of 070 in their study of nurses in a general hospital the behaviour of nursing staff towards residents with dementia was observed during three days on each unit by two researchers although the observations show sufficient interrater reliability there were differences in how the researchers interpreted the interaction between nursing staff and residents in addition with the results of this study it is impossible to determine whether treatment of residents differed over time in the units and whether nursing staff reacted to the presence of the researchers however precautions were taken to optimize the reliability of the findings one researcher observed all 37 units on all occasions the observations were carried out at three different moments which were not known to the nursing staff in advance and researchers were asked to report possible reactivity effects of nursing staff if they became aware of them overall reactivity of nursing staff to the researchers was found to be limited which is consistent with earlier research by schnelle et al who found no effects of reactivity of nursing staff when using observations to assess quality of care third although we corrected for several characteristics at staffand unitlevel we expect that the relationship between social networks and identity may also be contingent on other characteristics that were not part of this study furthermore the relationship may also be mediated by other mechanisms which we discussed in the theoretical background but were not part of this study such as social support the power of our multilevel analyses was restricted to 35 units at the highest level of analyses and only a limited amount of unit variables could be taken into account consequently our analyses are not extensive and it is important that future research identifies which other aspects and mechanisms mediate the relationship between networks identification work motivation and behaviour of staff in longterm care an important characteristic which we would like to mention separately is the experienced workload of nursing staff as it may be expected that especially workload is related to the time nursing staff spend interacting with residents for the 35 units the average workload was not extremely high although we found a weak correlation between workload and the density of communication networks we found no significant correlation between workload and organizational identification or motivation workload was significantly correlated to nursing staff taking sufficient time for residents and the number of times nursing staff called residents by their name interestingly those two aspects of the treatment of residents were not significantly correlated to either the existence of boundarycrossing ties or to the work motivation of nursing staff these results show that workload is important when studying the treatment of residents in longterm care but seems to affect the treatment of residents through different mechanisms and on different aspects in this study we focused on the relationship between social networks of nursing staff and the treatment of residents with dementia at the macrolevel by studying the attitudes and behaviour of staff at the microlevel for this we followed the micromacro scheme that is often used in sociological studies raub et al state that micromacro models aim at explanations of macrooutcomes and at incorporating macroconditions in the explanation rather than at explaining individual behaviour as such in the next paragraphs we will discuss our findings in view of this micromacro explanation boundarycrossing ties of nursing staff with relatives acquaintances of residents were investigated using a question based on the smallworld problem although the accuracy of small world chains by respondents is questioned and the response in our study was limited the results indicate that this type of question is suited to gain insight in indirect ties of nursing staff with residents who are extremely vulnerable our definition of boundarycrossing ties was closely linked to the concept of embeddedness as described by granovetter and uzzi we proposed two mechanisms through which boundarycrossing ties affect treatment of residents on the macrolevel contacts provide information and boundarycrossing ties enhance trust and provide opportunities for control in this study a positive relationship was found between the existence of boundarycrossing ties and the treatment of residents in dementia units however due to our study design we cannot unravel if this result is due to information exchange or to the trustcontrol mechanism yet the findings of this study indicate that when a boundarycrossing tie exists a staff member is more likely to treat all residents of the unit better not only the resident with whom the boundarycrossing tie exists this may be ascribed to the fact that the boundarycrossing ties in our study indeed can be seen as a measure of social embeddedness of staff and residents in the community which decreases the inclination of staff to act in selfinterest at the cost of residents for this mechanism we focused on the behaviour of nursing staff and not on the behaviour of residents as they due to their dementia are the most vulnerable party in the exchange relationship and are not able to maintain their social networks themselves although we found a positive relationship between boundarycrossing ties and the treatment of residents by nursing staff our findings must be seen as a first attempt to unravel how embedded ties may influence quality of care in healthcare settings for instance in our study no attention was paid to the fact that information about untrustworthy behaviour of relatives and acquaintances of residents may also find its way to the dementia unit and may affect the behaviour of nursing staff towards particular residents furthermore we have no information of values and norms that are shared between staff members residents and third parties outside the organization baker and faulkner name this cultural embeddedness and they use the term double embeddedness to include both structural and cultural embeddedness our research is also closely linked to the concept of job embeddedness as constructed by mitchell et al to explain employee turnover job embeddedness not only incorporates connections to colleagues and organizations but also includes connections of employees with the community and people in the community all in all the findings implicate that it may be beneficial for longterm care facilities to employ nursing staff who have ties with relatives and acquaintances of residents outside the organization as this positively affects the treatment of residents this may be achieved by recruiting staff from the community where residents originate from on the microlevel we found a relationship between networks organizational identification and work motivation the results show that the communication network between nursing staff of a unit is important for organizational identification especially when few or no boundarycrossing ties exist no main effect for boundarycrossing networks at the individuallevel was found we hypothesized that relatives and acquaintances of residents would regard nursing staff as representatives of the facility which would make their groupmembership to the facility salient yet our results indicate that organizational identification is not so much the product of the salience of individual groupmembership but is shaped by closelyknit communication ties with other staff members at unitlevel in combination with the existence of boundarycrossing networks at the individuallevel this finding does not correspond with earlier findings of bartels et al who found that internal communication patterns were especially important for identification with the lower levels of the organization and external prestige was important for identification with the organization as a whole perhaps our findings are a result of our view on groupmembership implicitly we assumed that nursing staff would regard residents as members of the facility yet when nursing staff do not regard residents as members of the same group contacts with residents will make staffs membership to the organization salient all the time and contacts with outsiders will become less important this may explain why no main effect for boundarycrossing ties on organizational identification was found it may also explain why especially communication ties with staff members seem to be important for identification with the facility as only staff members are seen as the fellow members of the group two more aspects of our study need to be discussed first we investigated the existence of boundarycrossing and communication ties of nursing staff and not the strength of these ties it may be expected that very strong ties may hinder the treatment of residents for instance in our observations we incidentally noted that strong ties may also result in nursing staff talking to each other during care instead of interacting with residents when ties with relatives are strong this may lead to less criticism and an unwillingness of relatives to impose sanctions this is the weakness of strong ties that flache and macy addressed in their study although we found no indication for a negative relationship between the density of communication ties and the treatment of residents such a negative relationship may exist if the ties are particularly strong it is important that further research focuses on this possible adverse effect of strong ties second we based our study on the assumption that a good treatment of residents is an overall aim of the facility thus we expected that residentoriented behaviour of staff coincides with formal groupnorms moments of observation especially morning care and dinnertime were specifically chosen because some interaction with residents was part of the job in this regard noncompliance with organizational norms was not a subject of this investigation yet it would be interesting to study how behaviour of nursing staff towards residents is influenced by groupnorms and under which conditions nursing staff will turn against organizational rules implicitly our results emphasize an important point to be able to provide good care to residents with dementia in longterm care it is important that organizational norms and protocols focus on the interaction with residents the results show that social networks of nursing staff play an important role in care processes in longterm dementia care the findings indicate that care may be improved by facilitating contacts between nursing staff and relatives of residents with dementia in the community although we did not look at the actual presence of relatives in the unit our results tie in with other studies that underline the importance of contacts with relatives of residents in longterm care furthermore care may be improved by facilitating informal communication among staff members especially when no or few contacts between nursing staff and relatives of residents exist recent studies have demonstrated that higher staffing levels are related to better quality of care in nursing homes although it is difficult for longterm care facilities to increase manpower because of costs results of this study indicate that care may also be improved by changing extraand intraorganizational communication patterns further research is needed to study how social networks of nursing staff affect other aspects of care

this study investigated social networks of nursing staff and staffs behaviour towards residents with dementia we focused on two types of networks communication networks among staff and networks between nursing staff and relativesacquaintances of residents data was collected in 37 longterm care units in nursingand residential homes in the netherlands in units with more networks between nursing staff and relatives of residents staff treated residents with more respect and were more at ease with residents social networks were also positively related to staffs organizational identification which in turn related to their work motivation and their behaviour towards residents

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steadman jones therefore suggested not to translate archival silence into historical passivity ie the cultural passivity of the lower classes as too many scholars have done though more than a quarter century has passed since steadman jones made these observations still only a handful of historians have addressed private creative and domestic modes of leisure in general and hobbies more specifically as widespread popular phenomena this lack of attention to the home as the legitimate domain of an entire culture of creative leisure is only one symptom of the fundamental bias of historiography which takes nearly all popular leisure to be passive and nonproductive chris waters pointed to the deep roots of this tendency when he showed how john stuart mill in his on liberty identified all forms of lowerclass leisure activity with a passive conformist and absolutely noncreative popular culture 4 in this context even revisionist historians like peter bailey and hugh cunningham did not steer clear of the received notion that yokes popular leisure to activities experienced mostly in the public sphere while they did recognize the emancipatory potential of numerous kinds of leisure activities they failed to grasp the importance of domestic types of creative leisure in particularly hobbies 5 cunninghams revisionism for instance prompted an examination of the rich inventory of leisure types in the second half of the nineteenth century yet the majority of which involved groupor communityoriented activities that took place in the public sites like parks public libraries museums or public baths and in commercial leisure sites like beaches race tracks fairs music halls the penny gaffs and circuses as popular leisure sites in that respect bailey and cunningham did recognize the cultural agency among members of the working classes similar to the way richard hoggart described the mass leisure culture of the first half of the 20 th century hoggart …was equally alive to the powers of agency and creativity in workingclass communities people in leeds and elsewhere fought continual battles not for the most part in favour of abstract ideologies but in order to make ends meet to achieve pride selfrespect and if possible the little comforts of life these were not struggles which merit high priority in the globally transformative schemes of hegemonic intellectuals but they were a matter of necessary and urgent priority to those on the ground 6 and yet one can plainly see that lacking from this rich inventory of leisure activities are individual domestic modes of leisure the core of which involves a wide variety of handicraft hobbies no doubt the very definition of leisure activity as something that took place mainly in the public arena got in the way of addressing victorian domestic leisure and impeded the understanding of this phenomenon as an important instrument in the subjects social toolbox 7 and so these forms of leisure defined by the participants themselves as occurring during their leisure time are almost entirely absent from the historiographical discussion cunningham even stated in relation to the notion of leisure time that until midcentury no unified concept existed to describe the full panoply of leisure activities so that the everyday use of the word leisure at least until the last decades of the century was restricted to designations of those serving in the role of the commentators the meaning of the word leisure was accordingly abstract people talked in terms of concrete activities like going to the pub or to the races but not he argued about leisure proper 8 as distinct from this notion of leisure this article argues that for many members of the working classes amongst others artisans of all kinds cabinetmakers factory and agricultural workers house servants workmens housewives seamstresses grocers and policemen who spent many hours engaged in the intense productive labour of a hobby the word leisure was associated with a concrete experience and carried emancipatory significance referring to a stretch of time unfettered by the employers authority and the strains of the work place it is in this sense that the notion of leisure was not necessarily applicable only to the higher class as thorstein veblen argued it was more than just the prodigal conspicuous and nonproductive use of free time through which the privileged liked to distinguish themselves or their kind 9 this class bias regarding the notion of leisure did not leave the discussion of hobbies untouched either at least two historians ross mckibbin and steven gelber have looked at victorian leisure from the point of view of the domestic hobby 10 both scholars however mistakenly assumed that the domestic hobby became a popular practice only in the last two decades of the nineteenth century gelber based his periodization on an imprecise linguistic analysis that focused on the unfavourable connotation that accompanied the word hobby contending that before about 1880 a hobby was a dangerous obsession only after that it became a productive use of free time 11 he took the absence of the word hobby from mundane language as conclusive evidence that hobbies were not common until the last decades of the century this is substantiated according to him by the dramatic linguistic mutation the word hobby had undergone by the end of the century a transformation he illustrates through two articles published twentyfive years apart in charles dickens magazine all the year around 12 in an 1865 article entitled hobby horses hobbies were presented as a pastime that while perhaps not actively harmful was esoteric bizarre and mainly elitist activities listed included recreating historic battles with toy soldiers fishing fox hunting collecting art china… gardening… moral philosophy… selfpity homeopathy social reform… and giving parties 13 a quarter of a century later an article in the same publication entitled about hobbies displayed none of this irony and mockery towards the hobbyists 14 in this latter article described by gelber as the de facto manifesto of the new home leisure the hobby was no longer presented as something eccentric and obsessive but rather as an antidote to ennui 15 mckibbins contribution to the study of hobbies as creative leisure is crucial insofar as it questions the chronic dichotomy between leisure and work and suggests instead a complementary and more fertile approach according to which … for skilled craftsmen the hobby was often simply an extension of ordinary work routine with the crucial modification that routine was replaced by autonomy and choice 16 yet his historical examination of the notion of the hobby like gelbers is inadequate as mckibbin misinterprets the publication of the popular magazine hobbies beginning in 1895 as evidence that hobby activities became widespread among labourers only towards the end of the nineteenth century however number of contemporaneous documents and treatises dealing with modes of creative leisure establish conclusively that domestic hobbies were already widespread among workmen in midcentury and the word itself was explicitly and positively applied one such document among others is the tractate the artisan his recreations hobbies written in 1870 by william fretton of coventry this text is notable not merely for its use of the word hobby but because of the detailed way in which its author links hobbies to leisure practices that were common in the family lives of many workmen it suggests a domestic leisure pursuit for artisans and workers of both genders involving mostly labourintensive hobbies based on handiwork or systematic collecting for artisans and workers of both genders by no means does this pamphlet intend to preach or moralize the text reflects rather an actuality a certain way of life as well as an attempt to remove the traditionally sceptical tone of the word hobby hutton says every man has his hobby horse and it is no disgrace prudently to ride him he is a prudent man who can introduce cheap pleasure without impeding business 17 by combining recreation and work fretton effectively imported the realm of work into the domestic domainor as he himself put it poetically here again is a kind of rest in doing labour of love 18 between a historiography and a sociology of leisure why is it then that forms of domestic leisure and above all hobbywork escaped the attention of the historiography of lower classes leisure practices i propose that historiography has failed to grasp the notions of creative leisure and hobby mainly because it avoided dynamic and comparative sociological models almost entirely relying instead on three intuitive assumptions about the nature of leisure activity the first of these was that leisure occurs where there is no work and vice versa second it was assumed that leisure activity being voluntary demands no regularity and is obviously beyond the purview of work discipline the third assumption was that leisure must be pleasurable or at least relaxing and restorative to these was added a belief that if the working classes did subscribe to some form of consistent creative leisure activity it must clearly have been rational recreation a form of activity imposed from above by social missionaries or political reformers hence this activity should be seen as an extension of the social control that sought by means of the hegemonic capitalist ethos to instil praxes of selfimprovement these assumptions however are misleading if we wish to assess the full meaning invested in these creative and private leisure activities among the victorian lower classes in this case sociological theory comes to our aid by casting doubt upon the limited notion of rational recreation while also offering alternative considerations first that just as being enjoyable does not turn work into leisure so being arduous skilful and disciplined does not thereby turn an activity carried out in leisure time into work and second that leisure taking place under relative freedom at a selfdirected pace and with selfselected contents plays a key role in enabling selfexpression and a sense of selfworth 19 the sociology of leisure successfully explains how people can be deeply involved in leisure activity that requires work skills and selfdiscipline because it takes account of sentiments like freedom selfesteem pride satisfaction and a sense of achievementall of which may equally result from leisure as from work the sense of achievement is high when the core activity is endowed with such intense appeal that the line between work and leisure is virtually erased in this context the notion of serious leisure as opposed to casual leisure developed in the early nineteeneighties by the canadian sociologist robert stebbins may come in handy 20 serious leisure is defined by stebbins as the systematic pursuit of an amateur hobbyist or volunteer activity that participants find so substantial and interesting that in the typical case they launch themselves on a career centred on acquiring and expressing its special skills knowledge and experience 21 casual leisure by contrast can be defined as an immediately and intrinsically rewarding relatively shortlived pleasurable activity requiring little or no special training 22 it typically involves play relaxation passive or active entertainment and occasionally such deviant activities as drinking and moderate gambling serious leisure then is a productive activity systematic and ongoing which relieslike the world of work upon accumulated skill and knowledge that can be seen and appreciated by other members of the community the serious leisure player is invested in a lengthy process of learning and of honing his or her skills until frequently the hobby becomes a substantial career a leisure career that affords no less of a sense of self than would derive from success in the domain of work it is writes stebbins the kind of selfworth and social respect that cicero must have had in mind when he coined his famous dictum otium cum dignitate 23 moreover in contrast with those approaches that regard payment or its equivalents as a clear mark of distinction between work and leisure subjects of a serious leisure career may eventually gain partial or even full livelihood from their hobby 24 all this is the antithesis of the organizing principle of the historiography of leisure which as described above mistakenly assumes that the industrial revolution cut off the traditional and popular practices of creative leisure and replaced them with a multitude of casual leisure tactics instead of creative leisure the historiography preferred to deal with recreation pastime or amusement unlike the various forms of casual leisure which are overwhelmingly discussed at the macro level serious leisure is mainly the business of the lone player and can only be fully appreciated through close observation of a particular leisure work this individualization of leisure work is reflected in the personal narratives brimming with a sense of achievement that subjects recount to themselves or their surroundings thus the study of serious leisure requires the use of microhistorical strategies it obliges us to learn about the broad phenomenon via specific reports personal stories or marginal events these while insignificant in themselves might emerge as synecdoches details that as hayden white argued are representative of the whole 25 james anderton as a serious leisure actor if as giovanni levy put it doing microhistory is to some extent to prefer an individual portrait over a group portrait then the story of james anderton born in 1825 provides the study of serious leisure with a particularly detailed and illuminating individual portrait of a serious leisure devoted player 26 the case of this lincolnshire agricultural worker is the ultimate exemplar of a serious leisure career a prime instance of a culture of commitment to quote the sociologist alan tomlinson 27 anderton devoted an entire decade of his life to the construction of a model of lincoln cathedral out of one million and eight hundred used corks ten years of dedicated leisure work that culminated in andertons participation in the south kensington international exhibition of 1862 like other independent exhibiters anderton received little partial and casual mention in the official publications covering the event as well as in other texts that accompanied the exhibition in a collection of letters submitted to the durham chronicle in the autumn of 1862 the journalist francis mewburn noted the corks model but seemed to look right through its creator not even mentioning him by name anderon was an invisible man as axel honneth would say in portraying social invisibility 28 the official catalogue of the exhibition makes two separate references to anderton the first entry appears under the name james anderton and carries the title lincoln cathedral omitting any reference to the fact that it was made out of a vast number of corks in the second entry under the title the english cathedrals in corks anderton is mentioned briefly alongside the ingenious product of the professional architect j norbury 29 anderton also received the following summary mention in the comprehensive commercial catalogue that came out in the same year the cork model of lincoln cathedral is a curious specimen of patient labour somewhat ill employednot the most flattering comment particularly when compared with the great model of the new bourse at berlin which is the most interesting in this class of objects 30 it was george rowdon burnell wellknown author of practical and theoretical books on construction bridges civil engineering and metal work who was charged with editing the catalogues section on architecture the encounter between anderton the hobbyist and burnells professionalism was doomed from the start indeed burnell would have preferred that andertons work be classified as a curiosity rather than architectural artefact while anderton for his part never meant to be part of the professional architectural scene with its long tradition of wellmade models marked by precision subtlety and close adherence to the rules of perspective one has the impression that andertons cork model did not in the least resemble that genre descriptions of his model are more reminiscent of gombrichs wooden horse of which gombrich writes it is usually content with its place in the corner of the nursery and it has no aesthetic ambition… it is satisfied with its broomstick body and its crudely head 31 if the architectural model aims to tell us something about an existing building or to illustrate a building yet to be constructed andertons model purported to convey more about its maker than about lincoln cathedral its makers pride had more to do with the herculean feat of collecting one million and eight hundred corks than with architectural accuracy the exhibition organizers choice to include the corks cathedral in the architecture section was one of default reflecting at best a taxonomic perplexity and more likely a fundamental failure to grasp the meaning and motives of this dedicated hobbyist two further unofficial sources published a decade after the exhibition provide us with more information about anderton and the evolution of his hobby one is an 1871 pamphlet likely published on andertons own initiative and the other is a picturesque magazine reportage that appeared in 1870 in the highbrow gentlemans magazine these two documents offer invaluable biographical information and teach us in particular that following the 1862 exhibition anderton developed a highly profitable career involving the display of his cathedral as part of a travelling sideshow in peripheral towns the pamphlet in fact makes substantial and deliberate use of the earlier reportage and in addition includes autobiographical sketches an engraving immortalizing the cork master and his wife and a selection of presscuttings from the local popular journals showering the corks cathedral and its builder with it is a stupendous piece of workmanship to be built with such materials and very ably shows what may be done by patience and perseverance 32 ill1 james anderton and his wife flanking a church corks model 34 the picture symbolically juxtaposes proudly the tools of the agricultural worker and the product of his leisure time which sit side by side in natural harmony the life of the ingenious agricultural labourer james anderton builder and founder of the model of lincoln cathedral as shown in the exhibition london 1862 made from one million eight hundred old bottle corks newcastleupontyne 1871 p 16 23 hargreaves article must be read as a doublelayered story in the first layer the author brings andertons story as the cathedral builder himself tells it while in the second he introduces his own impressions upon meeting anderton and his cathedral a screen of irony but also a considerable measure of respect and even admiration separates the protagonists narrative from hargreaves own observations and interpretations hargreaves uses two modes of representation one is direct speech ie a simple and literal rendering sometimes through quotation of what anderton said and the second is a report cast in hargreaves own ironic language of the event as perceived from the external point of view of the onlooker thus as the author combines his own trenchant voice with andertons naïve articulation and rustic language a complex expression emerges forming a kind of counterpoint duet the fusion of these two modes of expression subtle mockery laced with admiration and amazement on the one hand and an earnest innocence on the other produces a tension that tells us something about the patronizing attitude of gentlemans magazine readership towards popular forms of creative leisure in general and especially handicraft hobbies hargreaves irony is manifest from the articles very first paragraph an exposition in which he describes how he first came to learn of the subject of his current writing assignment not long ago i had the honour of seeing the modern wonder of the world no one will be surprised to learn that i felt greatly excited by the spectacle … not until a few weeks ago did i learn that the great marvel of the age was in england was in the good old city of d was in a structure temporarily erected in the market place for its reception and that it was open to all visitors who could command copper coinage to the extent of three pence sterling 35 and yet hargreaves admiration for the impressive model seems to have triumphed over his mockery his subsequent description of the corks cathedral reveals his ambivalent and complex attitude towards the model and its maker it seems that the very human encounter between the writer and the hobbyist impedes the formers efforts to render the latter invisible the writers sarcasm undermined by the hobbyists story and by his speechact anderton did exactly what honneths invisible man as social subject attempts to do to counter his own invisibility through an active striking out that is aimed at prompting others into cognizing him 36 striking out is a metaphor designed to capture the core of the various practical efforts through which subjects attempt to make themselves noticed and indeed in the case of hargreaves account of his meeting with anderton out of disrespect emerges recognition his description becomes detailed accurate and rich as though hargreaves wanted to impress the structures actual splendour upon his readers before me rose up like a fairy fabric say rather like a dream in cork 37 one alteration nevertheless had been made to the model since it was first displayed in south kensington above one of the gates at the front of the cathedral hargreaves noticed a small metal plate attached close to a pennysized slot the slot took coins which caused the miniature church bells to ring for the pleasure of the spectators and to satisfy their fascination with automata of various kinds a legend inscribed on the metal plate declares « in plain and homely english » as hargreaves took care to note the following at the international exhibition 1862 thousands came there this model for to view and thousands yet do come to hear this peal of bells above you there the peal of bells you all must know put a penny in and off they go 38 the inflected irony regarding andertons financial gains from his hobby becomes more explicit when hargreaves states that anderton « turned his cork into gold » this sarcasm leaves no doubt as to hargreaves status as a faithful representative of the liberalwhiggish mindset that regards obsessive hobbyhorse as an extravagance reserved for gentlemen with time on their hands on this view a hobby has the right to exist only in the sphere of symbolic properties and never where there is a real need to earn a livelihood wherever amateurism and professionalism or hobby and livelihood became entangled contempt set in 39 corks and a cathedral in south kensington a case study of victorian serious revue dhistoire culturelle 3 2021 the encounter the hobbyists pride as a biographical spectacle hargreaves describes the encounter with anderton as a theatrical event andertons assistant announces the impending entry of the ingenious man and the protagonist enters the display area with its expectant crowd like a venerated actor but his appearance is a complete anticlimax anderton is a small man dressed in his traditional agricultural labourers smock which as we shall see later was destined to play a significant role in his biography in a few moments an individual small in stature plain in aspect provincial in his dialect deficient in his aitches and dressed in a white jacket or smock made his appearance and i soon discovered that i was in the presence of the inventor designer architect builder joiner glazier plumber painter carver moulder and proprietor in fee simple of the majestic pile before me 40 in complete contrast with hargreaves cordial sarcasm the biographical narrative in the second source the 1871 pamphlet sketches the illiterate anderton son of a hardworking unlettered family of saddle and bridle makers with pride and selfesteem the pamphlet tells the reader that young james showed extraordinary skill at traditional carving from a very early age his leisure moments he devoted to making ingenious windmills out of hemlock ornaments in rushes fly cages puzzle chains c and it was these pursuits despite his lack of education or his crude dialectthat made his name so famous throughout england 41 what we see here then is a selfimprovement biography that revolves around traditional hobbymaking rather than intellectual enhancement rendering its subject anderton the archetypal serious leisure actor his leisure career evolved slowly and persistently starting from small models he moved on to large ones made of wood and these foreshadowed his great future thus we should read the biography of anderton the consistent hobbyist as evidence of the existence of forms of traditional leisure as well as of the popularity of types of selfimprovement that involved devotion to the world of domestic handicraft hobbies and this devotion doesnt come without difficulties ample empirical evidence shows that those who engage in serious leisure tend to describe themselves as living in a world of absolute commitment and undergoing considerable hardship for the sake of their hobby serious leisure activity is not a way of relaxing or an escape from daily routine on the contrary the intensities associated with serious leisure sometimes bordering on madness maintain an ambivalent relationship with daily life of which the leisure practitioners are well aware 42 indeed anderton proudly tells his audience stories that glorify his hardships such as the anecdote about an acquaintance who upon first hearing about the cathedral model suggested that anderton apply for a berth at a neighbouring asylum 43 these accounts of hardship therefore can be considered a type of speech act through which anderton the invisible man renders himself visible difficulties obstacles and their surmounting are integral ingredient of the experience the rhetoric and the biography of the serious leisure actor as a someone seeking recognition hargreaves describes andertons life story as a central part of his narrative our journey round the cathedral was in a great measure biographical … how he came to conceive the idea of constructing a minster in cork … he himself could … he spoke quite solemnly on the point and i concluded from his manner that he regarded the conception as a kind of visitation from some supernatural source and looked upon himself as a man with a mission compelled to execute some inscrutable decree of fate 44 asked to explain what had driven him to such a demanding activity and failing to find reasons in the actual world anderton came up with a kind of metaphysical explanation as though some extraneous occult power had told him to build the corks cathedral it is the kind of rhetoric that reflects what tomlinson refers to as a culture of commitment without which serious leisure loses its unique substance in this spirit of commitment the hobbyist must create his own timetable and set himself challenges binding by hardships exacting difficulties are central to enhancing the significance of the hobby activity and anderton indeed imposed upon himself a number of such testing complications for instance he chose to erect his cathedral strictly from individual used corks rather than employing bought pieces of cork or any other material such as wood for a frame and base or paint for a finishing touch one further selfimposed constraint was andertons commitment to do all this only in his hours of leisure that is to say at night all day long he must toil at his ordinary tasks and then when evening came must slave at his cathedral instead of dozing at his own fireside or lounging at the alehouse with his pipe in his mouth and his tankard at his elbow 45 it is significant to note that anderton describes the time devoted to work on his hobby with the term leisure and not with any of the purportedly common phrases such as recreation time pastime or simply free time leisure time is qualitatively different it is a state of mind a feeling a mood a sense of absolute liberty including the liberty to imbue free time with meaning rather than leaving it an empty technical notion that refers to the unoccupied hours that remain after work and other everyday duties thus anderton effectively illustrates that as early as the midnineteenth century leisure time as an actual and quotidian notion was perceived among serious leisure devotees not as an abstract idea but as a praxis dominated by the typical features of a work discipline such as necessity skill persistence hardship difficulty and an exhausting routine to demonstrate his own exhausting routine anderton told his spectators that living three miles away from the city of lincoln he could only see the cathedral from considerable distance and was forced to walk back and forth many hundreds of times to take in all the details one small detail … cost him no less than eighteen miles walking 46 collecting the corks was of course itself very toilsome a professional cork cutter estimated that the cost of the cork used in the model would have added up to £62 so buying the raw material was out of the question anderton began by collecting used corks himself but as his story reached more and more people members of the community started supplying him with an ongoing stream of corks 47 in this respect anderton compromised his vow to abjure outside help proving that he too like other serious leisure participants needed at least the recognition of his community he picked up all the corks he could find in the streets of lincoln or glean from the river witham the older they were the better for his purpose as they would impart a mellowed air of antiquity to his cathedral other people as he humorously observed might have the liquor if they liked but give him the corks and thus he should have the best of the bargain a sentiment which i fancied was but faintly endorsed by the audience 48 this kind of relationship between the hobbyist and his community implies the dialectical nature of the serious leisure praxis individuation on the one hand and the necessity of the community on the other 49 commenting on the link between individuation and recognition honneth argues that … human individuation is a process in which the individual can unfold a practical identity to the extent that he is capable of reassuring himself of recognition by a growing circle of partners to communication subjects capable of language and action are constituted as individuals solely by learning from the perspective of others who offer approval to relate to themselves as beings who possess certain positive qualities and abilities 50 the granting of recognition depends consequently largely upon appreciation of the subjects achievements and his ʽpositive qualities taking into account his hardships and the extent of his investment according to honneth the subjects selfesteem depends largely on that which his social surroundings consider valuable and significant since not everything human beings do is regarded as equally valuable a persistent struggle is conducted by groups and individuals who experience a lack of recognition and respect the societal significance of serious leisure activity then is not a matter of a solitary ego appraising itself so much as an intersubjective process aimed at gaining respectability and recognition often however the difficulties of the dedicated serious leisure actor also spill over into his family life andertons description as articulated by hargreaves of his relationship with his wife who did not take kindly to the cathedral project sheds interesting light on the domestic aspect of handicraft hobby and the tensions that could arise in the narrow and suffocating confines of workingclass homes i regret to state that the patient architect was not blessed with an equally patient wife the good lady finding corks on the table corks on the floor corks in the kitchen corks in the chamber corks in every quarter frequently lost her temper and « banged » them at the head of her husband 51 mrs andertons diffident attitude towards her husbands hobby is presented with humour and jolly exaggeration yielding a domestic melodrama that reproduces representational conventions regarding the home with a central role reserved for the everprudent woman still mrs andertons disapproval reflects faithfully the objective difficulties posed by a corks cathedral in excess of one and a half meters high three meters in length and a little over two meters wide to a family living in a cottage the size of a living room the essence or moral of this family farce is obvious the harder the conditions under which the hobbyist works the closer his serious leisure toiling approaches a calling the exhibition a workers smock in south kensington work on the corks model went on for ten and a half years consuming almost all of andertons free time after sunset he would dedicate himself to his hobby toiling until midnight on saturdays and until two am on weeknights it is likely that the work continued into sundays as well occupying at least part of the day of rest and including walks back and forth to lincoln cathedral otherwise it is hard to explain a tenyear time span for such an enormous undertaking what went on in the anderton household during these years did not stay unknown as his fame spread andertons home became a kind of pilgrimage site and what had hitherto been his private affairs came to be to an extent a matter of public interest 52 when the model was complete according to the pamphlet anderton took it on the advice of friends to the 1862 international exhibition 53 andertons journey with his model to london was like the rest of his life obstacleridden as the result of an accident the model was seriously damaged and this put andertons patience and persistence to a grave test but there was more to come london posed tough social challenges hargreaves chose to describe andertons strangeness and alienation in the metropolis through an encounter between anderton and a welltodo london relative a meeting whose unforeseen consequences were to change the course of andertons life andertons strangeness is highlighted through the linguistic jumble generated by the combination of dialect with hargreaves ironical observations it would seem however from a confidential communication with which the ingenious man favoured us that his opulent relative axed about his health and his family and his prospects in life and london the gentleman also axed about his model declaring with the freedom which wealth confers that his nephew must be a rum fellow to dream of making a cathedral in cork far more important still as it then appeared he axed his visitor about his clothes and on learning the low state of his wardrobe this remarkable and very exceptional relative instead of abandoning the poor artisan on the spot took him to a tailors and had him promptly arrayed in habiliments which would bear the scrutiny of the metropolitan eye 54 and so anderton now dressed for the occasion stood beside his cathedral ready to regale the audience with his explanations and stories but also to receive and enjoy their generosity but alas his sunday best did not serve its purpose his entire receipts for many days did not exceed one shilling how account for this mournful fact possibly thought he he did not look stupid enough for the post … an acquaintance happening to enquire into his receipts solved the mystery « why james » said he « you have got far too fine a coat on your back how can you expect people to give to a gentleman in broad cloth try your own old smock » next day the patient man took his stand by the cork chapterhouse in his labouring attire and what does the reader think was the result why in the course of a few hours he pocketed £44 in good solid cash from that time money poured in and when the exhibition closed the lincolnshire husbandman had realised the magnificent sum of £800 without selling a single cork in his cathedral 55 the apparent respectability bestowed by andertons new suit functioning like a costume did him a disservice for in the gentlemans system of values no money should be paid for leisure activity thus it was only once anderton changed back into his traditional agricultural workers garb that is to say from the moment he replaced the costume with a uniform that the money started flowing from the point of view of the audience which consisted in the first weeks of the exhibition of the upper classes andertons good old smock acted as a familiar code 56 it allowed him to transform himself into folksy show case as his workmans smock functioning as a uniformrelocated him and his model in the domain of toil and labour this meant that the smock fitted the dominant whiggish ideology which regarded leisure and work as wholly separate categories key to the turning of andertons luck this incident concerning his dress was to have a powerful effect on his view of himself the conversion of the meaning attached to his traditional work clothes came to be a landmark in the story of his life as hargreaves renders it somewhat sarcastically upon the builder of the minster himself the incident made a profound impression his gratitude to the garment which had effected such a change in his fortunes was so great that he resolved to wear a white smock to the day of his death no more fashionable coats for him … indeed i am strongly disposed to believe that if her majesty were to command his presence at court to receive the honour of knighthood he would make his appearance in the famous white smock which had turned his cork into gold 57 while originally the linkage between the work smock and the corks cathedral as a product of leisure was rather loose once anderton donned his smock as a uniform the smock came to serve as the platform for his serious leisure career and a token of his emerging respectability consequently the smock completely lost its functional link to the work domain and was recharged with symbolic meaning in the decade following the international exhibition anderton converted his hobby into a successful career over the course of his life he produced only two more models a pair of corks churches inside one of which he reproduced the scene of his own wedding with his three models and his white smock anderton attained what mckibbin calls ideal work in terms both of his material prosperity and of the construction of his identity and selfhood the agricultural worker clearly became an affluent man with the display of the cathedral at the 1862 international exhibition yielding an initial sum of £800 and a further regular income provided by the travelling sideshow at provincial towns a few days at a small town could earn him £50 all in all from the first day it went on public show the corks cathedral brought in about £3000 yet these financial gains however important did not overshadow the mental and moral gains the sense of potency selfworth and recognition his hobby had provided him as hargreaves compelled to admit for of all good properties in this world one of the grandest is the power of saying to difficulties out of my way dont dream of daunting me … for here was a man who had sacrificed all the leisure of more than ten years … perhaps however the fact which impressed me most of all about the son of genius was the sense of victory achieved i am the man as did it all exclaimed he with an air of triumph … he had struggledhad foughthad vanquished … i could not but admit that it was a grand thing to be a conqueror even if it be only in cork the patient man was now the triumphant man 58 the story of this selfsufficient triumphant man thus aptly illustrates geoffrey crossicks argument that the will to seek this independence and the moral qualities needed to achieve it were proof of respectability 59 yet anderton rose in the world in another more profound sense he shifted his workethics industriousness skilfulness hardship patience to the domain of leisure activity turning by this the former into a symbol of autonomy rather than a sign of subjection the devotion and commitment transformed his hobbytoil into a kind of secular pilgrimage whose end laid the prospect of selffulfilment and selfrealization as a respectable human being as well as a legitimate citizen in other words the marquee and everything that occurred within ie the cork spectacle turned into representation of a worth an expression of the ongoing abstracts the article points to the culture of productive and creative leisure among the midvictorian english working classes from the standpoint of domestic hobbymaking largely ignored by the historiography of leisure relying on previously unpublished primary sources it analyzes a test case centered on a lincolnshire agricultural worker whose modelbuilding hobby became a lucrative career and a platform for selfimprovement though his tale is fairly eccentric it nevertheless demonstrates the broad range of popular leisure practices mainly handicrafts hobbies among working men and women these leisure habits the article argues challenge the historiographic conventional dichotomy between work and leisure to address this historiographical lacuna the article proposes using sociological models such as serious leisure hitherto excluded from the historical research which explain the involvement of workmen in labourintensive hobbies as a measure of their sense of selfworth and autonomy it concludes that a devoted hobby career was not just an effective instrument of selfimprovement but also an expression of the legitimate demand of the working classes for recognition and acceptance into the civil body

as long ago as 1975 gareth steadman jones noted that historiography on victorian leisure has largely ignored the concrete ways in which workmen artisans shopkeepers and other members of the working classes organized their private and domestic leisure activities as a result he argued the cumulative picture conveyed by research into popular recreation and leisure is out of perspective 2 its «sharply outlined foreground» is occupied by evangelical improvers of the public mores methodist activists aristocratic patrons utilitarian employers who offered leisure activities subject to their calculations of increased output wellintentioned reformers goodhearted philanthropists and skilful leisure entrepreneurs behind these figures hardly visible are the blurred features of the urban masses occasionally their vague profiles are illuminated by incidents of class conflict and some forms of resistance but typically workmens leisure is associated by the historiography with uninhibited drinking gambling absenteeism or popular and ragged entertainment it is jones argued as if the only records of the bourgeoisie came from the bankruptcy courts the only evidence of marriage from divorce petitions 3 corks and a cathedral in south kensington a case study of victorian serious

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introduction industry 40 will allow new forms of interaction between humans machines and software systems such phenomenon are known as the industrial internet of things services and people where interconnecting things services and people via the internet will improve data analysis optimise operations boost productivity and flexibility enhance reliability save energy and costs and generate innovative eservices for smart factory environments 1 smart devices and smart wearables such as data goggles or tablets will increasingly make it possible for humans to interact with socalled social machines and powerful social software systems will guide operators in increasingly complex cyberphysical systems including smart machines and supply chains as temporarily equal partners at the shopfloor 2 moreover with the emergence of the social internet of industrial things manifested as smart machines with social properties namely social assets such will share their status information and cooperate via enterprise social networks to achieve a common goal an optimal smart factory production system 3 this paper explores the role of the social operator 40 in the context of smart and social factory environments where humans machines and software systems will cooperate in realtime to support manufacturing and services operations furthermore a highlevel social factory architecture based on an adaptive collaborative and intelligent multiagent system will be introduced in this paper as a proposal to enable such cooperation as well as some production scenarios envisioning how social operators social machines and social software systems will communicate and cooperate with each other via enterprise social networking services to accomplish production goals in the social internet of things services and people the social operator 40 and its social companions an operator 40 is defined as a smart and skilled operator who performs not only cooperative work with robots but also work aided by machines as and if needed by means of human cyberphysical systems advanced humanmachine interaction technologies and adaptive automation towards humanautomation symbiosis work systems 4 moreover a social operator 40 is a type of operator 40 4 that uses smart wearable solutions together with advanced humanmachine interaction technologies to cooperate with other social operators social machines and social software systems in order to communicate and exchange information for mutual benefit and alignalter activities as well as share resources so that more efficient results can be achieved at the smart and social factory of industry 40 with the emergence of smarter factory environments and the social operator 40 smart wearable solutions 5 hmi technologies 6 and adaptive automation strategies 7 will play a significant role when combining different interaction mechanisms and sharing and trading control strategies between social operators social machines and social software systems towards a social factory 8 a social factory is a live enterprise social network with powerful middleware and analytics backend to improve the connection between social operators social machines and social software systems working together in a smart production environment and the data created within the networking process 8 towards a sustainable learning factory 9 10 according to 8 a social factory should be able to provide the right information and the right time and place to the right person machine and or software support humans under any working conditions engage humans to contribute to new knowledge creation treat humans machines and software as equal partners and learn from all this socialization of knowledge by explicitising it in this context the faithful social companions of the social operator 40 will be other social operators social machines and social software systems the social operator will be able to interact with these other social entities communicate and exchange information align or alter activities share resources and work together on joint tasks social factory architecture components technologies the next generation balanced automated production systems 11 12 consist of hardware software and humanware components coexisting with mechanical and human autonomy as well as with humanmachine collaboration capabilities where autonomy and synergies between human machines and systems create a social sustainable and competitive factory the next subsections will detail selected areas of relevance hardware smart wearable solutions and the internet of things several smart wearable solutions part of the iotsp paradigm have been designed for a variety of purposes as well as for wear on a variety of parts of the body such as head eyes wrist waist hands fingers legs or embedded into different elements of attire 5 in order to techaugment operators physical sensorial and cognitive capabilities 12 similarly a diversity of things has been embedded with electronics software sensors actuators and network connectivity in order to augment their capabilities such is the case of smart machines now capable of operating autonomously avoid and correct processing errors learn and anticipate future events and interact with other machines and systems 13 software actively adaptive agents for humanautomation symbiosis the essence of agent technology is to mediate interaction between human beings and technological artefacts hence at has been considered an important approach for developing socially sustainable factories where human agents can cooperate with other human agents and artificial agents as hybrid agents and emerging agents to keep their agenthood 12 and therefore optimally leverage human skills and automation capabilities at the shopfloor in order to provide human inclusiveness and harness the strengths of human beings and machines to achieve new levels of efficiency and productivity that neither can achieve alone 14 and that not compromise production objectives 12 agents agenthood is defined by wooldridge ciancarini 15 as a system with the following properties autonomy reactivity proactiveness and social ability according to yamasaki 16 in xu et al 17 an active interface is a type of humanmachine interface that does not only wait for users explicit input but also tries to get information from users implicit input and external environment based on the gathered information it acts spontaneously and keeps the system in advantageous conditions for its users with users being human agents or artificial agents in this case furthermore an interface agent can learn by continuously looking over the shoulder of the user as hesheit performs actions against other artefacts and provide the users with adaptive aiding as well as of alternating the activities instead of human 18 in this sense a human or machine in the physical world will coexist with its associate human or artificial agent in a cyberphysical environment so that as an intelligent agent can evolve by itself as a human or machine users proficient level improves 18 for humans such learning evolution could be tracked by means of advanced trained classifiers 19 20 while for machines the use of different machine learning techniques 21 might be considered the use of intelligent and actively adaptive collaborative multiagent system to coordinate the support of manufacturing and services operations at the shopfloor is proposed to achieve humanautomation symbiosis 11 12 at the social factory and its smart production environment in such a setup active interfaces within the social iotsp of the factory as interface agents will allow to gather information from the social operators social machines and social software systems agenthood status and send a request for cooperation to other human or artificial agents in order to keep their agenthood and therefore production running in this sense the social factory should be considered as a collaborative environment of intelligent multiagents 22 where humans and machines twin agents use interface agents to facilitate communication between them and the cyber and physical worlds and other agents such as broker agents support tasks allocation and control sharing trading 23 in the cyberphysical production environment fig 1 presents a highlevel social factory architecture based on an adaptive collaborative and intelligent multiagent system fig 1 highlevel social factory architecture based on an acimas such intelligent mas architecture will aim to facilitate communication between the social operators social machines and social software systems assist them to distribute tasks and share trade control in collaborative tasks maintain as much as possible human inclusiveness without compromising production objectives and record and track humans and machines evolution as their proficient levels improve through learning and practice the following agents will operate in the social factory fulfilling different roles  human agents represent the humans and their capabilities in the system and are a duo consisting of human interface agent which allows a human to interface with the rest of the system  artificial agents represent the machines and their capabilities in the system and are a duo consisting of machine interface agent which allows a machine to interface with the rest of a system  interface agents represent a set of interaction rules and conditions for supporting humans and machines interfacing with the rest of a system their active feature allows the interface agent to constantly learn and evolve its rules by being trained by observation imitation feedback and or programming in order to be able to personalise the assistance to its user agent 24 and such assistance be provided in an adaptive and dynamic manner and only when required to help the human or machine in difficulty to main hisherits agenthood at the tasks at hand by different automation or mechanisation invocation strategies 11 12  broker agents represent the levels of automation 25 26 available in the system and the rules for sharing and trading control in humanmachine cooperation in order to efficiently allocate labour and distribute tasks between the automated part and the humans at the workstations of an adaptive production system 11 12 27 humanware the human factor in adaptive automation systems humanware is defined as a function of leadership followership and the reciprocal interaction between the two where leadership is a leaders willingness to fulfil both task accomplishment and group maintenance and followership is followers voluntary desire to follow their leader and to achieve their tasks 28 in the social factory the social operator 40 will be empowered with technology and thus encourage collaboration with other social operators social machines and social software systems at the same time the social operator 40 will be monitored with the help of atcs 19 20 and other detecting and preventing error approaches like digital pokayokes 4 29 for poor humanware in order to avoid human error and provide a virtual safety net in this context the main goal of adaptive automation based on active interface agents and brokerage agents is to prevent errors and to reduce outoftheloop performance of the humanware by preserving an adequate level of situation awareness and mental workload 30 while providing a crucial perception of empowerment materialised into an appropriate level of freedom 31 for the social operator 4 12 enterprise social networking services production scenarios enterprise social networking services focus on the use of mobile and social collaborative and interface methods to connect the smart operators at the shopfloor with the smart factory resources including other social operators social machines and social software system such connections include social relations among the workforce and between social operators and smart things and services to interact share and create information for decisionmaking support andor alignment or altering of activities and their related resources to achieve a compatible or common goal extended from 4 in this case the social operator is considered the main focus and the following scenarios are always centred on the social operator 40 while there are many other scenarios possible and worthwhile to be analysed this is not the focus of this research work social operator networking scenarios one of the possible collaboration scenarios is a social operator interacting with other social operators in such a social operator to social operator scenario the use of adapted social network services like a b2b facebook or twitter that are capable to facilitate eg onetomany communication incorporate location based services and realtime sharing of media or allow for facilitating a dynamic community based capability matrix such esns supported by an intelligent and actively adaptive collaborative mas can enable opportunities and realtime multimedia communication capabilities between social operators using smart wearables that can empower the workforce to communicate and contribute with their expertise to different problemsolving scenarios at the shopfloor by bringing together the right people with the right information and the right time to address a situation without certain limitations social machine networking scenarios enhancing the senses of the social operator 40 through eg smart wearable tech enables herhimit to engage in social interaction and communication with social machines within the esns sioit can connect through interactive machine learning smart operators with smart things in social networks for sharing information and exchanging messages about their location condition operation status and availability for improving at machine level the asset reliability and at production line level the material flows and resources productivity towards social problemssolving and optimisation of the production system social software systems networking scenarios similarly to the social operator 40 interacting with social machines being alwayson and connected enables the social operator to naturally engage in communication with social software systems this can be envisioned as a virtual assistant with an artificial intelligence backend like ibm watson where the social operator can either actively ask questions that the system will answer based on available informationdata or passively the social software system might monitor the environment and behaviour and provide proactive information andor decision making support through voice video or holographic communication channels this paper is suggesting a social operator 40 concept in the context of smart and social factory environments furthermore a highlevel social factory architecture based on an adaptive collaborative and intelligent multiagent system was introduced taking advantage of a multiagent approach for interconnecting and interoperating multiple agents across an enterprise social network to provide solutions by means of temporary collaborations in situations where expertise and capabilities are spatially distributed finally some production scenarios envisioning how the social operator 40 will communicate and interact with other social operators social machines and social software systems have been presented

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introduction gold mining has a long history in indonesia because gold has long been a key commodity globally in some instances the extraction of gold and related activities has gained support from the various levels of the indonesian government and locally affected communities in banyuwangi regency religious teaching and development phraseology have been combined in support of mining activities and as a way to obtain consent from the affected communities this support has been led by a religious organization called nahdlatul ulama such action from the nu could help to ensure the success of the goldmining operation including by oppressing the antigoldmining movement as shown in the case of the tumpang pitu hills goldmining conflict1 medeiros argues that the role of religious organizations in civil society creates a political hegemony for the dominant and subaltern classes through ideology culture and consensus studies have shown that goldmining activities cause many negative effects on the affected communities including environmental degradation air and water pollution and socioecological damage2 furthermore in banyuwangi goldmining conflicts have often occurred due to competition for employment environmental damage and water pollution and social jealousies between proand antimining groups3 these problems have prevented local peasants from accessing land in the hills the source of their livelihoods which has led to resistance from the affected communities in sumberagung village where the gold mining takes place bijdragen tot de taal landen volkenkunde 179 537 as a consequence various social groups including farmers fishermen and young people have opposed all mining activities since 19974 and have established social movements to this end in banyuwangi in both 2015 and 2017 there were clashes between the antigoldmining movement the mining corporation and the local police which included the involvement of religious organizations since then the antimining movement has been plagued by internal divisions as well as experiencing external pressure from religious and social nationalist organizations in banyuwangi that aim to safeguard the state and safeguard the interests of the extractive industry in the tumpang pitu hills operated by pt bumi sukses indo 5 the ongoing situation is described as being a battleground and has led to various forms of exclusion or oppression although objections to gold mining have been strongly voiced by banyuwangis antimining movement the central and local governments have remained silent due to the golden share of 10 that is donated by pt merdeka copper gold tbk to the banyuwangi government in 2016 the kementerian energi dan mineral of the central government identified the goldmining operation as a vital national strategic asset in decision no 631 k30mem20166 and it was highlighted as a source 4 permadi and dewantara 2018 ike ningtyas pasca rusuh yenny wahid mundur dari merdeka copper and gold tempo 30112015 yennywahidmundurdarimerdekacopperandgold 5 the corporation pt bsi is a subsidiary of pt merdeka copper gold tbk it is a national corporation with its headquarters in jakarta the corporation engaged in the goldmining business in the banyuwangi regency after securing goldmining licence no 188547kep429011 2012 from the local government of banyuwangi 6 see ismail et al 2018 and gold mining began in 2016 and by march 2017 the corporation had extracted 25063 ounces of gold and 6420 ounces of silver in 2018 167506 ounces of gold and 140738 ounces of silver were extracted see fu ulfah sepanjang 2019 produksi emas mdka tumbuh 3315 persen bisnis february 2020 comread202002241921204973sepanjang2019produksiemasmdkatumbuh3315 persen by 2019 this had increased to 223042 ounces of gold and 409492 ounce of silver before a reduction in annual quantities in 2020 to 157175 ounces of gold and 549440 ounces of silver by december 2020 the mineral resources of pt merdeka copper gold tbk were estimated at around 328 million ounces of gold and 853 million ounces of silver based on these figures the central government obtained a tax income of idr 45860000000 in 2016 increasing to idr 54760000000 in 2017 in 2018 the tax paid increased significantly due to the phase of extraction with the central government receiving idr 514024000000 in 2019 idr 688717000000 was paid in tax furthermore the corporation shared royalties with the local government of banyuwangi of idr 66850000000 in 2017 idr 125078000000 in 2018 and idr 165258000000 downloaded from brillcom 02232024 045432pm via open access this is an open access article distributed under the terms of the cc by 40 license alkatiri and kiwang bijdragen tot de taal landen volkenkunde 179 537 of income for the economic development of the territory empirical debates and studies of social movements have not represented all types of mining conflicts this is because most of the literature on mining conflicts and social movements has focused more on western societies where attention is mostly paid to the political dimensions and less to the social and cultural perspectives having said this a growing number of studies exist on social movements in developing countries including ones dealing with the role of religious and social organizations and the sociopolitical context some scholars have underlined and emphasized the decline of social movements as an important theme but such a theme is unpopular with other social movement scholars moreover it is simply not described in the strategic and tactical methods mentioned in some of the literature therefore gamson has encouraged scholars to construct better theoretical arguments concerning the movements decline in indonesia research around the role of religious organizations in goldmining conflicts is still limited the existing literature dealing with conflicts around mining in indonesia has not touched on the role of religiousnationalist organizations in specific local social and political contexts there are very limited studies on the involvement of religiousnationalist organizations in goldmining conflicts for example arti shows that the establishment of a sustainable ecological movement by catholics and indigenous religions in manggarai has been able to stop mining activities in the regency arti argues that the establishment of the local antimining movement was driven by religious forces and shaped by the interactions between catholic and indigenous religions for centuries and was successful in pushing the district government to issue a moratorium on mining by pt aditya bumi pertambangan however other studies of goldmining operations on the tumpang pitu site have found that religious organizations take the opposite approach furthermore there have been two other findings related to the role of the nu in the goldmining sector first alfian has demonstrated that the nu as a religious organization has engaged a global capitalist entity that influences the nus position and thinking concerning the mining project in the tumpang pitu hills alfians article highlights the internal dynamics among the in 2019 see ka rido menambang emas tanpa melupakan tanggung jawab sosial berita jatim december 2020 tanpamelupakantanggungjawabsosial bijdragen tot de taal landen volkenkunde 179 537 nus prominent leaders which indicate that while several leaders of the nu have rejected the mining operation in banyuwangi others have supported and benefitted from it second the research outcomes of wardhani and cahyati demonstrate that the antimining movement in banyuwangi has used different methods and formations framing and shaping the impacts of mining on the community in a way that ensures wide support from its members the interesting point is that pt bsi has established relational ties with both political actors and religious organizations including the nus members in order to support the issuing of the licence for the corporation those previous studies have limited their discussions to the resistance of religious organizations along with the affected communities to mining companies the internal dynamics of the religious organizations and how the religious organizations maintain their relationships with the company however these studies have rarely addressed the local social and political conditions such as the involvement of the religious organization in protecting the interests of the goldmining company this article addresses an important issue the decline of the antigoldmining movement in banyuwangi due to the involvement of religiousnationalist organizations in the promining countermovement it is essential to understand that the religious organization the nu has played a significant role in obtaining consent from the local community both through adding mining investment slogans into religious teaching and by coercion which has resulted in the weakening of the antimining movement in banyuwangi regency this article analyses three important elements that have contributed to the decline of antigoldmining discussions in banyuwangi first it identifies the subgroups within the antimining movement and analyses the divergence of agendas within it this divergence has weakened the antimining movement internally second the gramscian hegemony perspective is deployed to analyse the involvement of the nus elites in accepting mining investment and linking investment slogans with religious teachings about the use of natural resources in order to persuade the common people to think as they do third the article underlines the roles of religiousnationalist groups in safeguarding the community and state from communist ideology and assesses the use of politicalideological rhetoric to diminish any antimining movement which thereby exposes the religiousnationalist groups as a promining lobby with strong ties to economic and business interests within the extractive industry 2 the decline of the movement hegemony and the role of social organization an analytical framework social protest regarding mining activities has often been analysed by scholars in both developing and developed countries to establish the causes of social conflict in this sector scholars have found several causes of conflict related to the demand for and securing of the mining resources social conflicts in the mining sector have been connected to the unequal relationship between corporations and developing countries conflicts between the management of corporations and labour the environmental impacts on local communities the repressive regimes working in the mining industry and human rights and indigenous rights and livelihoods in rural areas in a social context andrews et al declare that the dynamic social relationships and conflicts between a corporation and an affected community have often been underlined in social research studies studies show that to challenge a corporation the affected community establishes a social movement supported by activist groups to voice their disapproval of the project either during the initial phase or during ongoing mining operations however while some social movements have developed and succeeded many have failed to achieve their main aim due to negotiation the cooptation of leaders by opponents of the movement repression by the authorities and other forms of social control and the dissemination of false information by various actors including the corporation the government security institutions and social groups that take an opposing stance another wellknown mechanism of controlling a social movement is through hegemony according to antonio gramsci hegemony is connected with power and domination concerning life values norms and the culture of dominant social groups over other weaker or subordinate groups using consent as the main method with coercion or domination as other possible means funfgeld underlines the consent aspect as being a convincing way for dominant groups to impose certain ideas on weaker groups consent can be derived from education and local values where the hegemony is not challenged because the education system does not teach its students to think critically on the contrary education is considered the essential pathway to gaining consent to continue the hegemony bijdragen tot de taal landen volkenkunde 179 537 this approach is promoted by the intellectuals or civil society within the society who work for the dominant groups the intellectuals are members of social institutions such as schools churches political parties the mass media and others who implement and maintain the dominant groups preferred ideology and values to subdue societys thoughts and desires in funfgelds view each intellectual group develops its own model of organizing consent in indonesia social conflicts between proinvestment stakeholders and the antimining movement can be analysed using gramscis concept of hegemony particularly in terms of the decline of a movement such a decline is the result of both the use of enforced consent methods and the political approaches taken by intellectual elites politically such a decline can therefore be seen as a consequence of the indonesian politicaleconomic power structure and its pursuit of neoliberal policies the oligarchic relationships inherent to this politicaleconomic structure have ensured the establishment of alliances that benefit these businesses with both central and local government and not only with government officials and private actors but also with thugs and paramilitary groups that pressurize threaten and use violence against social movements or local protest groups this has led to predatory domination and coalitions forming over public resources as the dominant group a corporation is politically powerful in mining projects persson writes that dominant groups can extract consent from subordinate groups through the use of development slogans that indicate that the project investment is considered legal legitimate and bringing prosperity to all stakeholders the corporate slogans about prosperity have been used to establish hegemony over communities in particular through implementing social assistance in the form of a csr programme while such programmes have been seen as a way to control a movement by offering social and economic assistance to affected communities taking this approach actually maintains and secures the companys interests besides these social and political strategies religious and cultural values could also be used as complementary ways to limit the impact of a social movement the decline of the social movement in banyuwangi regency has been shown to be the result of a combination of techniques religious and nationalist organizations have taken roles that directly and indirectly support corporate and local government policy regarding the goldmining project the religious leaders have strong ties with the majority of the followers of these religious bijdragen tot de taal landen volkenkunde 179 537 organizations including the nu and its members the majority of the nus members are grassroots followers who respect the religious leaders for their religious teaching and cultural values zulkifli has stated that the relationships engendered by the importance placed on the religious doctrines and cultural values of the nu by the organizations followers are carefully utilized by the kyai for most scholars and followers it is still prohibited to reject or disobey any command or instruction of the kyai or gus in what fox and dirjosanjoto describe as a patronage relationship this combination of social political and cultural approaches is used by religiousnational organizations to reduce the impact of the social movement weakening it and thereby assisting the corporation in gaining consent from local communities and maintaining its strong position visàvis the mining operation project as well as putting pressure on the antigoldmining movement methodology according to tarrow research into social movements should be carried out when an event has reached its peak and the decline of social movements should be studied in the context of its development particularly with regard to the influence of the local political context a lack of political support may lead to powerlessness this study took a qualitative approach based on the observation of several protests particularly in 2019 and 2020 and of the livelihoods of farmers and fishing communities in the villages of sumberagung and pesanggaran as the main locations of our field research these two locations were chosen for two reasons first the village of sumberagung is affected directly by mining operations therefore it has become the centre of the antimining movement second the village of pesanggaran is located near the mining operation and is the place where two key social groups have originated one consisting of farmers and members of the fishing community which is considered to be the first antimining movement group and a second composed of former illegal miners and groups of youths the villages were visited three timesfrom october to november 2018 in july 2019 and from january to february 2020to study the lives of farmers and fishermen as the main opponents of the mine as well as looking at the antigoldmining movements progress and the promining movements responses interviews were conducted with four prominent figures in the antimining movement and two in the promining movement and subsequently with others using the snowball technique to make contact these individuals bijdragen tot de taal landen volkenkunde 179 537 included religious leaders in the nu the five heads of the villages two martial arts leaders and several members of the antimining movement from the farming and fishing communities in addition information was also gathered from three other villages through focus group discussions particularly with those in the fishing and farming communities moreover additional information was also gathered from officials of the subdistrict and district of banyuwangi structured interviews were also conducted with the top managers of the corporations the collected data were useful for analysing and mapping the actions of both movements and their affiliations and interests in order to fully understand the movements the combination of the snowball and deliberate methods was used to ensure that relevant information was obtained from the informants and that the researchers established the entire picture alongside field research supporting data were gathered through secondary sources such as books newspapers and other related documents particularly those which discussed and analysed the sociocultural and historical backgrounds of the local and affected communities the social groups differences the influence of the religious groups and the conflicts escalations and patterns from 2009 to early 2018 4 the sociopolitical context of the mining conflict institutional support and policy inconsistencies scholars have pointed out that the sociopolitical environment in which goldmining activities take place is impacted by issues such as the environment community resistance the inconsistency of regulations and policies and weak government institutions in the case of the goldmining activities in banyuwangi three sociopolitical aspects have been analysed institutional support for the mining company leading to the inconsistency of forestry policy implementation environmental risks and societal opposition according to ismail et al the issue of forestry policy in the goldmining area of banyuwangi has become polemic since 2000 when the hakman group corporation submitted a mining licence application to the local government the proposed mining area covered 409136 ha including several natural conservation areas such as the taman nasional meru betiri which was not only conserved for its benefits for the natural environment and biodiversity but also because it supplied water and food for the local community on consideration of the risks to the park the local bijdragen tot de taal landen volkenkunde 179 537 regent of banyuwangi ratna ani lestari rejected the application however triatmojo et al have explained that the regency did issue a mineral survey licence to pt indo multi niaga in 2006 followed by an exploration permit for 20072015 covering 1162145 ha of the tumpang pitu hills as part of sumberagung village ismail et al have noted that imn also requested permission from the provincial government to mine the forested area of south banyuwangi and requested permission for exploration activities from the ministry of forestry both requests have been granted however the ministry of forestry has only granted access to 198780 ha of the protected forest area in october 2007 the provincial assembly of east java issued a letter of recommendation to the district and provincial governments as well as to the kementerian kehutanan to upgrade the exploration permit to an exploitation one this was followed by the granting of an exploration licence by the governor of east java to pt imn ismail et al have shown that those recommendations were considered unprocedural by the provincial assembly and not in line with the zoning regulation for the tumpang pitu area which had been declared protected forest set aside for the local community in pesanggaran7 in 2012 pt imn sent a letter to the regent of banyuwangi abdulah azwar anas asking for the transfer of the mining business permit to pt bsi the permission was granted until 20148 in 2012 the regent of banyuwangi proposed a change of status for 974328 ha forest from that of protected forest to productive forest the minister of forestry zulkifli hasan only accepted such a change for 1942 ha this decision was seen as the path to realizing goldmining activities smoothly in 2014 the local government of banyuwangi announced that the government had gained a 10 golden share in pt merdeka copper gold however the reality of this share has been questioned publicly because of the lack of detail provided about it several heads of villages local politicians in the banyuwangi assembly and social and political activists have noted that they have insufficient information about the goldenshare issue in an interview a politician in the local assembly stated that knowledge of this golden share is not well known publicly due to the political culture of banyuwangi 7 ike ningtyas pasca rusuh yenny wahid mundur dari merdeka copper and gold tempo 30112015 merdekacopperandgold 8 putri akmal kata bupati anas soal kronologi izin tambang emas tumpang pitu banyuwangi detiknews 2632016 kronologiizintambangemastumpangpitubanyuwangi bijdragen tot de taal landen volkenkunde 179 537 whereby the elites make the political decisions and ensure that these are in keeping with their own interests the offer of a golden share to the local government and the people of banyuwangi has been insufficient to stop the local community from protesting the presence of pt bsi because they are aware that the benefits of the golden share may not cover several of the environmental issues that have occurred in goldmining projects around indonesia the antigoldmining movements coordinator from pancer was taken to sumbawa to visit the location of the newmont case in teluk buyat thereby increasing their knowledge of the risks of gold mining according to the antimining coordinator in pancer hamlet and sumbermulyo village the change of forestry status and the use of mercury and cyanide could damage the soil and the sea the presence of these chemical substances could affect fishermens and farmers livelihoods and have socioeconomic consequences for the affected community as occurred in 2016 when mud flows due to heavy rain and water overflow caused pollution in the katak river and on pulau merah beach affecting the fishing and tourism industries the local community is also worried about blasting activities that could lead to air pollution in the pulau merah area furthermore the deforestation of and extraction on top of the tumpang pitu hills have caused concern in the local community they fear that the hills may be lost as a natural breakwater for tsunamis as they acted in 19949 a report by kristanto mentioned that the goldmining activities in banyuwangi may cause the loss of some part of the hills considered the natural breakwater for southern banyuwangi which is susceptible to tsunamis10 environmental and livelihood issues have been the main points raised by the local community in its struggle to stop the goldmining activities in sumberagung village however the protests over those risks have been minimized by pressure from powerful religiousnationalist organizations bijdragen tot de taal landen volkenkunde 179 537 the antimining movement the internal challenges raised by the variety of groups and motives the conflict between the corporation and the antimining movement is concentrated in sumberagung village to some extent rejection of the mining activities has also spread to two other villages kandangan and sarongan in the subdistrict of pesanggaran where it involves other social groups and interests and where an antimining movement led by the farming and fishing communities has also been established from our interview with the heads of the two villages it became clear that this rejection of the mining activities within the two villages is due to concerns over seawater pollution and the potential expansion of the production area which may affect control of the land and springs around the villages and the national park in contrast in sumbermulyo and pesanggaran villages there is less antimining sentiment the head of sumbermulyo village stated that the population of his village consists of people from a variety of professional backgrounds such as farmers government employees traders and home workers in contrast the majority of the people of pesanggaran village used to be illegal miners in the tumpang pitu hills before the current goldmining operations began the profits obtained from this illegal activity were used to buy land and property and in their development therefore most of the people in this village seem to be wealthier than the majority of the people in the other three villages furthermore sumbermulyo and pesanggaran villages are a bit further away from the mining site although the antimining groups are not wellrepresented in the village small representative groups used to voice their rejection of the mining operations with protests and demonstrations taking place in sumberagung village based on our findings we have divided the antimining movement into three frontline groups and described their roles within the dynamics of the mining conflict the first frontline antimining group consists of those who have been directly affected by the mining operations and have taken a strong principled stance against the mining activities they are particularly concerned about their livelihoods and about the negative outcomes of mining such as environmental and water pollution they also emphasize the cultural meaning and value of the hills this group consists mainly of residents of sumberagung village who work in the agriculture fishing and tourism sectors the majority of the members of the fishing and farming communities are concerned about the possible natural changes in the tumpang pitu hills that would affect their lives the hills are seen as the natural breakwater for the sea as it protects the local community from tsunamis this was evidenced in june 1994 when almost all the coastal zones of the regency were damaged bijdragen tot de taal landen volkenkunde 179 537 by a tsunami while the people of pancer hamlet in sumberagung village who lived behind the tumpang pitu hills were less affected the hills are seen as a natural protector that may save lives in the case of future tsunamis the fishing community is also worried that seawater may be polluted by the mining activities affecting the fishermens income and family life in 2008 the fishing community established the forum peduli masyarakat nelayan banyuwangi to voice their views concerning mining exploration alongside the agriculture and fishing sectors some young people from pancer hamlet involved in the kelompok sadar wisata consider tourism a new promising sector for the area they have tried to find opportunities in this sector to develop the village and create a better life there while avoiding the uncertainties of agriculture and fishing the majority of those involved in the tourism sector are between fifteen and forty years old and these include a few fishermen who work in the sector during the offseason for fishing between september and february members of this younger group have no qualifications to work in the mining industry and therefore the tourism sector is their only hope for the future as a consequence some of them have become antigoldmining activists rejecting the mining project because they believe that tourism and mining cannot be developed in the same location side by side as is occurring in sumberagung for them agriculture fishing and tourism are enough to sustain their livelihoods the second group of antigoldmining activists is seen as an opportunistic group whose members are indifferent towards pt bsi on the whole they have not been directly affected by the mining and live in other villages within the same subdistrict despite this they play important roles in the survival of the movement often taking advantage of it they can be divided into several groups the heads of the villages the unemployed who were formerly employed by pt imn former illegal miners of the tumpang pitu hills who mined before the exploration phase had taken place and former contract workers of pt bsi the first subgroup of the second group includes the heads of the villages within the subdistrict generally speaking in the subdistrict of pesanggaran the majority of the heads of the villages have positioned themselves as antimining albeit indirectly although they form a part of the local government and therefore are supposed to support the governments policies they still support the antimining movement through silent tactics their positions with the local authority has not stopped them from rejecting the mining operations four of the heads of the villages have demonstrated their antimining positions while one village head tends to take a more moderate line bijdragen tot de taal landen volkenkunde 179 537 the second subgroup of the second group is made up of former employees of the previous mining company pt imn servicesector workers and former illegal artisan workers in the tumpang pitu hills these individuals are usually between the ages of twentyfive and forty years old and are enthusiastic about the mining sector they have high expectations that their interests can be accommodated through the sector at least if they have worked in the sector for a long period this is particularly true of the former illegal miners who have experienced the numerous effects of the mining sector however these former employees are not really fighting for the communitytheir focus is mainly on their own interests as jobseekers there are two basic issues regarding employment in the context of banyuwangis mining operation first pt bsi promised to recruit the former employees of pt imn after this company dismissed them however according to the antimining movement pt bsi has not recruited all the former employees of pt imn the second issue is the employment criteria as not all of the local people are qualified to work in the industry kapesa mwitwa and chikumbi explain that the topic of employment has become a matter of contention in the extractive industries because specific skills are required from our observation this second group is the one that maintains the dynamics of resistance however members of this group may leave the movement when they see attractive opportunities or offers from any party particularly from pt bsi in the context of the antimiming movement in banyuwangi this opportunistic attitude could potentially influence the strength or weakness of the resistance one of the antimining movement coordinators in pulau merah and a prominent member of the asosiasi perhutanan sosial banyuwangi admitted that there were opportunistic individuals within the antimining movement that could be bribed or satisfied by offers during political campaigns by particular political candidates or with regard to projects from pt bsi consequently the antimining movement is easily weakened and reduced bebbington et al believe that such internal dynamics could lead to the failure of a social movement the third main group in the movement consists of environmental activists and student associations who normally advocate for the community affected by the mining activities these activists support the antimining movement in banyuwangi through advocacy and protests and by providing comparative data for the affected communities the environmental activist groups are wahana lingkungan hidup indonesia and jaringan advokasi tambang and banyuwangis forum for environmental learning there has been involvement from several student organizations from the local universities including the gerakan mahasiswa national indonesia bijdragen tot de taal landen volkenkunde 179 537 of banyuwangi islamic student associations the nus youth environmental organization called front nahdliyin untuk kedaulatan sumber daya alam the banyuwangi forum for environmental learning the pusat studi hak asasi manusia universitas airlangga centre for the study of human rights of airlangga university jaringan advokasi tambang and the forum konservasi indonesia jawa timur the student movement and youth organizations in the capital of jakarta have assisted the affected community in its struggle these groups mainly appeared on the scene in 2008 with environmental protection and local livelihoods as their main agendas for several years rejection of the mining operations was voiced sporadically by these organizations until a more cohesive social movement was established in 2012 in 2018 as mentioned above several organizations including the student and community alliances and the forum for the care of banyuwangis fishing community took the initiative to establish a new antimining organization the banyuwangi movement forum later the banyuwangi peoples forum which embraced all elements of antimining activities the bmf was supported by the fnksda and banyuwangi solidarity forum separately however the bmf has provided little financial support while the fnksda is not fully supported by the nu as its parent organization however the new movement has not been as unified as expected in our interview with a prominent leader of socialforestry activism in banyuwangi it was noted that all the groups within the antimining movement have different backgrounds and interests and the bmf has not been seen as a source of power or a strategic alliance but rather as a temporary coming together the movements lack of focus is due to its members chasing personal interests and setting differing agendas as a result the movement has not remained strong with many individuals and groups disappearing after achieving progress for their interests or surrendering or taking up other causes the leader of the fishing community of sumberagung village also noted that the antimining movement also consists of other groups associated with political parties local bosses and prominent individuals which has created distrust among the antimining movement internally due to the various hidden agendas of these political figures as a consequence the antimining movement has appeared to be in a steady decline over the last few years the internal challenges of the antimining movement of banyuwangi the internal causes of the decline of the antimining movement in banyuwangi can be linked to the behaviour and personal interests of the heads of the villages who have supposedly played important roles in the survival of the movement often taking advantage of it these individuals want to maintain at least their current social status and ensure their future political careers by winning votes in the case of banyuwangi they have established social and political contracts to secure possible votes even though this breaches their duty as public servants in one particular case one of the heads of a village who was elected for the period 20172022 committed to continue the policies of the previous village head who had been a supporter of the antimining movement at the time of writing the head of the village was trying to maintain support for his social and political positions for the 2022 village elections similarly another village head declared that as he had been elected mainly by antimining movement members and could see the possibility of using these votes as a stepping stone to election to the local parliament he has had to accommodate the antimining movements interests in his platform giugni and passy have highlighted that if members of the elite did not respond to minority demands they would risk not being elected in the future strong opposition to the mining operation has also been demonstrated by another village head as his proposed corporate social responsibility programmes have been ignored by the company since 2015 according to the companys management officials the village programmes would be considered by the csr team of pt bsi however the restructuring of the internal management of the company has led to changes to socialprogramme priorities the disappointment felt by the head of the village has led to his opposition to the presence and future possible projects of the mining company in his administrative territory through our conversation it became clear that the head of the village has not stopped any villagers from joining antimining movement protests in sumberagung village it was confirmed by one of the antimining coordinators in pulau merah that protesters from the villages of kandangan and sarongan have participated in protests due to their having a similar perception of the situation and to show solidarity however the majority of the heads of the villages and some of the former employees of the previous mining company have admitted that they have in some instances taken advantage of the conflict the heads of the villages have used the issue of gold mining to gain political support and votes in the village downloaded from brillcom 02232024 045432pm via open access this is an open access article distributed under the terms of the cc by 40 license bijdragen tot de taal landen volkenkunde 179 537 elections by voicing antimining demands during their leadership of the village in one instance the head of a village signed a political contract with the antimining group for these village heads the most important thing was electoral success however their antimining agendas have not been easily realized postelection because of the need for the village heads to follow the local governments instructions meanwhile former employees have taken advantage through participation in projects and csr programmes with the company our findings show that the company has approached former employees through its csr programmes as a substitute for earlier promises to recruit them as permanent employees when pt bsi replaced pt imn initially this approach was welcomed by the former employees however this goodwill did not last due to the termination of contracts and changes in the companys priorities the majority of the former employees became disappointed and got involved in conflicts with the company in response to this the company accepted project proposals and offered csr programmes to the former employees and the affected community generally this conflict cycle has existed since pt bsi took on the mining operation in the tumpang pitu hills in other words the economic benefits and personal gain of the former employees have been prioritized over voicing rejection of the goldmining project castells has observed that the failure of a social movement can also be linked to opportunistic approaches from certain individuals or groups that see the social movement solely as a political arena it is wellknown that the bmf has representatives from various subgroups and with various concerns this has contributed to a seriously weakened social movement according to the head of pesanggaran village the antimining movement has gained support from former contractors of pt bsi who worked under limited contracts for the company towards the end of the construction phase from 2013 to 2015 these include small local enterprises food suppliers welding service providers and other service sectors according to the human relations department of pt bsi the termination of such contracts has led to disappointment and resentment conflict is therefore inevitable as the terminated contractors can no longer see any benefits to be derived from the presence of the company the corporate response building consent with the local community in the mining sector environmental damage the prosperity and livelihoods of the local community and employment levels are sensitive issues that need an bijdragen tot de taal landen volkenkunde 179 537 adequate response from the corporation in question because they are sources of social conflict in this sector these issues in our view have become the central focus of pt bsis efforts to obtain consent from the local community in this regard the company has emphasized that its mining investment brings fewer risks in comparison with other mining activities elsewhere in indonesia and that it will bring prosperity for all stakeholders including the affected community in sumberagung village and the communities in pesanggaran subdistrict more generally regarding the environmental issues pt bsi has responded by sharing information related to the technology used during the production phase through the media seminars and dialogues with the local community according to one of the general managers of pt bsi the corporation has declared that the method used in the mining project is environmentally friendly the heap leach method as it is called does not generate mine tailings as waste the ores are intercepted recycled and reused at the end of the project the ores will be rinsed to remove any waste before replanting11 however the antimining movement is still distrustful of the company due to the mud flood that occurred in 2016 and the information regarding environmental damage provided by environmental activist groups such as walhi and jatam in terms of employee composition the total number of employees working for pt bsi in december 2020 was 2735 of these 2708 employees are from the local community in banyuwangi regency and just 27 are foreign employees according to the pt bsis head of hr the workforce has mostly been recruited from among banyuwangi residents with particular attention paid to the pesanggaran subdistrict however the company acknowledges that the majority of the locally recruited staff are unable to work at higher levels in the business due to their limited education and capabilities the coordinator of the antimining movement in pancer told us that many local youths have been employed by pt bsi but that their employment has gradually ended due to contractual agreements which he believes means that the number of local employees has significantly decreased bijdragen tot de taal landen volkenkunde 179 537 furthermore pt bsi annually announces via its csr programme that the companys presence has benefitted the local people12 from our observations bsis financial support for various local homebased industries has assisted the growth in businesses particularly among local housewife groups in sumbermulyo and pesanggaran villages this is also true in sarongan and kandangan but to a lesser extent due to their geographical locations and dependent on the individual proposals and the villages resources however the company is more concerned with sumberagung village because this is the location of the mining site and is where the strongest resistance to the operations can be found the company has tried to develop basic infrastructure and homestay opportunities as part of the development of the area as a tourist destination particularly in pancer where pulau merah and mustika beaches are located in an interview one of the top antimining movement leaders who is also the leader of the womens antimining group admitted that the company has supported the local community in pancer through csr programmes by building roads providing a school bus for local children building tourism infrastructure parks and lighting and carrying out other social charitable actions according to her these actions are an attempt by the company to obtain consent for the mining from the local people in pancer as they aim to show that goldmining investment brings economic and social benefits she confessed that this has led to a reduction in the strength of the antimining movement because the majority of its members have begun to accept this support and have changed their attitude towards the company therefore she is worried that the next generation may be seduced by this support and not continue to fight the mining operations she realizes that the antimining movement has been in decline for the 12 pt bsi has divided its social responsibility into five priority areas since 2016 economic empowerment education religion and culture health services and infrastructure see bumi suksesindo sekilas perusahaan 2020 perusahaan and bumi suksesindo tentang csr 2020 suksesindocomtentangcsr in 2020 the corporation increased its social budget for four of the five sectors namely economic empowerment education health and infrastructure the total amount allocated to the infrastructure sector was idr 15000000000 for 122km of roads in five villages irrigation disaster prevention and the provision of other public facilities moreover the budget for education was idr 25000000000 for learning centres scholarships libraries school buses and educational infrastructure meanwhile the corporation has offered idr 26900000000 for the development and empowerment of more than 45000 local people in five villages through economic and health programmes between 2014 to 2019 see a amenan bsi siapkan dana program csr ppm rp 269 miliar berita satu 2020 miliar bijdragen tot de taal landen volkenkunde 179 537 last few years although she believes that there is still a group of antimining activists who stand up for their cause our findings show that the corporations attempt to win the publics consent for their mining operations has not entirely been accepted by some members of the local community particularly the first group outlined above the negative track record of mining activities in other places is front and centre in the minds of the affected community in sumberagung village as a result the corporation has had to seek support from other entities such as social organizations relationships between the corporation and religious organizations establishing organic intellectual arrangements and seeking consent from local communities in the earlier stage of exploration in the tumpang pitu hills a group of ulama from nu in banyuwangi had shown their discontent with the presence of pt imn in the regency in 2009 200 ulama and leaders of islamic boarding schools expressed their objection to the mining exploration plans13 at a meeting they recommended rejecting all types of mining activities due to the industrys monopolistic management environmental unfriendliness and the destruction of the way of life of affected communities nevertheless some local ulama expressed a different view stating that the nus judgement towards the company should be based on scientific evidence and that the company should therefore have the opportunity to explain their operational plans14 the opportunity to give an explanation was seen as a way for pt bsi to seek consent from a religious organization in this case the nu for pt bsi the mining project in the tumpang pitu hills is an investment that will bring prosperity to all stakeholders without harming the environment alfian has described the nus point of view as being based on islamic thought in that mining activity in banyuwangi is allowed if it meets several important criteria these include answering questions about the reasons for the exploration who exploits the area and benefits from the exploitation the business ethics 13 ulama banyuwangi rekomendasikan tolak tambang emas koran tempo 1632009 korantempocoreadberitautamajatim159638ulamabanyuwangirekomendasikantolaktambangemas 14 tolak monopoli tambang emas batsul masail ulama nu surya 1632009 yatribunnewscom20090316tolakmonopolitambangemasbatsulmasailulamanu bijdragen tot de taal landen volkenkunde 179 537 involved the management of the mining activity for the common good and hazard avoidance as a result of the meeting at which pt bsis plans were laid out the scholars of the nu split into two groups for and the against the mining project the promining group sees that mining activity in banyuwangi could bring income and prosperity to the local government and local communities in contrast the antimining group argues that the environmental damage caused by mining would have negative consequences for the communities as has occurred in other mining locations these differing views remain a stumbling block for mining operations in banyuwangi these contradicting opinions are still expressed today according to a kyai in the city of banyuwangi these divergent opinions are considered normal within the organization because of the range of interests related to political support access to economic resources and the need for funds for their educational institutions therefore a kyai may accept personal financial support from certain corporations or entities in exchange for endorsing these corporations investment objectives and gaining consent for these corporations activities from their followers through their religious teachings alfian has stated that this type of beneficial personal support for mining activities in banyuwangi is due to the existence of multiple interpretations of mining activities dating back to a lajnah bahsul masail15 meeting in 2009 moreover these divergences of opinion make the nu seem a pragmatic and flexible organization in our view this type of personal agreement with a kyai or local official of the nu can be seen as an organic intellectual arrangement that benefits the corporation as described in the concept of hegemony it can be used to establish and produce consent with most nu scholars and followers for mining investment due to the focus on the positive aspects of mining this raises questions about the religious organizations role in the mining project in banyuwangi in our interview with the coordinator of the antimining movement in sumbermulyo it became clear that the majority of local grassroots nu members have met strong opposition from several local officials and kyai of the nu who have seemed to support the mining activities of pt bsi the local grassroots members of the nu have come together through prayer or pengajian and have participated in environmental activities 15 lajnah bahsul masail is an internal committee of the nu which consists of certain figures this internal committee deals with decisionmaking concerning religious social and economic issues one of the issues discussed at a 2009 committee meeting was the goldmining project in banyuwangi regency bijdragen tot de taal landen volkenkunde 179 537 led by the fnksda however they have avoided direct contact with the corporation and the nus local elites from our observations however the local grassroots membership of the nu in sumberagung and the fnksda are not strong enough to directly challenge the nus local elites or kyai this change of attitude has been seen through a shift in support for the mining corporation in banyuwangi several of the nus top members from the national to the local levels have close connections with the corporation supporting it through rhetoric on its social and economic benefits and in exchange accepting important positions in the corporation nahdlatul ulama was chosen because of its members historical support of and relations with the company but also because it has the largest number of muslim community members in the country members of this religious group have taken on key roles high up in the company a similar situation can be seen in the history of the previous mining company in the area the imn which was directed by the daughter of the former indonesian president abdurrahman wahid widely regarded as one of the most influential leaders in the nu wahids daughter was invited by other commissioners of pt merdeka copper gold with whom she was friends to become the companys director however she resigned from the company in 2015 before conflict broke out between the corporation and the affected community of sumberagung16 and was replaced by another member of the family the appointment of members of the former indonesian presidents family is believed to have been a way of gaining support from the religious groups members and society in banyuwangi at present another influence can be seen through the connection between pt bsi and the presence of the religious groups most prominent figures in management positions at the company the ketua majlis wakil cabang pesanggaran has been appointed to fill an important position in the community relations department of the company moreover media indonesia has reported that the central leadership of the nu has also shown its preference for supporting the company the chief of the nu in jakarta flatly refused to listen to several antimining group members when they approached him17 darimerdekacopperandgold 17 terkait tambang banyuwangi pbnu memihak manfaat bagi rakyat media indonesia 3082018 pbnumemihakmanfaatbagirakyat bijdragen tot de taal landen volkenkunde 179 537 it seems that this religious organization and its affiliates are increasingly important not only as a means of networking but also in terms of political support and in their role as future conflict mediators however this reciprocity could be potentially used to certain persons or groups advantages 9 coercion dynamics and the decline of the antimining movement the role of the religiousnationalist organization efforts to put pressure on antimining activities have been in place since the rejection of the corporations exploration phase the divergences of opinions among the kyai and the strong resistance shown by the first antimining group illustrate that the message regarding the investment from the corporation as a result of mining and the organic intellectual arrangements with several of the nus elites have not been accepted by some of the nus grassroots and local communities and consent has not been achieved as a result the rejection of mining activities has taken the form of violent resistance in our interview the head of the antimining movement in sumbermulyo village mentioned the huge demonstration against pt bsi that took place on 4 april 2017 on the main road in pancer part of sumberagung village the movement and the local community marched towards the company headquarters with several banners the protesters gathered at the companys headquarters and some chanted their demands while others held the banners aloft however many of the participants in the march were surprised to discover that one of the banners depicted communist symbols it appears that the banner had been donated by an unknown person as the march was in progress the coordinator said that this suggested that the unknown person was a trained individual with the appearance of a member of a security service and therefore the coordinator suspected that the banner had been donated in order to label the protestors as a subversive movement the coordinator noted that all the other banners had been produced in the movements leaders house and their production witnessed by members of the local police and other members of the local community if there had been communist banners produced in the house then the antimining leader would have been immediately arrested as a consequence of the inclusion of these communist symbols the antimining movement of banyuwangi has been accused of being sympathetic to communist ideology therefore legal measures have been taken not only by the formal security services but also by religiousnationalist organizations in january 2018 anticommunist groups responded by establishing the massa gerakan anti kebangkitan komunis under bijdragen tot de taal landen volkenkunde 179 537 the command of a religious leader led by the nu and its affiliates such as the barisan ansor serba guna or banser several martial arts groups and nationalist youth organizations including the pemuda pancasila the national defence brigade and the forum suara blambangan among others have joined this movement18 the head of forsuba accused the antimining movement of being a provocateur and an illegal movement that does not reflect the interests of the affected communities forsuba asked the security services to investigate the situation and take appropriate action19 as a result the local police has arrested several of the coordinators of the demonstration and processed them not only as ordinary criminals but also as rebels that might be a threat to national security20 it is well known in indonesia that propagating communist ideology including its symbols and activities is strictly prohibited the majority of citizens are aware that the following of communism has been banned since 1966 under the soeharto regime21 therefore any person who is associated with such ideology is considered a rebel a label which can then at any point in the future be used for political purposes historically the nu had a long battle politically with the communist political institutions in indonesia this began when the nu was a political party during the transition from the sukarno to the soeharto regime in the 1960s at that time the nu was an independent political party and a competitor to the partai komunis indonesia this led to several clashes between the forum petani indonesia a group affiliated to the pki and banser a semiautonomous paramilitary brigade affiliated to nu these clashes then continued between the pki and another of the nus 1948and 1965 thus a breach of this ideological prohibition was placed squarely at the feet of the antimining leader and his collaborators this was seen as an appropriate moment to implement coercive measures against the antimining movement by accusing the antimining movement of being communist opportunities arose for the security services and religiousnationalist organizations to act legally to prevent and control the antimining movements activities however according to the coordinators of the antimining movement in sumbermmulyo and sumberagung villages the accusation of being a communist organization and the arrest of the movements leader budi pego in 2017 were used to discredit the movement and prevent it from recruiting new members spreading its ideas and receiving public support to some extent the antimining coordinators in pancer acknowledge that some ordinary people did lose sympathy for the antimining movement at this point and would no longer join it since then social control of the antimining movement has been enforced religiousnationalist groups have established an anticommunist awakening movement building informal security posts arranging convoys in certain places in banyuwangi to counter the antimining movement and conveying messages about the dangers of communist ideology as a result the antimining movements activities have been reduced significantly since the arrest in 2017 of budi pego because of the pressures applied and control taken by the religiousnationalist organization we have observed that antimining activities were limited during 2019 and 2020 having been reduced to small demonstrations or protests that avoided clashing with the corporation and security services and that the antimining movement was based in pancer hamlet the movement believes that its activities are being monitored by the security services and religiousnationalist organizations and that its members could be arrested at any time as a consequence of being accused of having an affiliation with communist ideology and the arrest of the antimining leader and his fellow protestors there is no consistency and no firm figurehead for the movement every possible method has been used to legitimize the religiousnationalist organizations presence and give credence to the idea of communism as a dangerous alkatiri and kiwang bijdragen tot de taal landen volkenkunde 179 537 ideology in indonesia to some extent the reasoning given by the religiousnationalist organization has been accepted by many people in the pesanggaran subdistrict who believe the antimining movement to be associated with communist ideology however the involvement of officials of the nu who were working at pt bsi and its affiliated groups to put pressure on the antimining group is still being questioned by those who understand the situation and this includes those in the first group of the antimining movement and the nus grassroots followers these individuals have questioned whether the nus elites were truly acting against the communist ideology and defending the pancasila as the national ideology of indonesia or whether this exposure of the movement as communist has been a businessrelations exercise with a hidden agenda within this mining conflict as pointed out by a kyai interviewed in banyuwangi economics and business relations may be the main reasons for taking action against the antimining group in the view of giugni and passy the promining movement has used the opportunity to raise public awareness of the danger of any issue which may threaten the goldmining project or provoke conflicts between the corporation and the affected community speaking as though it represents the public at large the more support it obtains the more legitimate its countermovement becomes because of the pressure that has been applied the movement has changed strategies moving from an anarchist approach to a gentler tone with the aim of entering into a dialogue with the local government of banyuwangi to find better solutions while still rejecting the presence of pt bsi however the coordinator of the movement from pancer hamlet has said that persuasive approaches to the local government have not as yet been successful therefore resistance has had to continue through the use of a mixed approach including violence blockades intimidation and talks at the grassroots level as well as symbolic protests such as group prayer street banners and hunger strikes as occurred throughout 2019 and early 2020 however all in all the number of protestors involved seems to be declining conclusion in summary banyuwangis mining conflicts have seriously affected communities and social groups in the miningoperation area particularly in sumberagung village the communities affected by the mining activities in the tumpang pitu hills of banyuwangi are worried about the risks of mining as is often the case in other mining locations as a result social movements have bijdragen tot de taal landen volkenkunde 179 537 been established over time by these communities to voice their opposition to the mining operations the divergence of opinions among socioreligious elites such as the kyai of the nu has created the opportunity for pt bsi the mining company to approach members of the nu individually as a result several promining elites of the nu have come to organic intellectual arrangements with the company mixing religious teaching with slogans about the socioeconomic benefit of mining investment in order to persuade their grassroots followers and local communities and gain their consent for the operations tensions between pt bsi and the affected communities have been recorded due to their differing views of the mining activities pt bsi has declared that the technology used is environmentally friendly the affected communities are doubtful of this and have demanded that the corporation withdraw from the tumpang pitu hills as a consequence tension distrust and conflict have occurred continuously with clashes breaking out in 2015 and 2017 resulting in the arrest of prominent leaders of the antimining movement internally the antimining movement in banyuwangi has faced significant weaknesses such as opportunistic behaviour in terms of local village heads who want to meet certain political agendas or members and jobseekers who aim to benefit personally externally the antimining movement has faced pressures from religiousnationalist groups led by the nu which have acted to safeguard the state from communist ideology and have framed the antimining movement as a communistaffiliated group as a result coercive measures have been taken against the antimining movement the use of anticommunist rhetoric by the promining lobby has successfully destroyed the agenda of the antimining cohort at the same time promining elements have gained significant support from the wider community to apply pressure and take control of the antimining movement consequently the antimining movements activities have been weakened and its membership has declined however this decline does not mean that the antimining movement in banyuwangi has failed it continues to voice its disapproval and rejection of the mining operations at the grassroots level in banyuwangi regency albeit in more subtle tones

although the banyuwangi antimining movement clearly has the capacity to grow this article argues that the movements manoeuvres against pt bsi seem to have become weaker since 2017 the article seeks to explain how the interests of the internal groups within this local social movement have weakened its position and how religiousnationalist organizations that is the nu and its affiliates have manoeuvred to defend the state and the corporation indirectly the data have been qualitatively collected through indepth interviews focus group discussions fgd s and relevant documentary sources by using the gramscian concept of hegemony this article shows that the decline of the antimining movement is related to the agendasetting of individuals and subgroups in the movement as well as the ability of religiousnationalist promining groups such as the nu and its affiliates to use their influence legitimacy and ideological rhetoric to this end combined with some social and political characteristics of east javanese society

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introductionbackground on march 11 2020 the world health organization declares covid19 a pandemic and within 96 hours the entire united states of america was thrown into a whirlwind shutting down borders schools and organizations to contain the transmission of the infectious disease known as the coronavirus in the first quarter of 2020 americans clung to their television screens as the number of covid19 cases crept across the globe as more cases developed organizations had to reassess the human capital cost in light of dwindling revenue the decision by us organizations to furlough andor lay off workers lead to an unprecedented 147 percent unemployment rate this is the highest rate and the largest overthemonth increase in the history of the data the number of unemployed persons rose by 159 million to 231 million in april the united states drew a clear line in the sand nonessential employees had to cease working in physical buildings or be able to work remotely in addition the economy slowed which forced companies to decide who they can still afford to pay research question for years the idea of worklife balance has been a topic of discussion among human resource professionals and this topic could be instrumentational in understanding the paradigm shift that has occurred in the mindset of workers post pandemic over the last year the data has demonstrated there are more jobs open then available individuals to work and there appears to be a gap to investigate why there is a delta of five million between job openings and unemployed individuals this research looked at what obstacles workers encountered that prohibited them from reengaging in the job market after the pandemic within the framework of maslow hierarchy of needs theory in the third quarter of 2020 the cdc released guidelines and tools to reopen the united states schools and corporations as the postpandemic fog cleared organizations found themselves in an unexpected and unprecedented crisis henny states the us economy is poised to take off in coming months as it rebounds from the coronavirus pandemic but the recovery faces a new challenge in an apparent labor market shortage employers are reporting difficulty in onboarding new workers even though the nations unemployment rate is at 6 and some 97 million americans say they are actively looking for a job according to labor department data henney goes on to emphasize people who had either been terminated furloughed or voluntarily left the job market are slow to return for fear of catching covid19 or walking away from unemployment benefits that provide greater stability than working a fortyhour week many legislators and media hosts suggested individuals are not returning to the job market due to the increased stimulus checks extended unemployment benefits and eviction bans being in place the financial windfall of money was one potential reason for individuals not participating in closing the labor shortage however we suspect this could be an attributing factor but not the root cause the purpose of this research is to explore what obstacles have prohibited workers from returning to the job market after the pandemic their lack of labor participation has led to a deficiency of economic pollination throughout the united states causing shortages delays and stock outs literature review maslow discusses the basic needs that every individual faces as they progress through life according to mcleod maslow hierarchy of needs states there are five tiers of human needs that can be further broken down into three categorical needs listed lowest to highest base needs psychological needs and lastly selfactualization maslow goes on to state individual must fulfil or satisfy the lowerlevel need prior to transitioning to the next level and thus we set out to demonstrate this has been observed over the last two years with respect to the covid19 pandemic and the slow return to the workforce during the government shutdown individuals were able to fulfil the basic needs through the accumulating savings from minimal commute lack of vacation spending andor federal stimulus package which provided 300 a week child tax credits and instated eviction bans in addition individuals were able to develop meaningful relationships with immediate family as the distractions of commutes activities and social meetings were halted once the restrictions were lifted connections with extended family and close friends became more heartfelt and cherished individuals were able to reflect on worklife balance and their own selfworth which leads to the top of the pyramid doing something that is fulfilling and not just a job but the thing we were created to achieve according to maslow the five levels of maslows hierarchy are as followed 1 physiological needs are at the base of the pyramid as these are biological needs such as food water warmth and shelter 2 safety needs are centered around safety security and order 3 belongingness and love needs are where individuals seek personal connections through meaningful relationships with others 4 esteem needs hinge on establishing respect and achievement for oneself and in the eyes of others and lastly 5 selfactualization needs are described by maslow as selffulfillment…the desire to become more and more what one is to become everything that one is capable of becoming conceptual model and propositions this study utilizes an inductive qualitative methodology to understand what elements are being considered while reengaging in the labor force by workers corporate america has been thriving for years whereas workers have been struggling to manage the stress of making ends meet with through the current living wage according to maurer richter and rosenberg e the job opening and labor turnover reported that approximately 45 million americans quit their job in november of 2021 and some noted attributing factors were pay flexibility commute family safety and improved working conditions according to richter the pandemic created a space for individuals to reconsider their work and their priorities and what they want to do the pandemic changed everyones perspective on working conditions salaries standards and overall worklife balance in addition to the perspective shift k through 12 educations morphed into virtual learning from homes dining room tables and kitchen islands became the new classroom and parents became pseudo teachers the measures listed above were put in place as a strategy to reduce the spread of covid19 nevertheless the closures of daycaresschools buildings and the implementation of healthcare screens made returning to work more challenging over time social distancing and immunization strategies were implemented which slowed the spread of covid19 and therefore corporations were able to resume supplying goods and services however corporations found themselves without individuals to conduct tasks which would produce saleable goods and services workers seemed to have found a way to embrace life without work at the same time there seemed to be a shift in how workers viewed the meaning of work could the dismissal of their services have triggered an awakening in their sense of selfworth as corporate america struggles to entice workers to trade in quality family time for eight hours days on a production line there appears to be resistance the call for workers is being made on social media television billboards and radio stations nonetheless there is still a labor shortage the way of work is on the brink of collapse and understanding the mindset of workers could be the key to entice individuals back to the job market to identify what is unfolding we have performed a document analysis to set the framework propositions p1 the pandemic changed the workers sense of selfworthselfactualization as individuals leave jobs in pursuit of more fulfilling purpose p2 the time away from work during the pandemic has led to individuals value fulfilling belongingness and love needs above having a job p3 the labor shortage provided an environment that allowed workers to negotiate compensation packages as esteem needs were met research method the research methodology was structured to identify what obstacles have prohibited workers from returning to the job market after the pandemic according to the bls there are approximately 11 million job openings and six million unemployed individuals in other words if every person was placed in a job vacancy there would still have a deficit of five million individuals in addition the labor force participation rate is down two percent hovering around 615 the lfpr shows the number of people seeking work or working expressed as a percentage of the total population and is calculated by taking the total labor force and divide it by the total civilian noninstitutionalized population baker states the lfpr aides in understanding the landscape of the labor market as it indicates the number of individuals who are unable or unwilling to work at the current wage to understand the phenomenon that is unfolding a document analysis was conducted to identify various document sources that provided a firsthand account of the job market landscape and the working individuals perspective bowen and morgan state the use of document analysis as an unobtrusive and nonreactive methodology which allows for avoidance of social desirability bias is representative across spans of time and the method is more efficient in cost and time when compared to other qualitative research methods according to cardno the approach and management of the content is straightforward and rarely requires internal review board approval to analyze the data this research study and the methodology was vetted through the temple internal review board and determined to be exempt in the words of mitch kapor getting information off the internet is like taking a drink from a fire hydrant and therefore it was crucial to select the most appropriate sources that both represented the labor market and the individual being sought after for employment to ensure a holistic viewpoint was presented 76 documents across three types were analyzed to investigate the paradigm shift occurring in workers across the united states data collection in selecting where to obtain data we searched the internet from april through june of 2022 using the key phrase of why people arent going back to work why are people not returning to work the great resignation and the great reshuffling the title and opening paragraph of each article was read prior to importing the article into the qualitative analysis system a total of 45 articles were identified and imported into a data file within nvivo using ncapture to effectively observe the tone sentiment and voice of the worker the reddit social media platform was selected thus the rantiwork subreddit community was selected to observe content that is curated and promoted by site members through voting to obtain a more representative sample from the working individual 31 rantiwork subreddit posts were analyzed over a month the subreddit rantiwork is a community for those who want to end work are curious about ending work want to get the most out of a workfree life want more information on antiwork ideas and want personal help with their own jobsworkrelated struggles the reddit posts were unfiltered and firsthand accounts from individuals who were or had worked the posts contained emotional language imagery and stories that opened the door into their life and shared actual situations pertaining to work and why they were or had left the job market the reddit platform was selected as it provides a forum for the people to share content from their point of view and in through their own voice according to the reddit site reddit is a growing family of millions of diverse people sharing the things they are care about most and with over 100000 active communities and 13 billion post and comments this platform is a representative sample of individuals at the center of this research data analysis all documents were compiled through the search criteria listed above in accordance with proferes et al the documents were obtained and imported into the nvivo system the records were screened and any duplicates or unretrievable full text articles were removed the remaining documents were either stored in a data file labelled website or reddit each document was systematically coded in nvivo a computer assisted qualitative data analysis software two rounds of document analysis were performed the first round contained and coded 60 documents however to ensure data saturation was achieved an additional 15 documents were coded as a robustness check as specified by miles the articles and posts were processed through first and second cycle coding by assigning descriptive labelsmeanings and then consolidated into code clusters which in turn condense into themes the first level coding was utilized to reduce the qualitative data to allow a more manageable focus the second level coding process was used to consolidate the first level codes into more generalizable terms that narrows the focus level 3 coding was employed to further refine the content focus and move towards critical density better known as themes data analysis and resultsdiscussion this study set out to explore what obstacles have prohibited workers from reengaging in the job market after the pandemic within the framework of maslow hierarchy of need theory the document analysis yielded fortyseven first cycle codes which were consolidated into nine second cycles codes and five themes the five main emerging themes were identified as salary stumbling block steward of care sense of worth and stress results the codes listed above were systematically categorized into themes with the total number of times the code was linked to a file andor references the data indicates that sense of worth was the highest referenced with denoting 498 references followed by salary at 301 stress at 90 steward of care at 74 and stumbling block at 29 the data suggest that during the pandemic individuals that were released from their employment experienced a paradigm shift within where a sense of selfworth emerged according to krugman the pandemic gave employees more time to think about their careers the pandemic gave american employees time and opportunities to reassess their situations and priorities we would claim that surrounding factors caused by the pandemic allowed for the four lower levels known as the deficiency needs to be met thus given rise for individuals to engage in the growth needs according to mcleod growth needs continue to be felt and may even become stronger once they have been engaged and hence this sense of selfworth to upskill and take ones time finding the right job that brings about happiness this newfound realization has led millions to redefine what requirements need to be in place for them to accept an offer workers are leveraging unions and strikes to demand better conditions in return for their services workers are demanding a living wage wages are not the only factor in job quality with the pandemic likely propelling people to reevaluate what they value and want in a job workers also place a high value onand now have the leverage to demandbenefits such as paid family and medical leave and health insurance a workplace safe from harassment illness and physical injuries flexible scheduling a better worklife balance and a career path with clear upward mobility the days of saying you are valued and are essential to the organization are over if the companies support and actions are not mirroring the sentiment essential workers are tired of being thanked one day and then treated as expendable the next day …the headline isnt that theres a shortage of people willing to return to work instead its a scarcity story we have a shortage of safe goodpaying sustainable jobs therefore the results support p1 the pandemic changed the workers sense of selfworthselfactualization as individuals leave jobs in pursuit of more fulfilling purpose and p2 the time away from work during the pandemic has led to individuals valuing fulfilling belongingness and love needs above having a job as the study progress the initial code of worklife balance moved into focused coding as work conditions and finally into axialthematic coding of sense of worth thus leading to the workers awakening of their sense of selfworth after the pandemic the changing dynamic has led to a power shift that has given workers a negotiation platform that did not exist prepandemic in this current environment individuals are negotiating for a sustainable salary flexibility better working conditions which will lead to less stress for example one reddit post referred to the current salary at a specific job as poverty wages and made a declaration to reclaim your life this one post focuses on the obstacles created by working for low wages and highlighted that it deprives individuals of their times with hobbies friends and family if the salary cannot sustain the lowest level of need such as water food and shelter why should one allow it to strip away the benefits obtained in the next three levels ergo workers are leveraging the labor shortage to demand an improved working experience inclusive of salary stress reduced conditions and acknowledgement of the workers sense of worthesteem value hence supporting proposition p3 the labor shortage provided an environment that allowed workers to negotiate compensation packages as esteem needs were met furthermore the pandemic has created an environment that has demonstrated that remote working can be equally as effective during the pandemic several organizations quickly reconfigured operations to enable employees to work from home after more than 365 days with productive results individuals are associating hybrid work environments as normal one survey demonstrating that 68 of workers prefer the option to work from home in the same article the prudential survey showed that 1 in 3 americans would not want to work for an employer that doesnt offer at least partial remote working the hybrid working arrangement plays another key role in whether worker can andor are willing to return to work many working individuals are stewards of care for children or elderly relatives that has caused them not to be able to return to work according to the biden administration between february 2020 and march 2021 520000 mothers and 170000 fathers between ages 20 and 54 left the labor force and have not returned many needs or want to work but cannot because of childcare disruptions moreover individuals have been able to engage in loving meaning relationship with family that has fulfilled the sense of connection that has been traded for years of work the last two themes that emerged were stumbling block and stress many individuals had to contemplate whether they could or should return to work due to obstacles that existed individuals were faced with wanting to accept an offer but the following had to be considered cost of childcare versus salary school scheduling vaccination policies and jobs availabilitylocation the stumbling blocks that could impact ones ability to return without interruption has led to declining and delaying acceptance of offers in line with hossain et al the global pandemic has had an impact on the mental and physical wellbeing of individuals parks etal states previous studies suggest that depression anxiety disorders substance abuse increased suicidal tendencies and ptsd commonly follow major economic crises or natural disasters and this crisis is no different stress has seeped into everyday life as individuals continued to navigate through school closures unintentionally contracting disease andor infecting others financial instability food insecurity disruption to routine and having to be everything to everyone in one space these stressors in combination with the trauma of job loss…might be keeping some workers from returning to the workforce this trauma can erode confidence and selfesteem which surfaces doubt in skills and abilities the power of stress could be hampering ones esteem needs and ultimately surpassing the desire or ability for individuals to return employers need to convince their employees that they are taking measures to alleviate stress inducing factors from the workplace based on this study organizations need to develop a comprehensive package that acknowledges and appeals to the five levels of maslows hierarchy need theory individuals have had time to assess and meet levels of need within their life as these individuals have satisfied the lower need levels they are moving up the maslow hierarchy pyramid and thus requiring more than the prepandemic workplace baseline discussion as the job market is changing and the expectation of an acceptable employment offer is being redefined there are various elements the tangential that should be considered what happens if most workers never return to work andor continue to shuffle between companies will this labor shortage and the response to the potential and existing workers become a lynch pin to the success of organization culture and retention and if it goes unaddressed how will the economy respond dotsey etal mentions the absence of the workers will be felt in government programs such as social security and medicare or through family assistance… as a result a society with a lower participation rate is also burdened with higher tax rates because the government has a narrower tax base from which to draw revenue in other words the economy could reach a breaking point that will be felt by allinone way or another research contribution the purpose of this study was to explore what obstacles have workers encountered that has prohibited them from reengaging in the job market after the pandemic within the framework of maslow hierarchy of need theory during the height of the global pandemic educational institutions restaurants hotels and various corporations closed their doors in alignment with government mandates and this led to millions of individuals being laid off or furloughed nonetheless once corporations were ready to return to normal productions level the workers did not answer the call organizations quickly found themselves in a precarious business state where the demand had returned but inventory andor services could not be met as staffing shortages were felt across the country this labor shortage quickly became known as the great resignation where individuals were and are continuously saying no to job offers entirely based on the document analysis five emerging themes were identified these emerging themes salary stumbling block steward of care sense of worth and stress workers appeared to have an awakening in which the prepandemic work conditions and salaries are no longer acceptable the practical implications of this information could help organizations understand the worker in this current work environment organization can no longer just think about filling a seat as there are just too many to fill at this time the current five millionperson gap between unemployed individuals and job openings means organizations are left in a perilous state if the labor shortage continues the economy will continue to experience supply shortages delays to schedules and climbing inflation the findings from this study suggest workers are facing five obstacles that are prohibiting them from returning to the job market hiring managers and human resource representatives should be aware of these obstacles or consider asking question in the interview process to understand 1 what the biggest obstacles are and 2 are there ways to mitigate them in a way that both parties can be move towards agreement there is a potential for these findings to be incorporated into human resources strategies to engage attract and maintain workplace loyalty and commitment in a time when workers have the negotiating power limitation in accordance with bowen this study has unveiled several discussion points however there are limitations that require acknowledgement the research was conducted on 76 documents and posts which is not an extensive data set in addition document analysis is primarily generated for a purpose outside of research and therefore may not obtain insufficient details obtain biased selectivity which can skew the format or tone of document and content can have low retrievability as some documentation can be blocked or deleted boslaugh mentioned secondary data was not collected with this specific research question in mind the literature also suggests document analysis should be triangulated to add validity lastly reddit is one social media forum with a specific subset of individuals which may not represent the larger population

the objective of this study is to understand the paradigm shift that unfolded during the great resignationreshuffling 20202022 within the minds of workers with respect to not reengaging in the job market after the pandemic in early 2022 according to the us bureau of labor statistics bls there were approximately 11 million job openings and 6 million unemployed individuals the convergence of these two data points indicates five million jobs with vacant seats therefore we aim to answer this research question what obstacles have workers encountered that have prohibited them from reengaging in the job market after the pandemic within the framework of maslow hierarchy of needs theory to investigate this question and the associated unprecedented phenomenon an inductive qualitative research analysis was conducted to review and code archival data from three sources reddit posts the us government bls white house federal reserve documents and press articles the content from more than 1000 pages 31 posts and 45 articles was systematically analysed through first and second cycle coding to extract themes that identify the factors being considered by individuals who have chosen to remain on the job market side lines this article attempts to magnify the american workers voice in an environment where it could feel like nobody is listening shaw 2000 the findings indicate that salary stumbling blocks steward of care sense of worth and stress are the leading factors that may prohibit individuals from returning to work to triangulate these findings additional press articles government documents and reddit posts will be coded to increase the data set second study the research limitations include a review of only three document sources a focus on one country alone the united states and only one social media platform therefore it cannot be stated that this list is exhaustive more research is needed to include other platforms and sources nonetheless the findings could help organizations understand this paradigm shift and formulate recruitment and retention programs that address the factors and needs of employees in a post pandemic work environment that remains full of uncertainty and disruptions

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introduction the economic environmental social and cultural importance of family farming was recognized by the food and agriculture organization of the united nations and reflected in the implementation in 2014 of the international year of family farming this recognition aimed to put family farming at the center of agricultural environmental and social policies in the national agendas and later on by proclaiming the united nations decade of family farming as an opportunity to address family farming from a holistic perspective and to contribute to achieve the 2030 agenda for sustainable development this recognition reinforces the role of family agriculture in fighting hunger and poverty in preserving natural resources and the landscape in improving the quality of life of local and rural communities and in food security family farming is a concept used to identify agricultural production units that are managed at the family level and relies predominantly on family labor with a strong relationship between land labor and family the family is simultaneously a production and consumption unit work is organized by and for the family family farming is the most predominant type of agriculture worldwide it was estimated in 2014 to occupy about 7080 of the worlds agricultural land account for about 90 of agricultural production in 93 countries and be the source of 80 of the food consumed that guarantees food for 40 of the worlds households in europe in 2016 about 96 of agricultural land is dedicated to family farming where about 90 of the farming population works in this context the role that women play in this sector of agriculture also has been the focus of attention of various international bodies women represent on average almost half of the agricultural labor force playing a central role in family farming not only through their work but also because of their ancestral knowledge sustainable management of natural resources production and conservation of agricultural products as well as caretakers of children andor the elderly in 2011 in the state of food and agriculture 20102011 report with the subtitle women in agriculture closing the gender gap for development the role of women in the development of rural areas and the economy particularly in developing countries was recognized in the same report fao recognized the inequalities and difficulties that women farmers face compared to men farmers in various areas such as access to land education markets and services among others in 2016 the european institute for gender equality listed this type of gender inequalities in the agriculture sector at european level namely related with womens participation and representation in rural development and in decisionmaking positions in agriculture in fact in the same year in the european union only 3 out of 10 agricultural leaders were women the invisibility of women farmers and their work in agriculture as well as the preponderance of male at the center of the discourse in family farming originates a knowledge gap about women roles and importance in family farming this is specially relevant in countries such as portugal were family farming still represents 94 of the farms with more than 30 being managed by women furthermore at the national level there is no updated and indepth information about portuguese women farmers and their contributions at the social economic and environmental levels this article aims to give voice to women farmers and provide insight to help other researchers to produce knowledge about womens agricultural work in portugal which will contribute to the development of better public policies that respond to the real problems of family farmers and especially women farmers thus we intend to answer the following research questions how do women farmers perceive their activity in three rural areas of portugal what are the role and difficulties that women farmers experience in agriculture is there a gender division of labor in family farming women and family farming in portugal although major transformations have occurred both in agricultural activity and in rural territories and their communities over the last decades the most recent data from portugal suggest the importance that family farming maintains in the country in 2019 in portugal about 68 of the agricultural work volume is carried out by the family farming population occupying the 14th place in the european union only 131 of farmers live exclusively from agriculture and ∼23 occupy 50 of their working time on the farm most farms are managed by individual producers although the number of companies has increased in the last decade the representativeness of women leading farms is 333 but 479 of the farm labor force is provided by women the strong feminisation denoted by quantitative data in family farming is not a recent phenomenon in portugal the presence of women in agriculture is observed in portuguese statistics since the second half of the 20th century the statistical information available in the censuses despite some weaknesses and limitations suggested a growing female labor force in comparison to the male labor force in agricultural activity this increase is noted both as individual farmers and unpaid family workers this process of feminisation of the agricultural sector dialogued with broader social processes namely industrialization and the consequent rural exoduses in the case of industrialization this process caused the displacement of male labor to other areas of activity and made agricultural activity less prestigious and rewarding the rural exoduses are intrinsically linked to the greater opportunity for work abroad and in other professions offered to men in short these macrosocial transformations allied to micro dynamics within the family placed the woman as the center of work within family agriculture in countries such as portugal thus despite the reduction in agricultural assets in both genders the regular presence of women in agricultural work is almost always contrasted with an irregular and more or less important male presence in fact over the last 30 years old it has been women who have remained in agriculture the most national data reveals this trend while in 1989 there were 501978 men and 91870 women leading agricultural holdings 30 years old later 183916 men and 90332 women remained as managers of their farms this variation stands for a less 634 for men and less 17 for women despite the fact that there are more women remaining in the agricultural activity and that women assuming leadership of their farms have increased formal leadership positions continue to be mainly male territory in fact in portugal in 2019 around 69 of farm managers were men women hold only 31 of leading positions while in 1989 837 of farm managers were men and only 163 were women however this feminization of the agricultural labor force and leading roles has not been sufficient to eliminate gender inequalities in this sector although this feminization is evident nationally and internationally there are few studies that portray agricultural activity from the point of view of women remaining almost always around maledominated places of discourse it is thus important to better understand the issue of gender equality in it is important to note that the feminization of agriculture is not a linear process di erent geospatial contexts explain di erent paths for the feminisation of agriculture coupled with di erent broad social transformations some authors as cernea and lastarriacornhiel refer di erent factors leading to the feminisation of agricultural assets in contexts outside the portuguese case this specific social context and to identify factors of inequalities between men and women farmers gender roles in family farming with regard to european research on gender roles in agriculture sarah whatmore outlined some conceptual changes namely to stop looking at men and women as fixed categories but rather taking into account the meanings and practices that define and characterize them the use of gender role theory gave way to gender identity theory more specifically the representations in daily life of what it means to be a man or a woman farmer thus giving greater prominence to the roles and tasks performed by them discourse is one of the most used units of analysis in the literature to understand existing gender inequalities the results of studies carried out within this scope point to an everpresent patriarchal logic brandth carried out a study on gender identity in european family farming and identified that the positions of male and female farmers portrayed in the literature were linked to 3 types of discourses the discourse of the family farm masculinisation and detraditionalization and diversity in the first discourse the male farmer is portrayed as the public figure of the family and the woman is almost in a secondary position not participating in events outside the family circle land ownership is seen as something that should pass from father to son while women see their access limited and it is only possible to obtain the title of land owner through widowhood or marriage ie the title of land owner never comes from the womans choice but from marriage this type of discourse highlights the patriarchal character as one of the primary characteristics of family farming the second discourse focuses on the process of masculinisation of agriculture ie the transformation of agriculture into a markedly male area of work family farming has a strong masculine connotation as it is the man who controls and manages the family business so when one thinks of a farmer there is a tendency to imagine a physically strong male individual the process of industrialization of agriculture was a period where women lost part of the central role they had a good example of this is the mechanization of milk production milking used to be an important task for women but in the mid 1900s when the milking machine was introduced it became just as much an area of work for men and thus women were forced into a secondary position or into a position of housewife agriculture followed the global process of industrialization and with it an increase demand for more skills from farmers overcome with men being the first one to acquire them leaving women in a secondary role the third and last type of discourse portrays a shift toward the empowerment of women farmers research on women farmers in europe reveals the occupation of new positions such as farmer housekeeper business secretary farm assistant agricultural worker offfarm income earner the positions that women farmers occupy nowadays are changing according to haugen and brandth younger women farmers choose agriculture as a profession and calling themselves professional women farmers seek to acquire skills that give them autonomy in farm management such as driving agricultural machinery gomes et al made a more recent analysis of the scientific production on women in rural contexts and concludes that the current thematic focus can be grouped into two subthemes namely the gender relations and rural spaces that encompass discussions focused on class relations gender relations care and health right to access to water body and sexuality and gender and new ruralities that involve studies on rural development political protagonism the proposal for analysis that places the relationship between gender and class in the spotlight continues to be a usual conceptual path in the research of this theme however currently science has favored a poststructuralist perspective transcending the classic marxist vision in addition to the economic sphere the importance of gender relations is also recognized under an intersectional approach which takes into account the individuality of these women as well as their agricultural and community work and the analysis of the discourses of the subjects of various social spheres with regard to studies on gender relations in the portuguese rural space carmo sought to understand how the sociospatial divisions and social practices have changed according to gender in the last 30 years taking into account factors such as the modernization and urbanization of daily life in the rural community the conclusions of this study show some reconfigurations in relation to the traditional model of division of roles namely the widening and intensification of social contact with the urban environment for both men and women and the management of the domestic economy ceased to be exclusively the domain of women with men taking on some of the burdens related to financial matters and domestic consumption on the other hand the continuities of the patriarchal model of inequality still appear persistent and in large numbers the author found that sociability relations in public contexts are still more practiced by men as they live more regularly in urban and leisure spaces such as bars discos restaurants and cafés the appropriation of public spaces is also carried out differently according to gender differentiation since it is the man who identifies and presents himself with a more public image also accompanied by a greater intensity of regular social relationships added to this inequality of social capital there are also differences in the way men and women occupy the public space during socialization women talk more at the door of the house and in the markets while men use the café for this purpose which reveals a continuity of the figure of the woman associated to the domestic space the café which used to be called tavern continues to be a place described by women as awkward and where they do not feel welcome because it is dominated by the opposite gender these customs by allocating female power to the private and male power to the public reproduce an asymmetry of representations and meanings attributed to these gender identities in various dimensions of society of which agricultural work is no exception these customs imaginaries representations and meanings when incorporated in different spheres throughout life define the sexual division of labor and the appropriation of certain spaces based on the findings from an exploratory qualitative study carried out in two regions of the inner portuguese territories we intend to explore the meanings and perceptions of women farmers on different dimensions of their professional activity it is intended to contribute to the construction of knowledge about family farming with special focus on its gendered dimension and the need and relevance of including womens point of view in this field of studies likewise to denote the importance and need to undertake efforts to combat gender inequalities in this sector of activity as well as to value women roles which is so pressing in food systems worldwide with this work and similarly to other international theoretical approaches we intend to unveil and understand the discourses of portuguese women farmers something that has not yet been presented our main research questions are what are the perceptions of female family farmers toward the agricultural activity and their work what types of discourses are dominant in the portuguese agricultural scenario methodological approach and data collection this work results from the project mais women farmers in inner territories which aims to increase the civic and associative participation of women farmers in inner portuguese regions through their empowerment the promotion of the visibility of their social role and gender equality the focus of the project is family farming through a pilot experience in two municipalities são pedro do sul and sabugal where the family farming population plays a relevant role in 2019 the proportion of the family farming population was 20 in são pedro do sul and 307 in sabugal the proportion of women in the family farming population was 495 in são pedro do sul and 474 in sabugal that is almost half of the family farming population the percentage of women farmers aged 65 was 39 in são pedro do sul and 448 in sabugal the methodological approach used in this study is qualitative by seeking the meaning and the rational adjacent to the action which will allow us to explore the imaginaries and symbolic universes taking as unit of analysis the voice and discourses of the participants the qualitative approach allows the researcher to see inside the reality at study as a construction of the participants and not of the status quo around them there are several qualitative techniques all with different functions within the scope of the broader project of which this study is part the focus groups were carried out in an exploratory phase of research and aimed to better understand the women farmers of the municipalities in study as well as generate and evaluate ideas collected a priori through theoretical analysis on the subject they also allowed the team to facilitate access to individuals or groups normally reluctant to communicate its potential is to create threads of discourse life stories and experiences that are shared during the sessions focus groups are a qualitative research technique for gathering information in which a number of people are brought together as a group to discuss a particular topic of interest with the facilitation of a moderator who poses questions and encourages a diversity of opinions this type of group interviews is a qualitative research technique which allows for a deeper understanding and analysis of the perspective of a group of selected participants about specific themesissues once the type of focus group to be conducted had been defined the script was developed the script was constructed with few items in order to allow flexibility in the conduct of the focus group the items considered were how agriculture entered the lives of these women understand agriculture and rural life in these regions identify perceptions about the gender division of labor understand the socialpolitical involvement identify the main problems and needs participants identified among family farmers in both regions were selected based on their professional activity gender and familiarity with the issues under analysis with the aim of fostering a comfortable environment where all participants could share experiences on the topics addressed fourteen women farmers participated in the two focus groups these participants were chosen by the officers of the municipal councils and their selection among women family farmers was based on the availability to participate in the group interviews thus this is a nonrandom sample by convenience given the characteristics of the selection method of the participants the sample of this study is not representative of the women family farmers of the two regions nor of the portuguese women family farmers therefore the results presented here are limited to this study and sample the participants have an average age of 505 years old the youngest being 28 years old and the oldest 66 years old half have completed secondary education and the other half has a lower level of education most are married or in a situation of cohabitation as shown in table 1 the two focus groups took place in may 2021 in spaces provided by the municipalities where the conditions for the collective interviews where assured the interviews were conducted by a member of the research project with two people present in the room to collect information and to provide logistical support if necessary the focus groups had ∼2 h and the interviews were recorded in video to facilitate the material transcription and the identification of the speakers in moments of overlapping speeches the records of the participants speeches in the focus groups were subsequently transcribed this analysis was focused on the excerpts of discourse considered most relevant for the objectives defined in the project for the treatment of the qualitative data collected a categorical content analysis approach was used such categorization allowed reducing the complexity of the material identifying the main issues addressed and allowing its treatment the categories were defined based on the themes contained in the guide as well as on the strengths of the theoretical material gathered during the literature review and on the themes that emerged during the analysis of the material the findings of this analysis will be presented in the next section through excerpts of the interviewees speeches systematized and divided according to the dimensions of analysis and corresponding categories these are perceptions of agriculture gender division of labor in farming perceptions about their role and difficulties as women farmers analysis and discussion of findings perceptions of agriculture changes in agriculture the discourses of the focus group participants highlight four major changes in agriculture corporatisationentrepreneurship mechanization market competitiveness prices and community dynamicsagricultural popular economy logics professionalization and the increase of companies together with the greater entrepreneurship in the sector was one of the transformations identified by the participants these transformations are associated with the bureaucratisation of agricultural activity and the aggressiveness of the market when compared to the agriculture reality of previous generations todays agriculture does not compare with the old days it was subsistence farming today its business its a business and theres a lot of bureaucracy along the way it requires too much documentation and paperwork we are not farmers anymore we are a company we have accounting we have to do invoicing we work like a normal company with regard to mechanization the discourses highlight the ease and time savings in the performance of certain tasks which previously would have taken days improvements in the quality of life were also mentioned as the use of machines reduced the amount of tasks with high levels of physical demand as well as tasks that were performed with rudimentary work tools or the use of animals it completely changed came with tractors machines which in the old days was with the plow the cows plowing the land there are machines for everything today pretty much in the old days it took almost 3 days to plow with the help of the cows it was done in stages we loaded the pitchfork again for the cow cart with the cow cart we put soil in mounds now on my farm everything is done with a tractor the tractor has some hooks they take the manure and spread it and plow the use of machines has brought us some life quality price competitiveness as a transformation in the sector was mentioned one participant highlighted the difficulty of selling on some products especially due the lower prices on other selling platformsmarkets in other words the monetary devaluation of certain products makes it difficult for farmers in my parents time if my father produced potatoes he always sold them if he produced rye the price was always assured today if we wanted to produce potatoes there is no one who looks for a potato a kilo of corn there are also several references to the changes felt in terms of community dynamics and local economy these discourses mention the progressive abandonment of agriculture and rural territories as well as the disappearance of community activities and forms of conviviality that are lost or replaced by other social dynamics in the old days it was family farming it was uncles neighbors who helped each other today we cant even hire a friend or relative because if theres a problem on the farm all we earn on our farm is not enough to pay the costs of an accident disaster etc it was it was a joy it was a joy that we had there we never did that again about a community activity that was common when she was a child it was a happier time than now we would cut the grass make the small bundles and put that outside to make those dolls and then we sang danced it was a joy it was happier than now the discourse of the participants allows to contextualize their view on the agricultural activity within a specific time space this space is marked by major social transformations that the rural spaces and more specifically the territories of the portuguese interior have been experiencing as we can see these changes are not only limited to the professional context but also extend beyond the social context family dynamics and the community nature of family farming in effect these changes have confronted family farming with various threats and weaknesses to its continuity results from other works also refers to the discontinuity of the activity by household members as a result of occupations abroad the disappearance of local markets and traditional marketing circuits the devaluation of production in the agrifood chain the aging of the farming population and loss of property perceptions of farming as a profession let us now focus on the professional context of the participants and their vision in relation to their professional activity the first idea that emerges from the participants discourse is that agriculture is an activity opposed to following or carrying out studies many say why did you want that life because many studied and only i stayed in agriculture i was studying and when i got home from school i had a little paper saying that i should go with the cows here or there and i took the books i was obliged because i didnt stay at home to study there was no time to stay at home to study you take the books put the cows away and go you study if you want in fact this discourse indicates that the agricultural context of the family and the lack of access to certain types of services in rural territories constitutes a constraint to follow other life paths namely those in which an investment in formal education would be necessary in fact rodrigo already have referred to traditional family farming dynamics based on predetermined gender roles that restricted the woman to agricultural activity while the man was offered more options outside this activity on the other hand this discourse refers to a preconception of agriculture as an activity related to low qualifications this notion will be again mentioned in relation to life trajectories throughout the participants relation with agriculture trajectories into farming in relation to this category different types of trajectories of entry into agriculture were found let us begin with discourses that indicate entry into the activity via the family i have also always worked in agriculture since i was young i did a bit of everything yes parents were farmers and i also stayed here also a farmer i was also born there i was born in locality where she still lives and my parents had animals and its like that it was through them the parents that i learned i always worked in agriculture since i can say almost since i was born no but almost it was my parents life and so i continue it has always been my life to work in agriculture another way of entering and remaining in agricultural activity was through marriage i was studying and i would continue it was a higher education course only as i got married and got that big holding and they said you can continue and stay with this nevertheless we also found participants that suggested entering into agriculture as a personal choice either through free will or emotional reasons i was not a farmer it comes a little bit in the idea of me coming and learning something i am from here my husband works here so at the time we decided to go ahead and do we have some small plots of land that were left to themselves and we decided then to do a project we went ahead the project was approved i took this life option also because of my three children because when i came here to the village i didnt have anyone here my parents dont live here my inlaws nobody this choice of life was for my children the discourse analyzed also indicate pathways marked by a large volume of work and time dedicated to agricultural activity this results in work routines that take up entire days with uncertainty regarding overtime causing a certain relegation of time for rest and personal life im up at seven in the morning every day sometimes its midnight or one oclock in the morning and i have a cow to calve and im there in the field accompanying her the difficulty is that we can never schedule holidays when we are about to leave there can be a big surprise on the farm and it all hangs around its positive and negative its always swinging schedules are difficult with the weather and problems that arise on the farm the days are never the same every day is different its true we dont have holidays we dont have saturdays we dont have sundays we have to work at night we have to work during the day if they cattle remember to give birth we have to go they are the ones in charge its a life of hard work moving on to the difficulties experienced within the agricultural activity the data collected reveals difficulties at the level of marketing the production many times we do not have market for the product its a problem in calf rearing there are times when there is no market for the calves we never have a right price for the animals we never have a right market for the animals the uncertainties and difficulties in terms of the flow of production are further explored in other discourses the participants highlight the role of factors external to the activity in conditioning economic resilience its a profession of high economic risk youre always subject to a lot of things the weather when the cows calve well or not its always a life in uncertainty the income at the end of the year depends on all these factors its always a life of great uncertainty and it takes a lot of courage to be a farmer plus a woman we never know if we will harvest enough straw its always uncertain any work is always uncertain a machine breaks down a pipe bursts we only have money when we sell some calves and we only have money when we get subsidies although the difficulties and uncertainty of agricultural labor are highlighted in these interviews these appear in some cases associated with a discourse that emphasizes as a positive counterpoint the independence that this activity makes possible although the activity as we saw above is marked by external difficulties there seems to exist an intrinsic dimension that somehow compensates these extrinsic factors in fact the pleasure and enthusiasm are materialized in pride pride that the participants feel in their farm and produce especially from the recognition and opinions of others about it i have friends from all over and when they come here they say that this meat is spectacular and for some reason it is i kill two calves a year and when i invite guys over to eat they say the meat is wonderful still in this domain some participants characterize these perceptions and feelings as key tools for success within the activity those who go into this activity with pleasure and with love that is a very great strength in all the problems that arise if its not with their own will they dont make it those who take the farms forward its with pleasure and love now there are those who go there just because but after a year they give up any profession if you dont like it you cant do it now this one is a very demanding profession this dedication is perceived as the source of energy for enduring long working routines as well as for the necessary resilience in facing problems and difficulties and overcoming them that are the day to day in agriculture the discourse of the participants confirm that routines in agriculture are always changing never being exactly as predicted or in the previous day gender division of labor in farming as the gender division of agricultural labor is a fundamental dimension to the study of gender issues and the understanding of existing inequalities in agricultural activity we dedicate this section to the analysis of the discourse of the women farmers that participated on the focus groups on this topic eight interviewees stress the idea that there is no inequality or difference between men and women i think whether woman or man each one just does what he wants dealing with cattle we do everything the same women still deal better with animals on the question of strength its the same you just have to pull for her i can stand next to the man i have no fear at all i do everything like a man in the matter of my husband because if he does it i do it too there are no differences the differences may be in the issue of strength but that is not relevant the only thing my husband doesnt do is molding but he does everything he peels he waters one trend is clear in these discourses in general the participants do not identify or do not perceive situations of inequality within their work context with their partners they rather emphasize an equity between men and women assuming little significant differences however despite of it the analysis of the discourse presents several gender differences related with gender division of agricultural labor lets see we have an auction park if we look at the presentation of cattle most are men it is rare for a woman to go to the cattle show even if she is the farmer there are one or two i could probably list half a dozen thats all now of course the men it discards more for the man to do the business we both work he takes care of the selling and buying and i take more care of the notes and those things the papers in cases where the man has another profession of course the woman has to take care of everything these discourses highlight differences between men and women with regard to the decisionmaking spheres namely in public spaces the adage found in other spheres of society is also present in the social context of these women farmers men still dominate the formal decisionmaking spaces nevertheless and based on the experience of some participants decisions at the informal level are taken by them im the one who does the business im the one who decides although we talk to each other we talk between the two of us but im the one who says this comes from the beginning i have a person with me partner but he is more in another area im more with cattle and sheep then im the one who decides im the one who treats im the one who does the business although i ask for his opinion but im the one who gives the last word i dont even feel comfortable that someone else does it now the last word is mine always i happen to be the one who manages the holding what little it is laughs i dont give it up he husband collaborates a lot but im the one who takes the decisions it makes sense to find this type of independence in decisionmaking processes since some of the speeches already highlighted the autonomy that the agricultural profession conferred to certain participants however there is a clear tendency to consult their partners before taking a decision even though they imply that it is their word that counts the most we thus find an inversion between formal and informal decisionmaking contexts although on the informal level the women as a protagonist is not a trend in the sample in question in relation to the division of tasks between men and women in the agricultural activity carried out by these women some participants refer that this is carried out in an egalitarian way although in some cases there are tasks that belong to each member of the couple me and my name of the partner have other professions and other things so sometimes time management is not easy one day i go another day he goes to the farm yes he works yes he the husband also does it he does it with the tractor plows mills when its the potatoes they have to go there to sow the potatoes to help he also has to go there the participants discourse also indicates situations where the woman is the only component of the couple that carries out agricultural tasks theres a cow to calve and my husband is like never mind itll be fine but i say we have to go watch and he doesnt and i grab the car and go there to see i do everything by myself everything from scarifying to gardening everything because i cant wait for my husband the discourses suggest situations of clear division of labor between the members of these couples in which the woman takes the initiative and seems not to receive help from her partner also other tasks are clearly a responsibility of the men namely the tasks related with the use of agricultural equipment and specific tasks usually considered to be skill demanding such as pruning or applying pesticidesfertilizers but i see that it is like this the man is more tractor and coring and pruning the woman is the one who does all the manual work what p7 was saying that men work more with machines and women dont some of them are still afraid to take the tractor or to pick for the brushcutter this major distinction came from that of the man taking the artifacts and the machines and the women working more with their hands in fact the perception that the relation with machinery and equipment belong to the mens forum is reinforced by the participants taking into account the participants age it seems that younger women are the ones who are not afraid to perform tasks using machines compared to older women still at the level of the division of tasks between men and women some discourses refer to social imaginaries that feed differences between men and women in the performance of their activities women still deal better with animals men in general do not have the skills that women have to do several jobs at the same time we do the house life we still take care of this and that but they dont they do that and one thing at a time this last discourse is of particular interest since it denotes inequalities in the volume of work between men and women highlighting the double working hours of women finally a positive change in gender inequality within the agricultural activity is acknowledged however this recognition is made by women in younger age groups maybe in organic farming even in older people there is already a greater sharing of tasks on the fact that women impose themselves on men its like that its like that within my age group now in the older ones maybe not but the younger ones we are already more resourceful as a rule now there is not so much difference women we impose ourselves and thats it laughs perceptions about their role and di culties as women farmers finally and because this appears to be an extremely important dimension of analysis in the study in question we will analyse the perceptions about their role as women farmers either by themselves or by others the interviewees reported discrediting by men which arises in comments based on asymmetries in representation between the masculine and feminine other works related with gender divisions and agriculture these social representations construct gender and when they are asymmetrical they dictate not only a division of labor but also gender inequality once again it is possible to verify the social perception of agriculture as a male activity based on socially shared ideas resulting from social representations of gender these social representations are reflected in the strangeness of being a woman performing tasks or occupying spaces intended for men just because we are women i think its a discrediting of our work why ah shes a woman she doesnt have as much strength as a man she wont be able to do it when i started they said i couldnt stand it or manage just because i was alone and couldnt carry out the activity interviewer and did you hear that from family friends p3 in general from the male person first of all bearing in mind the age at which i started why i took up farming and the fact that i was so young that i was a woman and they said that i couldnt carry out the activity as well as a man when i had the sheep and when we started to sell the cattle my husband wasnt there because the sheep were mine my husband had his profession and the guy buyer arrive there like then your husband isnt here so now how can i buy the lambs from him i was like then if you have to buy them youll buy them from me buyer by the voice of the women and you sell me the lambs and then your husband p4 referring to her own voice my husband doesnt have anything so i mean this is mine is he the one in charge now men respect a man more than a woman all my life it was like that conclusions the exploratory data we present suggest that these group of portuguese women farmers from the inner territories work in a social context that has undergone major changes over the last decades whose impact is referred to in the discourses at the level of agricultural practices and activities marketing of products and in community dynamics in several cases the trajectories of life in agriculture started very early and the permanence in the activity was the result of external influence family or marriage on the other hand the agricultural work of these two groups of women as well as their own activity is characterized by long solitary and uncertain working days that they value due to intrinsic dimensions mainly the results of production independence regarding the organization of the work or the possibility of making their own decisions also in the gender dimension the publicprivate dichotomy is clear especially in decisionmaking places formal and public places are dominated by men informal and within the couple are equal places or dominated by the woman farmer often with consultation with the male partner gender is also a reason for discrediting their abilities as women farmers in the perception of some of the participants making their activity even more difficult the speeches of the interviewed women are compatible with the three types of discourses identified by brandth the premise of the first discourse that portrays the male farmer as the public figure of the family still holds true an example of which is pointed out in reference to cattle marketing spaces we also perceive that the agricultural tasks dominated by the man are the most mechanized ones since many of the female farmers do not know how to operate the machinery and in their discourse assume these tasks as being masculine manual work is still performed by women farmers which is related with the familybased and small scale portrait the discourse detraditionalization and diversity is also present in younger women farmers that choose agriculture as a profession and invested in agricultural projects and want an healthy and sustainable life for their families with regard to the analysis of gender relations lack of time and the need to attend to domestic responsibilities are the main obstacles that prevent them from participating in social and economic activities this is aligned with other authors such as gomes et al that mentioned that womens patterns of displacement and participation in activities stem from a demarcation of gender roles which still remain traditional and restricted to the private space of the home the discourses presented are not enough to allow wider deepening of some life dimensions of these women farmers in particular the life trajectories and other dynamics related to gender roles and representations with special focus on decisionmaking places also the limits of the information collection technique become clear throughout the exposition of the data namely the strong participation of some interviewees in relation to others and reduced approaches to certain topics in terms of limitations in the present sample the representation of women from older age groups influences the perceptions about the changes in agriculture that are usually considered to have more knowledge on this topic probably an effort of the moderators to encourage the participation of younger women in these interview topics would allow to collect information to compare meanings and perceptions these limitations can be compensated in future research in these areas articulating the participation of younger women with older women and thus promoting dialogues and data for intergenerational comparison however given the exploratory richness of the material we believe that these offer new evidence and clues for future research and work in these meanderings particularly at the portuguese level with special focus on portraits of the figure of the women in the family farming context in the first person by making this undertaking we will contribute to the construction of new knowledge on forms of gender inequality which have not been the target of intervention making the invisible visible is the first step toward what follows changing this invisible several international organizations recognize the fragility to which women farmers are subjected while also recognizing the benefits at local and global levels that arises from the promotion of gender equality in family farming holds since we are dealing with the most common type of agriculture that contributes with undeniable importance for the world food systems and for the fight against malnutrition and hunger also it is widely recognized that this sector support sustainable agricultural systems mainly based on traditional and ecological practices thus being pathways toward the sustainable development goals and against the current climate crisis in fact the profound transformations of global realities such as agriculture can no longer be analyzed only from one dimension but rather as a result of the intersection of different perspectives challenging disciplinary boundaries and taking into account all the faces of a phenomenon only by doing so it is possible to promote social wellbeing and contribute to the eradication of inequality funding 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 comissão de ética do politécnico de viseu 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 importance of family farming in food systems worldwide is recognized by di erent international bodies as well as the leading role played by women and the inequalities they face in this sector of activity the most recent data from portugal highlight the importance of this type of agriculture in this southern european country in of the total agricultural workforce in the country was concentrated in family farming with almost half of them being women this high permanence of women in agriculture is the result of a long process of feminization on this sector that is similar to other contexts despite this strong feminization of family farming there are few studies that portrait agricultural activity from the womens viewpoint since the voice of men is always predominant in all references based on the exploratory qualitative data from two focus groups carried out in two portuguese inner regions we intend to address the perceptions and meanings of a small group of women farmers regarding their activity the role taken by them in agriculture and the di culties they experience issues such as changes in agriculture and the sexual division of labor will also be addressed in this article within these groups women work in agriculture is perceived as long solitary and uncertain also the publicprivate dichotomy is evident with decisionmaking and public places dominated by men a prevalence of the discourse of masculinization still exists with certain tasks being attributed to men eg operations with machinery younger women and years old tend to overcome these gender di erences choosing agriculture as a profession and healthy and sustainable life for their families

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the past four decades have witnessed a plethora of studies on genderrole portrayals in advertising on television from the perspective of marketers and advertisers gender is a primary segmentation variable in developing marketing strategies and defining target groups also gender portrayals have possible effects on corporate images and on purchase intentions of consumers from the perspective of activists advertising councils or policy regulators however the stereotypical depiction of men and women in todays ads is problematic for many reasons it is argued that advertisers create and perpetuate gender stereotypes which may erode gender equality and harm society at large the accumulated empirical evidence clearly suggests that gender roles are highly stereotypical in television ads however despite this strong research tradition around the world it is less clear how a countrys culture shapes gender roles in tv ads this research deficit can be traced back to the research designs used in previous research in fact most research on gender stereotypes in television advertising is based on singlecountry studies because such studies work with a specific sample at a specific time of the year we cannot use them to compare findings across countries for instance if we see a difference between two studies from two different countries we may not be sure whether the observed dissimilarities reveal cultural differences or whether they can be traced back to differences in time frame sampling codebook or other characteristics of an individual study comparative research is therefore urgently needed only a very few studies have analyzed gender roles in a comparative fashion allowing for a test of country and cultural differences most of these studies have relied on one or two comparative gender indices and more recent indices have not been employed this limitation makes it difficult to come to a definite conclusion about the role of cultural variables in explaining the portrayal of men and women in tv advertising even more importantly almost all the relevant studies have looked at television ads in only two or three countries which is a clear limitation in terms of detecting cultural patterns in fact only paek et al looked at television advertisements across seven countries and used hofstedes masculinity dimension and the gender development index to explain genderrole portrayals although paek et als study is pioneering in many aspects they only tried to predict the gender of the primary character and the voiceover and sampled the material from different months bwhich may reduce the generalizability and the comparability of their findings within and across the countries also their data are from 2002 and it remains unclearas with most content analytical researchhow the findings can be generalized to more recent years even more importantly all the known prior comparative studies have not empirically modeled the influence of culture on gender stereotypes it is not the same to interpret differences between countries by drawing on cultural differences as it is to empirically measure and confirm the role of culture in an adequate statistical model if a specific culture shapes gender stereotypes then a countrys score on a cultural dimension should help to explain the degree of gender stereotyping unfortunately such a multilevel analysis is not known to have been conducted in extant research therefore the aims of our study were to observe genderrole portrayals around the world using comparable measures sampling strategies and classic as well as recent gender indices to explain country differences we analyzed a total of 1755 television advertisements from 13 countries which were selected based on their scores on various gender indices austria brazil china france germany japan netherlands romania slovakia south korea spain united kingdom and united states to date our study is the largest known study on gender portrayals ever conducted and we are the first to employ the concept of gender egalitarianism from project globe and various other gender indices at the same time genderrole portrayals in advertising research on gender role portrayals in us television advertisements started in the 1970s followed by research in great britain and europe in the 1980s and in asia in the 1990s generally this research has led to the consensus that gender roles are highly stereotypical in television advertisements across a range of commonly explored variables the most frequently analyzed variables are the gender of the primary character the gender of the voiceover the age of the primary character and the setting associated with the primary character analyses of the gender of the primary character led to rather mixed results in previous research with some studies showing male predominance others showing a female predominance and still others finding almost no difference nevertheless the majority of studies showed a predominance of male primary characters some research has indicated a relation between hofstedes masculinity index and the gender predominance of the primary character whereas others found the predictive role of hofstedes masculinity index to be minimal we thus hypothesize that there will be more men than women depicted as primary characters in our analyses the age of the primary character is another widely studied variable most studies report a predominance of women in the younger age segment whereas more men were found in the middle and older age segments in a metaanalysis eisend found that the odds of women being younger are three times higher than for men hence there are strong grounds to expect that female primary characters will be depicted as younger compared to male characters furthermore the predominance of male voiceovers is one of the most consistent findings in the literaturea predominance that is even more pronounced in asia compared to other regions previous research has indicated that a higher score in hofstedes masculinity index increases the odds of a male voiceover thus we predict that there will be more male voiceovers compared to female voiceovers in television ads in terms of product categories associated with a specific gender there are relatively few consistent findings this may be because different studies often employ different product categories one finding that was confirmed in most studies however was the association between women and body products or as other studies called them btoiletries bbeauty products and bpersonal care products as well as bhousehold and cleaning products for men product associations were less clear but some studies found associations between men and television advertisements for cars telecommunications electronics technology and computers based on these findings we expect that female primary characters will be more likely to be seen in ads for toiletries beauty products and cleaning products whereas male characters will be associated more with telecommunications electronics technology computers or cars the setting is another variable that has often produced clear gender divisions most often cited is the association of women with a home setting a metaanalysis shows that the odds of women being depicted at home are approximately 35 times higher than for men another finding that was similar across most of the literature is that more men than women are shown in a workplace setting therefore we hypothesize that female primary characters will be more likely to be depicted in a home setting whereas male characters will be more likely to be shown at work in addition to these commonly analyzed variables we focused on the working role of the primary character although categorizations differed several studies investigated whether the primary character was working or was a homemaker both leading to highly stereotypical results that suggested more men than women are working and more women than men are depicted as homemakers thus we expect female primary characters will be more likely to be seen in lower status working roles compared to male primary characters who will be more likely to be seen in higher status roles cultural models gender indices and advertising to fully understand genderrole portrayals scholars have repeatedly pointed to the important role of cultural differences the most widely applied cultural model in advertising research is hofstedes cultural dimensions including four dimensions power distance individualismcollectivism uncertainty avoidance and the masculinity dimension the most relevant dimension for the purposes of the present paper is hofstedes masculinity dimension which has been used in crosscultural content analyses on gender in advertising including studies comparing two countries and some comparing three or more countries however only a few studies have confirmed an association between the masculinity index and gender portrayals whereas more studies have led to mixed results or to results that were mostly opposite from those predicted by hofstedes masculinity index considering the mixed results of previous research in general and criticisms of hofstedes study in particularas being rather outdated and for its masculinity dimension that mixes two subdimensions it is crucial to use additional indices such as the more recent framework from the globe project its theoretical importance and promise have been mentioned in several articles on theory in advertising research still the globe study has been used rarely in gender stereotyping research to date in contrast to hofstedes study the globe project differentiates between societal practices and values practices are measured through questions regarding bwhat is while values are measured through questions regarding bwhat should be we have decided to use societal practices in our study because gender portrayals are about the way a society actually performs whereas values are about how a society should perform although hofstedes masculinity index influenced the globe project the latter separated this dimension into gender egalitarianism and assertiveness gender egalitarianism was defined as bthe degree to which a society minimizes gender role differences while promoting gender equality gender egalitarianism reflects societys beliefs about whether biological sex should determine roles in society gender egalitarian societies rely less on biological sex to make those determinations in such societies there is less occupational sex segregation more women in the labor force and in positions of authority and generally a higher status for women thus gender egalitarianism is clearly related to our study despite the call to use project globes dimensions in advertising research only a few studies to date have employed them these studies have included the dimensions of assertiveness performance orientation and humane orientation and they have indicated an association between globe dimensions and advertising evaluations thus no known study to date has used gender egalitarianism as a theoretical framework or used project globe dimensions in content analysis in addition to testing the predictive power of cultural models for gender stereotyping we take into account other dimensions related to gender development because previous research has indicated that gender role portrayals may be influenced by a countrys gender development paek et al found that the predictive role of the genderrelated development index by the united nations development program seems to be minimal for the gender of the prominent character in an advertisement however they also reported that the odds of using a male voiceover significantly increased as gdi scores dropped in his metaanalysis eisend used another gender index created by the undpnamely the gender empowerment measure and found a correlation between the gem and gender stereotyping in advertising our research extends these studies by testing whether the gdi the undps gender inequality index which replaced the gem due to criticism and the world economic forums gender gap index can predict gender stereotypes all of these indices are based on demographic data the gdi is based on gender gaps in life expectancy education and incomes the gii on reproductive health empowerment and labor market participation and the gggi is the most inclusive being based on gender gaps on economic political educational and health criteria furthermore besides hofstede our study uses globe for the first time in the extant research on gender portrayals as a theoretical framework because all indices differ and previous evidence of their impact on gender portrayals is mixed at best we ask as an exploratory research question how the five indices predict genderrole portrayals in television advertising method we analyzed gender role stereotypes across asia america and europe we selected the countries based on the following criteria first we wanted to have a broad range of countries that have different scores on various gender indices for that reason we have included countries with a high score on hofstedes masculinity index and with a low score as well as countries with a high score on globes gender egalitarianism index and a low score second we wanted to include the countries that were frequently sampled in previous studies for instance the united kingdom and the united states finally the selection was driven by practical reasons such as access to tv channels and the language qualifications of our studentscoders the most recent data from all gender indices were used in may 2014 15 h of primetime tv programming were recorded from those broadcasters with the largest shares of viewers for each respective country we focused on private channels because we were not interested in the effects of countryspecific regulations of publicservice broadcasters for austria we took the largest private channel as well as the largest public service channel because the audience share of the private channel is rather low for china we took cctv1 as the clearly dominating tv channel the recording time was split into three typical weekdays of the same week that is 3 × 5 h per channel the sample included weekdays and weekends to ensure a higher diversity of advertisements we started the recordings after mothers day in most of the recorded countries to ensure that no large countryandor regionspecific events occurred during the days of recording we focused on prime time because it was commonly used in previous studies because the definition of prime time varied by country we used the most inclusive definition like in most prior research duplicate ads political ads ads for films and cds public service announcements and ads with children animals or comic figures as dominant actors were not considered in our study after 150 ads were collected in one country we stopped additional data collection however the 3 days sampled produced less than 150 unique advertisements for several countries our sample consisted of 1755 ads these included ads from austria germany the united kingdom the united states france spain brazil netherlands romania slovakia china japan and south korea coding procedure and reliability the codebook was adopted from prior research the following categories were included in the analysis primary character product category voiceovernarrator age dominant setting and working role these are standardized measures in this research the coding team consisted of 30 coders from two major universities in south korea and austria coders were one of the authors and 29 undergraduate students receiving compensationcourse credit for their work students were unaware of the hypotheses and were native or bilingual in the language of the country they coded training sessions on using the codebook were held with all coders prior to testing reliability ads were randomly selected for the reliability test but had to involve a primary character so that all codebook categories could be included we performed three reliability tests using krippendorffs alpha one test was between coders for different countries on englishlanguage advertisements one test was between coders coding the same country prior to coding and one test used the coded material without coders knowing they were tested although 65 of the reliability measures in these three tests were above α 80 the lowest intercoder results for the numerous intercoder reliability tests were for primary character voiceovernarrator age dominant setting and working role this was still above the recommended chancecorrected agreement of 60 by neuendorf results primary character and voiceover in our first hypothesis we stated that there will be more male than female primary characters among all spots with a primary character 507 of the characters were women as can be seen in table 1 in some countries the share of male primary characters was slightly higher than those of female primary characters in other countries however the share was almost identical thus we cannot find a substantial male predominance of primary characters we also hypothesized that female primary characters would be depicted as younger compared to male primary characters as table 1 reveals this pattern was the case in seven countries for the other countries however there was no significant effect based on previous research we assumed in hypothesis 3 that we would find more male than female voiceovers when looking across countries the share of male voiceovers was in fact significantly higher than the share of female voiceovers confirming hypothesis 3 this result was mirrored in most countries the opposite effect however was found for france with 58 female voiceovers product setting and work role in line with prior research we expected that female primary characters would be more likely to be seen in ads for toiletries beauty products personal care and cleaning products whereas male characters would more likely be associated with telecommunications electronics technology computers or cars the findings are reported in table 2 in all countries but japan the association of female primary characters with toiletries beauty products personal care and cleaning products can be confirmed the association of male primary characters with products related to technology and cars was observed for brazil germany the netherlands spain and the united kingdom the effect was not significant by the conventional p 05 level for romania slovakia austria usa china japan and south korea another prominent finding in previous research is that female primary characters are more likely to be shown in a home setting whereas male characters are more likely to be associated with a work setting table 3 shows the findings for each country the stronger depiction of female primary characters in home settings compared to male primary characters can be confirmed in brazil china germany the netherlands romania south korea and spain there was no significant effect for six countries austria france japan slovakia usa and united kingdom when it comes to the dominant depiction of male primary characters in work settings we observed significant associations for austria germany france japan the netherlands and the united kingdom but no significant effect for south korea brazil the united states spain romania slovakia and china as can be seen in table 4 it was not the case that male characters are depicted in higher status jobs compared to female characters this association was significant only for japan however when interpreting our findings the very small numbers of depicted working roles need to be taken into account therefore we also checked whether or not a female or male character was depicted in any working role at all one could anticipate that male characters will be more likely to be shown in any working role compared to female characters as table 4 reveals the association between male primary characters and the depiction of a working role was statistically significant for austria france japan the netherlands slovakia and the united kingdom the association was not significant by conventional levels for germany brazil china south korea spain romania and the united states multilevel analyses so far we have observed how gender is related to the depiction of primary characters and we have looked at single countries although such an analysis is useful we are unable to explain why an association is found in one country and not in another thus the question we want to ask is whether variations in the association between gender and character depiction can be explained by cultural differences between countries in order to answer this question hierarchical linear models are needed multilevel models are warranted when cases are clustered within countries the advantages of multilevel analysis are that we can explain the individuallevel variation in the dependent variable while statistically controlling the variation across levels of analysis and that we try to predict the variation of regression slopes by including constructs at the country level in particular we will examine whether the country differences in the relation between gender and character depiction can be explained by the five indices introduced previously because our outcome variables are binary we ran a logistic hierarchical nonlinear model with the logitlink function using pql estimation with the statistical package hlm 7 the level1 model includes the gender of the primary character the level2 model includes the respective index because the level2 variables are correlated we ran a separate model for each index in the first step we computed the variance components in order to examine whether there is a significant amount of variance between the classes the upperlevel variance is significantly different from zero for the age of the primary character the product category body and cleaning products the product category technical products and cars working role shown and the status of the average level of a gender index for most outcomes the level1 effect of gender was statistically significant confirming hypotheses hypothesis 2 hypothesis 4a hypothesis 4b hypothesis 5a and hypothesis 5b however we could not confirm the assumption that female primary characters are more likely to be seen in lower status working roles compared to male primary characters who were theorized to be seen in higher status working roles yet female primary characters were less likely to be depicted in any working role compared to their male counterparts beyond the effects of the level1 predictor the main focus of the multilevel model lies on the crosslevel interactions between the gender of the primary character and the gender indices this interaction tests whether the variations between countries in the effects of gender on the outcome variables can be traced back to variations in the five gender indices in order to answer this question we first looked at the randomcoefficients model for the dependent variable age of the primary character no systematic differences in the regression slope between the countries were observed the same was true for the dependent variables of product category body and cleaning products setting home setting work presence of a working role and status of the working role however for the category of technical products and cars there was a statistically significant variation that could be explained by level2 variables thus for most outcomes there were no differences in the regression slope that can be explained by a specific culture as can be seen in table 5 we found no substantial crosslevel interactions for all five gender indices that is none of the five gender indices was able to explain why there was a stronger association between the gender of the primary character and the outcome variables in a given country put formally an increase in a gender index did not lead to an increase in the association between gender and the outcome variables discussion our study is the largest known to date on genderrole portrayals in advertising and it is the first known with sample equivalence using comparable tv programs to illuminate the effect of culture on genderrole portrayals in addition it is the first study known to test the role of gender indices for genderrole portrayals in advertising using multiple gender indices as independent variables and multiple genderrole variables as dependent variables we have found significant differences among the countries investigated although every country showed traditional genderrole portrayals for some variables some countries showed nontraditional genderrole portrayals for several variables and thus seem to use a more genderequal approach toward gender roles for example in the united kingdom no significant age differences were found between the share of male and female primary characters as well as male and female voiceovers and similar shares of men and women were shown at home similarly in the united states men were not stereotypically associated with car electronic products approximately the same number of men and women were shown both at home and at work and men and women were portrayed in work roles about evenly these findings align with those of several previous research studies showing that in the united kingdom and several european countries gender portrayals have improved in recent years by contrast advertisements in several countries such as germany were identified as highly traditional in the use of gender roles for almost all investigated variables across all countries some variables tend to indicate more traditional genderrole portrayals than others for example for more than half the countries the variables of voiceover age toiletrieshousehold products and setting produced significant gender differences although we were able to observe differences between countries we found that these differences cannot be explained by cultural or gender indices the effect of a specific culture in shaping advertising messages is therefore smaller than commonly thought this finding stands in contrast to eisends metaanalytic results showing that bgender stereotyping in advertising depends on developments related to gender equality in society rather than the other way around there are many potential explanations for why our study comes to a different conclusion first and foremost it is important to stress that no study of which we are aware has modeled the influence of culture in a multilevel model as should be apparent when looking at tables 1 2 3 and 4 one could easily pick two or three countries and explain the observed differences by different scores on gender indices however such an analysis strategy does by no means confirm that an increase in a gender inequality index leads to an increase in gender stereotyping across countries for this a multilevel model is necessary second it is possible that we have found no relationship between the cultural variables and stereotyping because gender portrayals in advertising are lagging several years behind actual developments in society unfortunately this cannot be sufficiently tested with the present data because we would need to draw a sample of tv ads over time third because gender stereotypes in advertising are decreasing over time our findings may be different simply because our sample is the most recent one reflecting a declining influence of culture that is although advertising and its genderrole portrayals may still vary across cultures in some cases they may become more universal due to global markets and networked publics fourth our study used equivalent samples in all countries which is not possible in a metaanalysis such as eisends fifth and finally gender stereotypes might not be measured sufficiently by gender indices and it may be that another index should be considered as more appropriate for measuring stereotypes limitations and future research directions as with every research project our project has several limitations these include a rather small sample size in some countries which was also the case in several previous studies more importantly our sample includes countries from asia europe and the americas but none from africa or oceania related to this point we were not able to sample all countries that we would have liked because of a lack of access to the tv channels generally the number of countries was very small for a multilevel model larger and more diverse samples are therefore needed in future research in addition our sample was drawn in may 2014 thus it is able to represent only this specific period additionally seasonal variations might be a concern in research on advertising furthermore although we strived to choose comparable tv networks this is a daunting task because various countries have different broadcasting systems in addition analyzing only one tv channel for each country even the most dominant one might not be fully representative of the pool of tv ads from each country finally we suggest that future research studies should attempt to analyze genderrole portrayals in television advertising over time using longitudinal approaches practice implications practitioners in the countries we analyzed are called to raise their awareness for gender stereotypes in television ads even when practitioners reside in countries with high gender equality gender stereotypes still prevail in television advertisements obviously current regulatory efforts do not seem to be successful in implementing an unbiased representation of men and women in television ads we suggest that advertising councils as well as advertising professionals should work toward a clearly defined set of recommendations about how men and women should be presented we also suggest that advertising educators should sensitize students about gender role depictions in commercials how they are observed using scientific methods and what effects they may have on women and men conclusion our study was able to show that there appears to be a global pattern of gender stereotyping still at work this finding is significant for two reasons first it is well known that gender stereotypes in advertising can influence genderrole stereotypes in society further perpetuating gender roles and gender inequality second our findings clearly suggest that gender stereotypes in tvadvertising can be found around the world independent of a given gender equality status in a particular country it follows that more progressive countries do not necessarily depict womenin terms of gender equalityin more progressive ways in television advertising we hope our research helps to spur a discussion among scholars advertisers and regulators on the global dominance of gender stereotyping in advertising working role there was no significant amount of variance for the depicted setting home and for the depicted setting work the results of the multilevel model are presented in table 5 because we included the grandmeancentered terms for the gender indices the effects of gender on the outcome variables must be interpreted as the effect of gender at the

although there are numerous studies on genderrole portrayals in television advertising comparative designs are clearly lacking with content analytical data from a total of 13 asian american and european countries we study the stereotypical depiction of men and women in television advertisements our sample consists of 1755 ads collected in may 2014 analyzing the gender of the primary character and voiceover as well as the age associated product categories homeor work setting and the working role of the primary character we concluded that gender stereotypes in tv advertising can be found around the world a multilevel model further showed that gender stereotypes were independent of a countrys gender indices including hofstedes masculinity index globes gender egalitarianism index the genderrelated development index the gender inequality index and the global gender gap index these findings suggest that gender stereotyping in television advertising does not depend on the gender equality prevalent in a country the role of a specific culture in shaping gender stereotypes in television advertising is thus smaller than commonly thought

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challenging and dismantling ageist attitudes beliefs and behaviors through intergenerational programs tia rogersjarrell 1 and brad meisner 2 1 york universitymississaugaontariocanada2 york universitynorth yorkontariocanada age stereotypes are complex and multifaceted individuals can demonstrate and embody numerous and varied positive and negative stereotypes therefore solutions to combat age stereotypes must also be complex and multifaceted additionally both social and physical forms of age segregation are common in our society this causes fewer and fewer opportunities for younger and older people to interact intergroup contact theory suggests age stereotypes can be reduced through increased intergenerational contact one way to encourage contact between younger and older populations is through intergenerational programming however there is a lack of literature investigating the effects of intergenerational programs on perceptions of aging the purpose of this paper was to critically review and explore literature on intergenerational programs to understand how they influence age stereotypes and ageist attitudes the available literature suggests that intergenerational programs involving young children adolescents or emerging adults interacting with older adults can significantly reduce age stereotypes towards older adults additionally older adults negative beliefs and attitudes towards younger people can also be deconstructed after participation in intergenerational programs intergenerational programs act to break down age barriers and promote connections and understandings between generations these programs challenge the belief that older and younger people should live and participate in spaces that are separate from one another providing opportunities for younger and older people to participate in intergenerational programs is one way to promote respectful relationships and enhance the quality of life and health of all generations health differences among people with varying profiles of awareness of positive and negative agerelated changes serena sabatini 1 obioha ukoumunne 1 clive ballard 1 manfred diehl 2 hanswerner wahl 3 allyson brothers 2 and linda clare 1 1 university of exeterexeterenglandunited kingdom2 colorado state universityfort collinscoloradounited states3 university of heidelbergheidelberggermany higher awareness of negative agerelated changes is related to poorer mental and physical health whereas higher awareness of positive agerelated changes is related to better mental health associations of health with aarcgains and losses have been explored separately but often people experience gains and losses concurrently using latent profile analysis we identified at the crosssectional level patterns of aarcgains and losses and explored whether groups with distinct profiles of aarcgains and losses differed in physical mental and cognitive health and demographic characteristics analyses were based on the largescale protect study conducted in the uk 76 women a fourgroup solution revealed the best model fit 45 of participants perceived many aarcgains and few losses 24 of participants perceived moderate aarcgains and few losses 24 of participants perceived many aarcgains and moderate losses and 7 of participants perceived many aarcgains and many losses the four groups differed meaningfully in health group 1 was the most healthy followed by groups 2 3 and 4 participants in group 1 were most likely to perceive their health as excellent reported the lowest levels of depression and anxiety and showed the best cognitive performance on average participants in group 1 were younger and more likely to be female employed and married compared to other groups considering the coexistence of gains and losses is important when relating awareness of agerelated changes to health existing scholarship in social gerontology has surprisingly paid little attention to broader loving emotions such as compassionate and altruistic love as potentially meaningful mechanisms for improving later life psychological wellbeing this study examined the influence of feeling love toward other persons and experiencing love from others on later life psychological wellbeing we conducted a 3wave longitudinal study of a representative sample of 340 ethnically heterogeneous community dwelling older residents of miami florida the increase in feeling of being loved and love for others led to decline in odds of reporting greater level of depressive symptoms over time the odds of reporting higher level of positive affect were significantly greater for older adults who reported feeling loved by others and expressed love for other people older adults who felt loved had 092point lower ordered log odds of reporting higher negative affect than those who reported lower level of love the impact of compassionate love on depressive symptoms and negative affect remained statistically significant even after adjustment for altruistic attitudes and emotional support the influence of loving emotions on positive affect was however explained by altruistic attitudes and emotional support our findings underscore the powerful influence of both receiving and giving love for the maintenance of later life psychological wellbeing we offer support for the expectation that love is a significant force in the lives of older adults that transcends intimate relationships loving others the impact of compassionate love on laterlife psychological wellbeing measuring selfperceptions of aging differences between measures when predicting health outcomes jordan boeder 1 and dwight tse 2 1 claremont graduate university claremont california united states 2 the chinese university of hong kong hong kong china the majority of selfperceptions of aging research uses either a combination of the agerelated cognition scales of ongoing development and physical loss or the attitudes towards own aging subscale to assess views on aging although these scales are used interchangeably the valence and the specificity of the view on aging being assessed are not consistent this study investigates how different measures of spa relate to one another and whether they differentially predict various types of health outcomes data from the 2008 and 2014 waves of the german aging survey a populationbased representative survey of adults aged 40 to 95 was used to examine the relationship between the agecog scales and the atoa subscale as well as the differences in the types of health outcomes each predicts the correlations between the agecog scales and the atoa were higher than the correlation between the agecog scales the agecog scale of ongoing development significantly predicted psychological health outcomes across a sixyear period while the agecog scale of physical loss and the atoa subscale predicted both physiological and psychological health outcomes evidence supports using the agecog scale of ongoing development to predict domainrelevant psychological health outcomes however the multidimensionality of spa is best measured by the atoa subscale or a combination of the two agecog scales both forms of measurement were found to maximize the amount of explained variance for psychological and physiological indicators of wellbeing and illbeing in the evolving situation of covid19 an outbreak of the contagious disease in a nursing home near seattle prompted urgent calls for precautionary tactics in seniorliving facilities worldwide the usa and china are the countries with the largest and second largest populations of people aged 80 more than two million older adults live in seniorliving facilities in the usa and the number of beds in seniorliving facilities in china has increased to 65 million in recent five years the risk of infections including covid19 is tripled in seniorliving residents because of age close living conditions and underlying health conditions infectious diseases account for one third of all deaths in people age 65 in the usa covid19 has a case fatality rate of 23 overall and as high as 15 in patients age 80 in china together with health and services interventions environmental interventions should be considered to prevent the possible spread of infections in seniorliving settings based on a literature review and using empirical data of 12 seniorliving facility designs collected in both countries this research analyzed the advantages and disadvantages of existing facility environments in terms of infection control environmental interventions to promote infection control are suggested in the context of individual facilities proposed interventions are analyzed at two levels spatial design and design details five factors are included visitors screening ventilation isolation rooms hand washing and daily temperature checks from the perspective of infection control the crosscountry similarities and differences of seniorliving facility designs are discussed session 2996 disasters and emergencies a focus on the implementation of disaster prepwise an online disaster preparation tool for older adults lena thompson 1 emily henja 2 travis beckman 3 and sato ashida 1 1 university of iowa college of public healthiowa cityiowaunited states2 rush universitychicagoillinoisunited states3 johnson county homeland security emergency management agencyiowa cityiowaunited states older adults are less prepared for disaster situations than younger adults due to expenses complicated preparation processes and lack of support we previously developed and tested a disaster preparedness program for older adults and showed its impact on improving preparedness and personal emergency support network using a 5step communityengaged approach and in collaboration with our stakeholder advisory board we adapted this disaster prepwise program to an online platform and developed implementation

how people manage their goals is central to adaptation across the lifespan however little is known about the individual difference characteristics that predict how and why people use different selfregulatory strategies the present study aimed to investigate associations of perceived agerelated gains and losses and their interaction as predictors of flexibility in goal management in older adulthood we also examined whether future time perspective ftp mediated the relationship between aarc and goal flexibility such that awareness of aging impacts perceptions of time remaining impacting how individuals evaluate and manage their goals a communitybased sample of 408 adults aged between 60 and 88 years was recruited via an internetbased research platform participants completed questionnaire measures of aarcgains aarclosses ftp goal disengagement and goal reengagement a flexibility index reflecting tendencies toward use of both goal disengagement and reengagement strategies was also analyzed although aarclosses was associated with lower goal reengagement and goal flexibility this association was weaker among those with higher aarcgains indicating that aarcgains may be protective in the relationship between aarclosses and goal management furthermore the association between aarc and goal management was mediated by ftp higher aarcgains were associated with more openended ftp which was associated with higher goal reengagement and lower goal disengagement on the other hand higher aarclosses was associated with more restricted ftp which was associated with lower goal reengagement and higher goal disengagement results suggest that subjective awareness of aging particularly awareness of gains has important implications for goal management in older adulthood

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background globally familycentered care is a wellknown healthcare approach for children and their families 1 2 3 4 it has over the past decades been touted as the new paradigm by paediatricians especially in the developed world 4 5 6 7 the institute of patient and familycentered care has identified four main concepts of it including respectdignity communication participation and collaboration 1 fcc is an approach to paediatric and child health care emphasizing respective collaborative partnerships between healthcare professionals and families of sick children in the paediatric health setting to meet their physical emotional social and developmental open access correspondence 1 school of nursing wisconsin international university collegeghana po box lg accra ghana full list of author information is available at the end of the article needs 8 9 10 when clinicians accept and implement fcc in neonatal care it can promote parental satisfaction and shorten the length of stay in the neonatal intensive care unit 1112 yet its application in the intensive care units is faced with several challenges due to contextual preferences across the world the practice of fcc in many countries has been reported for instance in asia the main concepts adopted were support visual information collaboration partnerships and mutual trust 13 14 15 the fundamental concepts of fcc on the american continent are information sharing participation respect and dignity and shared decisionmaking 1617 similarly in sweden the training of nurses and physicians improved their support for parents to participate in the care of their children and mentorship to junior clinicians in the icu was used to appreciate families as experts in the care of children 18 norway employed respect and empathy to yield family satisfaction 11 whilst denmark used family support to address the barriers of fcc 19 in south africa they employed family involvement and the provision of adequate information for infants and families to gain the satisfaction of parents in the icu 20 flexible visiting times were allowed for parents to connect with their hospitalized children in tanzania 21 apart from europe and the united states which utilize and implement these four concepts other parts of the world have implemented portions of them based on what works in their context in the case of africa little or no studies exist on fcc in the nicu especially in western africa and ghana these findings in the intensive care literature cement the argument for contextualizing the practices of fcc as different settings adopt what works best per their context furthermore what is also evident in these studies is that the findings are largely emanating from families perspectives albeit a few from clinicians perspectives meanwhile the involvement of fathers mothers nurses midwives doctors and health managers in one study will broaden the contextual practices and appreciation of fcc in any setting there is therefore a need to extensively explore the practices and experiences of both families and clinicians to gain a broader understanding of the contextual practices of fcc in ghana the practices of fcc in the nicus are poorly documented and hence its contextual practices and the experiences of families and clinicians are vague the primary purpose of this study was therefore to qualitatively study the practices of fcc in the nicu to present the experiences and contextual practices of fcc from the perspectives of families and clinicians in ghanaian nicus this may at least provide a dogma for future research on fcc practices in ghanaian nicus methods study design the researchers adopted a qualitative exploratory descriptive design 22 to study the contextual practices of fcc among families and clinicians at the nicu the rationale for adopting this design was to explain the phenomenon of fcc from the perspectives of families and clinicians such as nurses midwives and doctors in the nicu 23 additionally the family care theory was used as the theoretical framework 2425 this offered the opportunity to study the contextual practices of fcc in the intensive care units in the ghanaian setting the study was conducted between july 2020 and july 2021 setting the nicus of two public tertiary teaching hospitals in the northern and southern parts of ghana were used for this study these nicus do not have any documented practices of fcc albeit families are occasionally involved in the care via scheduled visitations families are not allowed to stay overnight at the nicus in ghana these neonatal units have open cubicle wards with optimum logistics and separate kangaroo care rooms that admit all kinds of neonatal cases including birth asphyxia birth injuries neonatal jaundice preterm congenital abnormalities and sepsis these babies are medically and surgically managed by mainly general doctors registered nurses registered midwives and a few specialists in neonatal care paediatrics and intensive care the cumulative bed capacity of the two nicus used in this study was 105 although they often admit neonates to almost double their primary capacities data collection the approved ethics and introduction letters were used to seek permission from the departmental and unit managers at the nicus of the two settings the head nurses of the nicus assisted the researchers in identifying clinicians who met the inclusion criteria of the study similar arrangements were made by the head nurses to sample families who stayed at least 24 h in the icu subsequently the participants were provided information sheets and informed consent with additional consent for a voice recording if they agreed to participate for data triangulation and to acquire diverse perspectives from the participants the researchers used both interviews and focus group discussions as techniques of data collection the first author conducted the interviews and fgds with the help of six trained research assistants the interviews and fgds were conducted in a secured room at each setting provided by the head nurses of the icus this was necessary to avoid interference as the data was audiotaped the researchers purposefully chose 84 participants to take part in 24 individual interviews and 12 focus groups with five participants in each group each fgd composed of five family members or clinicians and lasted for at least 45 min each individual interview lasted for at least 30 min the rationale for the collection of extensive multiple forms of data was to obtain thick data to provide a vivid description of the fcc phenomenon in the ghanaian nicus table 1 provides further details of the qualitative data collected for this study data analysis the researchers transcribed all the data into english text with the help of language experts where the interview language was the local dialect of the participants all transcripts were read severally by the researchers to check grammar and to get immersed in the data to ensure anonymity and confidentiality codes were attached to the transcripts the setting and the participants in this study hospital k was assigned code k and hospital t was coded as t interviews were coded as i fgds were coded as d families were coded as f and clinicians were coded as c serial numbers were added to these codes to generate the anonymous codes the researchers employed openinductive content analysis to extract fragmented data from the transcripts by comparing data transcripts and examining them for similarities differences and patterns the initial codes were kept close to the participants words all in a bit to ensure methodological rigour 26 the researchers then used focused coding to refine and theoretically sample the fractured data into groups by selecting key terms that subsume the initial codes created from the data finally the researchers reflected on the categories emerging from the data to integrate and weave all the fractured data together to arrive at the contextual perspectives of the participants on the practices of fcc in the ghanaian nicus these iterative content analysis processes were facilitated by importing all the 36 transcripts into maxqda version 2020 qualitative software the lexical search word clouds comparison of retrieval patterns and codesubcode model functions of the qualitative software were employed to conduct the analysis results participants backgrounds a total of 84 participants were recruited they comprised of 42 families 29 nursesmidwives and 13 doctors a total of 24 individual interviews and 12 fgds for both families and clinicians were conducted the ages of the families ranged from 1854 years with an average age of 31 years most of the family participants had at least a senior high school education with about 42 of them having tertiary education the clinicians were between the ages of 26 and 52 years with an average age of 38 years the clinicians had a minimum of 5 years of working experience and a maximum of 26 years of working experience categories and subcategories three main categories emerged from the data contextual practices of fcc family experiences and icu clinicians experiences of fcc practices contextual practices of fcc this data produced three subcategories to illuminate the participants perspectives of fcc practices in ghanaian nicus respect dignity culture and religion and multidisciplinary approach fcc in this context is partly practiced and refers to shared decisionmaking and respect between families clinicians and managers using a multidisciplinary approach to prioritize the provision of quality and satisfactory childcare respect and dignity to practice fcc clinicians must respect families and strive to understand their perspectives on care respecting the opinions of families will promote their participation in icu care the approach to families should preserve their dignity since the sickness of a child can cause disorientation however some clinicians did not accord some families the rightful respect due to such families poor sociocultural backgrounds culture and religion according to the participants families should be accepted into icus regardless of their race ethnicity or cultural background some families will refuse treatment for their children such as blood transfusions because of their religious beliefs in this context the gender of a child had a substantial impact on most families participation in the care process due to their cultural preference for male children over female children some families may abandon their female infants at the hospital and such practices may have an impact on the familys full participation in care as a result the participants stated that before fcc can be implemented clinicians should endeavour to learn and accept the cultures and religions of their patients and families multidisciplinary approach participants touted fcc as an important concept in child health that must employ a multidisciplinary approach including community health nurses and social welfare in the provision of childcare in the icus the chns for example will promote continuity of care through the identification of community support groups for discharged patients from the icus this will provide family support and integration of the sick child into the family and community especially for those with congenital abnormalities however there is a gap in fcc practices as clinicians seldom involve families in decisionmaking about childcare in the ghanaian icus this was due to the challenging nature of icu services even though the clinicians recognized the importance of involving the families in decisionmaking about the care of their critically ill children in the icus family experiences this particular category had three subcategories emotional stress lack of information and coping strategies emotional stress anxiety and emotional stress were common among families with seriously ill children hospitalized in the intensive care unit it feels empty very anxious and very awful they said describing their experiences the phenomenon of going home to sleep without the child generated this anxiety you cant sleep you feel like your baby is crying and boxes are carried with dead babies lack of information the absence of an open flow of information and feedback on the processes and progress of their childrens illness were unpleasant experiences according to the families this hampered their ability to fully participate in icu care and exacerbated their anxiety families in the intensive care unit desire more information about the care process to feel more at ease coping strategies prayers crying taking time off work and receiving occasional assistance from the staff were among the coping strategies used by families to deal with the anxiety associated with the icu phase of treatment even though some mothers grieved as a result of these events crying was also a way for them to vent and deal with the stress the following are some of the participants accounts of their experiences clinicians experiences the experiences of the clinicians relative to the practices of fcc in the ghanaian icus were described by three subcategories support counselling and education as well as funding challenges support the clinicians narrated that families need the support of staff and the system to deal with the stress of participating in the care of their critically ill children in the icus most mothers go through caesarean section and are often left alone to do laboratory and pharmacy errands the staff usually assists the families to meet these needs in our case some families were helpful in caring for their critically ill children while others were not some anticipated early discharge regardless of the outcome of their childrens condition which is challenging for the care providers such families sometimes requested discharge against medical advice because the mothers were left alone to support the care with limited resources to sustain their stay at the icu … my experiences with mothers in the care of their newborns have been okay some are ready and supportive and some are not supportive in the care of their newborns…tci2you can just imagine a mother who has just delivered probably through a caesarean section her husband has to be away to work and bring money so she is left alone with no sister and no supportkci1 the mothers are left alone to take care of the baby… the issue that you will encounter is that the mother is looking to be discharged irrespective of the babys state of health because of a lack of resources to take care of the baby tci6 counselling and education there were counselling rooms used for sharing information with the families at the nicu families were counseled by clinicians by reassuring them and explaining the childs condition to them the counselling sessions were also used to educate families and answer all their questions to allay anxiety due to personnel challenges this was not done for all families admitted to the intensive care unit the clinicians however indicated that permanent clinical psychologists in the icu would be helpful in addressing the emotional stress on both families and clinicians the clinicians educated families on the clothing of the babies feeding the critically ill neonates and maintaining the neonates body temperature via kangaroo care and extra clothing we have a counselling unit and every patient who comes goes through a firsttime counselling session… we explain to them the processes here and their childrens condition kcd3e we need a clinical psychologist in the icu because the icu is a very stressful place hence the role of a clinical psychologist cannot be under emphasized kci1 funding challenges clinicians intimated that in the icus services are very expensive this challenged the provision of care especially for teenage parents and those with congenital abnormalities requiring prolonged nicu stays they recommended strengthening institutionalbased funding including social welfare and setting up a national child health fund to support such needy families per expert assessment and interaction with families especially those who come with congenital issues it is identified that they have challenges like financial issues…tcd1c … intensive care is expensive and is quite a new concept in this part of this country where they are not able to afford the care and people dont really appreciate that a lot of resources are required to take care of babiestci6…the social welfare should work because some of the parents are teenagers who cannot fend for themselves let alone their critically ill children kci4our facility has a fund for child health support contributed by clients who come to the facility and some other donations but that fund is inadequate to meet the financial needs of families especially needy families with critically ill children requiring intensive care because its very expensive we need a national fund to support the family in the care of their critically ill children kci5 we could have funds where there will be donations for us to use to support the needy onestci4 discussions fcc in the ghanaian context is partly practiced at the nicus participants defined fcc as shared decisionmaking and respect between the clinicians managers and families using a multidisciplinary approach and education to prioritize the provision of quality childcare regardless of the familys sociocultural background the shared decisionmaking aspect of the finding is consistent with the philosophy of fcc in the canadian 27 and norway 11 contexts in the work of who decision making and patient satisfaction are essential components of ensuring quality health care 28 conceivably the increased icu admissions with their attendant workload on clinicians inadequate spaces and personnel in the ghanaian nicus may be accountable for the occasional involvement of families by clinicians in decisionmaking health managers the ghana health services and the ministry of health must take immediate steps to build more nicus across the country and expand as well as equip the existing icus with adequate logistics and specialized personnel the clinicians restricted the definition of fcc in the icu to only the father and mother of a sick child and therefore granted access to them alone yet respectful and dignified care 1 in our context is considered to be care that accepts all family members irrespective of their sociocultural backgrounds contrary to these findings the acceptance of all family members including extended family into danish icus improved health outcomes for preterm babies 19 perhaps this finding in the ghanaian setting was attributed to a lack of space and personnel at the icus to fully engage families as experts as proposed by the fcc concepts 1 maybe they would have attached more meaning to it if the bottle necks of space and inadequate personnel were removed this suggests that health professionals managers and institutions must create the needed spaces and train the professionals to build collaborative partnerships with families of sick children in the icus in making decisions on the care processes in that way quality care may be guaranteed as the families may feel involved and satisfied with the care the study findings also advocate for a multidisciplinary approach towards fcc practice in the ghanaian context a multidisciplinary approach to fcc has been recommended in a qualitative study conducted in finland 12 possibly the participants recognized the diverse roles played by different professional groups in supporting families in nicu care this means the implementation of fcc in the health system should be approached by all stakeholders including clinicians managers specialists and institutions like moh ghs and health facilities regulatory authority thus the implementation of fcc practices should not only be left in the hands of nurses and doctors but all these parties must be fully integrated into it to be successful community health nurses for example can be stationed in the nicu to follow up with critically ill children and their families after discharge via home visits furthermore the inclusion of community health nurses in nicus will help immunize babies and those with nonimmunerelated conditions under observation to prevent vaccinerelated diseases similarly a clinical psychologist in the icus will help both clinicians and families manage the emotional and psychological stressors including anxieties associated with the icu phase of care by so doing the health system will be in a better position to address the nonpathological aspects of maternal and child health that may affect their physical health this may also help to improve the overall health and wellbeing of icu patients families and clinicians additionally the study revealed that clinicians are willing to accept and support families to fully participate in the nicu phase of care clinicians recognise the significant roles families play in the nicu for example in providing information and purchasing medicine and supplies to support the care of their critically ill loved ones this finding resonates with the concept of fcc practiced in japan 29 however families were seen to be helpful in complementing the efforts of clinicians in the nicus in most cases to provide quality care at their best thus clinicians are not against the policies on the concepts of fcc practices in the icu the clinicians showed empathy to families with critically ill children in the icu but they maintained that the provision of funding for intensive care units will facilitate the successful integration and implementation of fcc into the icu since it will for example require more space and strict protocols of infection prevention and control for both parties families with critically ill children in the icus described their own experiences as being anxious 30 awful and painful this finding buttressed the initial call for a multidisciplinary approach to fcc practice where the services of a clinical psychologist including professional counselling can be provided for families to manage their anxieties further research might focus on monitoring the quality of icu care and evaluating client satisfaction in our context to better appreciate the drivers of quality care synchronize best practices across settings and harness the benefits of fcc strengths and limitations the study draws its strength from the multiple forms of interviews and focuses on group data collected to arrive at the findings presented however our findings are limited in their qualitative nature and also by the fact that the data was collected from only the nicu setting but the inclusion of 24 interviews and 12 fgds resulted in data saturation again data collection from different settings could have enriched the findings some of the family data were collected in local languages and translated into english with the assistance of a language expert this may have resulted in some data loss conclusions familycentered care is shared decisionmaking and respect between the clinicians managers and families using a multidisciplinary approach and education to prioritize the provision of quality neonatal care regardless of the persons sociocultural background interventions such as emotional support via counselling by a certified clinical psychologist regular information from staff and funding support from the government may help families cope with the nicu phase of care and build their confidence for continuity of care future research should apply multiple methods to study fcc in different settings of child health practice to help harmonize best practices for improved child health and family outcomes of health ghs ghana health services hefra health facilities regulatory authority who world health organisation abbreviations fcc familycentered care ipfcc institute of patient and familycentered care icu intensive care unit chn community health nurses nicus neonatal intensive care units fgds focus group discussions moh ministry competing interests the authors declare that they have no competing interest • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year

background families whether at home or at the hospital should be a vital part of newborn care however most families are excluded from hospital care particularly in neonatal intensive care units nicus this is incompatible with the concepts of familycentered care fcc and may compromise care continuity and family satisfaction following discharge from neonatal intensive care facilities the purpose of this study was to examine fcc practices in ghanaian neonatal intensive care units and provide the experiences and contextual practices of fcc from the perspectives of families and cliniciansthe study qualitatively examined the contextual practices of fcc from the perspectives of families and clinicians in neonatal intensive care units using an exploratory descriptive design with the help of maxqda software 36 transcripts were generated and their contents were analyzed results contextual practices of fcc family experiences of fcc and clinician experiences of fcc emerged as three main categories from the data respect and dignity culture and religion and a multidisciplinary approach were the contextual practices emotional stress lack of information and coping strategies were all common family experiences support counseling education and financial problems have all been experienced by clinicians conclusions shared decisionmaking counseling and education as well as respectdignity amongst clinicians managers and families using a multidisciplinary approach are the fundamental concepts of fcc approach in ghana acceptance and integration of fcc approach into neonatal intensive care units may reduce the burden of care as well as improve the quality of care further studies are needed to map out strategies and interventions for the integration of fcc into intensive care units

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public expenditure in higher education this reduction in funding has had a farreaching effect on the quantity and quality of research in most african universities the virtual lack of research has serious implications on the role of the university which is characterised by disciplinary specialisation and basic research which means public universities in africa are increasingly losing out on their role as producers and disseminators of researched knowledge for the development of their countries résumé avec quelques exemples précis tirés duniversités kenyanes cet article passe en revue le rôle de luniversité africaine post indépendance dans la recherche et le développement et leffet du néolibéralisme et le financement de ces activités it a été établi que depuis leur création pendant lère coloniale la mission académique des universités en afrique était essentiellement celle des universités partout dans le monde enseigner et faire avancer la connaissance par une recherche désintéressée et maintenir des normes denseignement à un niveau qui pourrait clairement être mis en relation avec ceux établis dans dautres pays suite à la réalisation des indépendances les universités furent désignées sous le vocable « universités de développement » ce qui voulait dire quil était attendu delles dentreprendre la recherche et de participer au développement de leur pays respectif la plupart des universités essayèrent de diverses manières damener plus loin lidée de luniversité de développement mais du fait de structures internes inhérentes ainsi que du climat politique prévalent celleci manqua démerger en tant qu « université de développement » cependant de tels défis à luniversité de développement ne réduisirent pas le rôle central des universités africaines dans la recherche et le développement il est demandé aux universités africaines comme aux autres partout dans le monde de répondre à une variété de besoins et de remplir beaucoup dobjectifs et ceci nest une question de demande externe mais lengagement multidimensionnel enraciné dans les traditions des universités ellesmêmes et de la profession académique il est démontré que lidéologie néolibérale qui exigeait un retrait significatif de letat de loffre social à travers des réductions drastiques des dépenses publiques dans lenseignement supérieur cette réduction dans le financement a eu des effets profonds sur la quantité et la qualité de la recherche dans la plupart des universités africaines le manque de recherche virtuel a une sérieuse implication sur le rôle de luniversité qui est caractérisé par la spécialisation disciplinaire et la recherche de base ce qui veut dire que les universités en afrique perdent de plus en plus sur leur rôle de producteurs et disséminateurs de connaissances de recherche pour le développement de leurs pays introduction the early african universities in both the anglophone and francophone africa were designed to train the elite for leadership and to provide breadth and depth rather than narrow professional training however the purpose of these universities was essentially that of universities the world over to teach and advance knowledge by disinterested research and to maintain high standards of teaching at a level which could be clearly related to those universities established in other countries many of the universities were therefore established as small elite institutions for training highclass personnel with independence universities in africa were perceived to have responsibilities which were in many ways different from those of the universities in europe and north america on which they had been modelled and an interpretation of these roles and related issues were expected to be characteristically different such universities and others which were established later were designated as development universities which meant they were expected to undertake research and participate in the development of their respective countries these expectations stressed the key responsibility of the university as one of serving its society in direct immediate and practical ways that could lead to the improved wellbeing of the national populace although the development universities appeared to be the popular expectation of universities in africa leading african scholars highly questioned the capacity of universities to undertake the development role especially since structurally virtually all of them were based on one or more western models the use of foreign languages as primary media of instruction as well as instructional materials among others in addition while there had been some changes in curricula they were still largely based on assumptions about knowledge from the north despite such challenges many of the universities in africa tried in a variety of ways to further the idea of the development university in varying degrees of imagination and conviction they embarked on efforts to enhance the social relevance of what they were doing in many areas of study however research is showing that the neoliberalisation ideology which favours free market economics and advocates for privatisation marketisation and performance as well as the shift of the cost of higher education from the state to the individual is having a major effect on the traditional roles of universities and their management practices with some specific examples from kenyan universities this paper reviews the role of the postindependence african university in research and development and the effect of neoliberalism and the funding on these activities role of african universities in research and development as pointed out above since their inception in the colonial era the academic purpose of universities in africa was essentially one of teaching and advancing knowledge by disinterested research and to maintain standards related to those established in other countries it is in that context that the early university colleges in the anglophone countries except for fourah bay college which was already associated with the university of durham the level to be reached in degree examinations had to be explicitly related to international standards through the special relationship established with the university of london nairobi for example was established in 1956 as the royal technical college in conjunction with that university this arrangement which was based on collaboration between university colleges in africa and foreign universities in syllabuses and examinations was expected to ensure that examinations and standards set at the degree level were those set in the foreign universities and led to the award of degrees of those universities with the achievement of independence in the1960s it however became increasingly evident that african universities had social purposes deriving from the influences to which they owed their own existence this was reflected in the universities attitude towards education as a public service and their readiness to undertake extramural responsibilities in subjects of study or those special aspects which seemed peculiarly relevant to an african context or even in the levels at which courses could be offered such as lectures in african studies which were attended by all undergraduate students in some universities furthermore a majority of the universities in africa were essentially public institutions created and maintained by national governments and planned to serve the needs of the nation rather than those of particular groups in the society unlike western and american universities african universities were expected to be instruments for change of the existing order and not to preserve it in some countries where they had been closely associated with the nationbuilding mission of the governments universities were regarded with considerable affection as well as esteem among the early influences on the emergence of postindependence african universities role was the tananarive conference on the development of higher education in africa of september 1962 under the auspices of unesco and the united nations economic commission for africa which played a complementary role to the conference of african states on the development of education in africa held in addis ababa ethiopia in may 1961 and had placed priority on the expansion of higher education the tananarive conference in particular addressed the role of higher education in the development of african countries in the context of cultural social and economic fields noting that apart from teaching and research functions higher education institutions had to assist in the building up of african nations as well as the unification of the continent the report stressed that in order to accomplish these tasks african institutions of higher learning should not become ivory towers detached from the society in which they are situated but must contribute to national unity within the states they serve another important influence on the development of higher education in africa especially towards the achievement of independence was the report of the ashby commission on postsecondary education which emphasised that higher education was a national investment and established links between high education and economic development the report recommended substantial expansion of higher education systems and the specific introduction of manpower planning as the rationale behind african educational planning this was in tandem with the national aspirations of newly independent nations and the process of expansion was taken up on a large scale the exhortation that universities in developing countries in general and africa in particular were to be demonstrably relevant for and totally committed to national development became so incessant and allengulfing that it saturated all speeches studies debates and discussion about these institutions one of the most eloquent exhorters of the role of the african university was the former president julius nyerere of tanzania in one of his speeches he said the university in a developing society must put the emphasis of its work on subjects of immediate environment to the nation in which it exists and must be committed to the people of that nation and their humanistic goals…we in poor societies can only justify expenditure on a universityof any typeif it promotes real development of our people…the role of a university in a developing nation is to contribute to give ideas manpower and service for the furthering of human equality human dignity and human development these perceptions in part gave rise to the notion of the development university in which universities were expected to undertake research and participate in development projects in the rural areas the development university was widely held by a set of expectations concerning the distinctive and practical role in the task of national development these expectations stressed the singular responsibility of the university for serving its society in direct immediate and practical ways that could lead to the improved wellbeing of the national populace although universities were to continue improving the relevance of teaching and research and contribute to human resource development their role should however go beyond these traditional functions to incorporate an expanded sense of social responsibility and policy relevance and to adopt new forms and purposes for their realisation universities were to take responsibility for such things as increasing food production addressing poverty of rural populations advising governments on house construction as well as social engineering to improve ethnic balance and national integration the new touchstones of university quality were its vocational and service contribution and its social commitment to demonstrate the intricate relationship between the state and universities and the implications for national development several governments attached the name of the nationstate to their universities for example the university of malawi university of zambia university of sierra leone and others however as mazrui pointed out the expectation that african universities should serve as major instruments of development in their societies by producing highlevel human resource relevant research and training appropriate skills and become potential innovators seemed to ignore some fundamental ethos and values underlying their foundation for example there were some elements of academic dependency on the northern institutions which were unmistakably clear he pointed out that structurally virtually all african universities in subsaharan africa were based on western models and use western languages as media of instruction relevant curricula to a large extent were still based on assumptions about knowledge copied from the north while aspects of international subject matter could be embraced specifically indigenous subject matter could only have very little place in terms of materials many universities relied overwhelmingly on books and materials published in the west while student admission and staff recruitment continued to put a high premium on prior assimilation into western culture despite the heavily embedded western foundation african universities embarked on some efforts to fulfil their new role as development universities in east africa for example following the establishment of the university college dar es salaam in 1962 the federal university of east africa was established in 1963 consisting of makerere college in uganda and the royal technical college nairobi the expansion of the federal university was driven by the human resource development with the rallying point being rapid growth in higher education especially university education like many other african universities the university of nairobi the oldest in the country tried in a variety of ways to further the idea of the development university in varying degrees of imagination and conviction it embarked on efforts to enhance the social relevance of what it was doing in areas such as an expanded role in extension work and community service a considerable contribution to national policy an effective fulfilment to human resource and development especially with regard to scientific and vocational careers and enhancing of national integration the independent government of kenya in particular placed great emphasis on the expansion of higher education and geared it towards the manpower needs of the modern sector of economic life although this particular task was expected of all tertiary institutions the university of nairobi being at the apex of the education system at the time had to play a major role in the development of the required human resource it took the lead in the provision of qualified persons to man the burgeoning economic and administrative institutions as the oldest and largest university in the country among the university of nairobis expected role was the development of outreach and extension activities or programmes on the whole such activities were not widespread although it embarked on increasing access to university education its college of education and external studies at kikuyu launched a wide range of adult and further education programmes through its regional extramural centres in the provincial towns of mombasa kisumu kakamega nyeri embu and nakuru and lately they have become colleges and campuses of the university furthermore to increase relevance and address among the main concern that university students graduate from the university knowing practically nothing about the intricate political and social structures of their own communities it established the institute of african studies to offer courses and programmes in culture and development the promotion of african culture and related activities were not confined to the student body within the university but included their responsibility for helping to promote a cultural awakening among the people or communities a purpose which is served best by considerable expansion of the normal range of extension or outreach activities although this was a function which falls outside the universitys customary responsibilities a number of the university schools faculties and departmentsinstitutes have embarked on extension or outreach programmes with adult groups as a way of promoting a cultural awakening with communities and enhancing nation building as well as furthering their education through classes and study groups in many cases the target groups have included an effort directed towards the vast majority who live and work on the land as well as the slum dwellers in the urban areas despite such efforts the university of nairobi did not fully live up to the expectations and ideals of the development university partly due to a number of factors first was the lack of training among the bulk of teaching force to teach development studies followed by the inherent conservatism regarding structural change and the functional overload because most of the new developmental functions had to be performed by the same academic staff as the traditional functions of teaching and research second for a long time there was a strong mistrust between the university and the national political leadership emanating from the notions of academic freedom and institutional autonomy which were hardly appreciated by the latter the kenyan regimes overriding concern for stability and its own survival at the time heightened its inherent suspicion that the university was the main or potential source of hostile criticism and serious opposition such suspicion seemed to be increasingly confirmed by events of the time there were widespread student and academic staff challenges to the regime during the late 1960s and 1970s which only strengthened its mistrust of the university as a base of opposition and discontent this contributed to a greater questioning of the fundamental purpose of the university and deeper penetration by the regimes into the vital areas of decision making previously within the realm of university autonomy the prevailing climate of caution and fear coupled with the general belief that the regime had informants in most classes prevented the emergence of a critical function of the university of nairobi as development university however such challenges to the concept of development university did not diminish the central role of the african universities in research and development much is expected of universities of the twentyfirst century in all counties african universities like others the world over are required to respond to a variety of needs and fulfil many at times incompatible aims and this is not a matter of external demands but of the multifaceted commitment rooted in the traditions of the universities themselves and of the academic profession an excellent example of how universities especially in developing countries find themselves pulling in all different directions came from a speech given by thabo mbeki the then president of south africa to the association of commonwealth universities the theme of his speech was the need for the revival of the african university to underpin the regeneration of africa it was noted that our entire continent remains at risk until the african university in the context of a continental reawakening regains its soul the new africa can only be a product of the creative interface between the public private and civil sector domains at the centre of this interface is education smith it is further noted that the system of education is to furnish society with a steady stream of citizens of vision and commitment it is not expected to be an enclave or an ivory tower whose curriculum has little relevance to the society in which it operates as an indian minister of resource development once noted education or more specifically higher education is the pathway to the empowerment of people and the development of nations knowledge generation has replaced ownership of capital assets and labour productivity as the source of growth and prosperity innovation is the mantra for development this realisation is so pervasive that nations are scrambling to create institutions and organisations that would facilitate the process of knowledge creation knowledge creation requires a network of scholars actively engaged in its pursuit because the search for the unknown is a product of engaged minds constantly challenging the known in an enabling environment the modern university is the ideal space for the ecosystem of scholars to search for new ideas in a spirit of free inquiry the positive contribution of tertiary education is increasingly recognised as not being limited to middle income and advanced countries because it applies equally to lowincome countries as it could help them become more globally competitive by developing a skilled productive and flexible labour force and by creating applying and spreading new ideas and technologies a world bank study on how to accelerate economic growth in subsaharan africa spelt out the crucial contribution of tertiary education in supporting development it observed that the key for success in a globalised world increasingly lies in how effectively a country can assimilate available knowledge and build comparative advantages in areas with higher growth prospects and how it can use technology to address the most pressing environmental challenges higher level institutions in subsaharan africa that are equipped to provide quality education and conduct relevant applied research can play a key role in producing workers with skills to assimilate technology and make effective decisions that help industry to diversify into a broader range of products good quality and relevant tertiary education is also key to stimulating innovations to produce new varieties and new materials and to develop sources of energy which can facilitate progress towards reducing poverty achieving food security and improving health another world bank study further noted that within the tertiary education system research plays a critical role in training professionals highlevel specialists scientists needed by the economy and generating new knowledge in support of the national innovation system neoliberalism and state funding of higher education in kenya with regard to funding during the era of the development university in kenya as in other parts of africa the university was viewed as the key engine which powered african development and hence the levying of fees was perceived as an unnecessary obstruction to that process for many african governments economic transformation of the continent was to follow from university education as a result after the achievement of independence in 1963 public higher education in kenya has been free with public expenditure covering tuition and students living allowances development costs instruction and research needs the rationale for such state subsidies of higher education especially tuition was based on among other things on the countrys desire to create highly trained personnel which could replace colonial administrators as well as ensure equity of access it was reasoned that unless the state subsidised the high cost of higher education many students would not be able to benefit from it and therefore the creation of highly qualified human resource would be seriously compromised in this regard from independence in 1963 to 1974 was the era of free higher education and its financing as part of public expenditure in addition the government met tuition fees and provided other allowances for students however as from the midseventies the kenya government went ahead to introduce its first attempt at infusing cost into its public higher education through a student loan scheme which was rolled out in the 197475 academic year as part of the 197478 development plan the loan scheme was introduced within the context of a free higher education which was however coupled with increasing student numbers that rose from 571 in 1964 to 3563 in 1973 and the economic difficulties the country has been experiencing since the early 1970s caused partly by the rising oil prices in 1973 it was noted that the economy declined from a gdp growth rate of more than 8 per cent annually between 1963 and 1972 to 4 per cent annually in the following year the student loan scheme was the first governments attempt to transfer the cost of higher education to students and their parents although the loans were meant to only cover personal expenses such as accommodation meals textbooks and stationery travelling and other effects while the government continued to fully fund tuition and capitation however while higher education generally remained tuition free the loan scheme heralded the advent of costsharing not only in higher education but in other sectors of education as well the loan scheme was generously administered as obtaining it was automatic the socioeconomic background of the applicant did not seem to matter much the kenya governments shift in the funding policy in higher education seemed to coincide with extensive research findings on the contribution of education to economic growth its costs and economic benefits and rates of return on the basis of such research as woodhall points out that the highest rates of return are usually for primary education followed by secondary education with higher education apparently being the least profitable investment in terms of social return such a conclusion had farreaching effects on some key international funding institutions the world bank for example in its paper financing education in developing countries made some key recommendations which included recover the costs of higher education through user fees and reallocate these resources to the primary level develop a credit market in higher education and decentralise the management of schools and encourage private and community schools in order to increase competition and generate a demandside push for better quality and efficiency the paper was emphatic that the funding arrangements at the time contributed to a misallocation of resources devoted to education because higher education was the relatively less socially efficient this position greatly contributed to the shift in donor priorities away from higher education to primary education leading to more extensive costsharing in higher education especially through the introduction of increases in tuitions and the use of student loans as opposed to grants and scholarships it was further reasoned that the argument that individual students or graduates should finance a greater share of the costs of higher education and that the share of the state should be reduced did not solely depend on the rate of return analysis it is shown that many studies had concluded that high dependency on state funding were simply unsustainable considering the competing demands and the often declining budgetary expenditure in many african countries in addition there were also powerful equity arguments in favour of changing the balance between public and private finance as participation in higher education was far much greater for children who came from upper income families especially from urban areas who have access to high quality secondary education than children from the poor disadvantaged rural areas it was noted that continued state financing was exacerbating inequalities in the world banks policy on education in subsaharan africa in particular made a number of recommendations which were supposed to improve both the internal and external efficiency of higher education in africa they included increasing student and staff ratios expanding access for parttime feepaying students and assigning to nonpublic sources the full cost of housing food and other welfare services provided to staff and students as well as expanding opportunities and improving quality by privatising institutions and functions however a more farreaching recommendation was the one on costsharing or cost recovery in particular african governments were called upon to relieve the burden of public sources of financing higher education by increasing the participation of beneficiaries and their families this paper was key in setting a stage for major adjustments in public university education in subsaharan africa the higher education paper seemed to be a reinforcement of the previous paper as it was noted that the extent of government involvement in higher education had far exceeded what was economically efficient as it had become a burden to the public finance in this regard countries were called upon to adopt policy reforms that could lower public costs to higher education which included costsharing and government withdrawal from meeting capital and recurrent expenditures in this regard the kenya governments shift in the financing of higher education since the early 1970s reflected the broad international thinking it was in tandem with neoliberal economic ideology which deemphasised government intervention in the economy and a belief in progress through markets or deregulation rather than state control liberalisation of trade and capital movement and privatisation of public enterprises and others this was made quite explicit in the following statement …the central thrust of the new policies is to rely on market forces to mobilize resources for growth and development with the role of the central government increasingly confined to providing an effective regulatory framework and essential public infrastructure and social services the government will limit direct participation in many sectors and instead promote private sector activities in emphasising privatisation and marketisation the neoliberal ideology requires a significant withdrawal of the state in social provision through drastic reductions in social expenditure at the same time the world bank pushed through the cost sharing policies in higher education by which parents and students had to assume a portion of the costs of higher education in the early 1990s following the granting of an emergency loan of us 55 million to finance public universities in kenya with the usual characteristic of world bank loans to poor countries some conditionalities were attached to the loan which included the institution of new financing strategies for higher education it actually made specific reference to costsharing in this regard the world bank effectively prescribed reduced funding by government to the higher education sector and the introduction of costsharing which meant that due to the world bank loan conditionalities as well as other related factors such as the poorly performing economy and implementation of structural adjustment programmes the kenya government was literally forced to shift its education financing by reducing its expenditure to higher education the government had therefore to depart from its own previous form of costsharing initiated in 197475 which did not include the payment of university fees and introduced a direct form of university fee payment as part of the costsharing strategy beginning in the 199192 academic year the new cost policy required parents and students to cover both tuition and student upkeep this costsharing policy also witnessed the abolition of all personal allowances which students had been enjoying it is important to also mention that before the world bank demands to introduce a new costsharing policy the kenya government had been contemplating making changes in the financing of higher education especially the discontinuation of tuitionfree higher education this was first signalled by the sessional paper no 1 of 1986 on economic management which pointed out the need to put some tight limit on ministry expenditures which was expected to grow by less than 2 per cent a year of inflation through 198889 the paper particularly identified the ministries of education and health as targets for reduced recurrent expenditures however the governments sessional paper no 6 of 1988 formally abolished tuitionfree higher education several years ahead of new form of costsharing put in place in 1992 it also needs to be pointed out that the change from free higher education to costsharing did not actually signal major financial responsibilities to parents and students the costsharing seemed to go hand in hand with a heavy subsidisation of the system and lowlevel cost recovery heavy subsidies applied to all students admitted through the then joint admissions board which covered among other things tuition and accommodation irrespective of their ability to pay such subsidised students paid around us 229 as tuition fees irrespective of their programme of study at the same time while public universities began levying fees for extra services such as food and accommodation the charges were below the market prices which meant that the government still continued to subsidise these services heavily it needs to be pointed out however that as changes were being effected in the state funding in higher education the insatiable demand for it in the country continued to grow as most public universities enrolled more and more students well beyond their capacities the government did not seem to respond to the situation with increased funding but instead embarked on a policy of financial cutbacks for example as a percentage of gross domestic product public funding of higher education averaged 094 per cent between 1996 and 2000 and declined to 074 per cent from 2001 to 2005 for the individual public universities in particular this meant that for the university of nairobi the decline from 1998 to 2005 was from 70 to 39 per cent while kenyatta university declined from 67 to 50 per cent as a result of the states insufficient allocations many of the public universities were in a state of financial crisis from the 1990s through 2000s the type of costsharing implemented by the kenya government which ensured minimal financial contribution by students seemed to exacerbate the crisis consequently most of the public universities could not meet their financial obligations and continued to pile pressure on the government to increase its expenditure on higher education in response to the universities persistent pressure for more funding the government began admonishing them to turn to other sources to meet their costs such as learning and research as well as capital development expenditure through policy papers the government exhorted public universities to seek more funding from markets and related sources for example in the master plan 1997 to 2010 public universities were called upon to develop nonpublic sources of their revenues including incomegenerating activities such as returns from research and consultancies with industries and employers services to the community agrobased production manufacturing for the market including making equipment for use in schools hiring out university facilities grants and donations from nongovernmental organisations and wellwishers and funding from alumni associations hence the government pointedly discouraged public universities from solely relying on public sources and the nominal fees they charged governmentsubsidised students research activities and output as already discussed among the key roles of african universities was the need to develop and promote knowledge through teaching and research in this regard it was an important function of universities to analyse interpret and explain the prerequisite conditions which would enable a society to rise to a higher quality of life for all its members african systems and institutions have the crucial role of knowledge generation synthesis adaptation and application to ensure the advancement of the national interest on all fronts be they economic social cultural as well as political central to such knowledge systems are the universities and their research and advanced training programmes africas universities continue to provide the bulk of their research and the training of virtually all key echelons of personnel admittedly alternative sites for the generation and adaptation of knowledge are emerging and assuming prominence in public research institutes private research centres firmbased research units regional and subregional centres nongovernmental organisations and so on however the trend is only beginning and has yet to pose a serious threat to the dominance of the universities as the core of knowledge generation reproduction and dissemination system in africa in this regard the strength of african universities and their research institutions is a key condition for the continents development hence the formulation of appropriate policies and mobilisation of the necessary resources in the support of universities research institutions has remained a key factor in development on the whole since independence in the early sixties most african universities have given a lot of prominence to research as a key function taking the example of the university of nairobi from the outset it placed itself as an important centre of research by establishing some institutions which focused mainly on research for instance the faculty of education at kenyatta university college then a constituent college the university had the responsibility of training all undergraduate and postgraduate students in the country one of its key departments was the bureau of educational research which had the explicit task of conducting and promoting educational research in addition the bulk of academic staff in the university obtained their first degrees in the university of east africa with its constituent colleges at makerere dar es salaam and nairobi and followed with masters and doctoral work at a diverse array of schools and departments abroad as well as at nairobi it was however noted that while the university at the beginning encouraged research as a means of effecting change and demonstrating its relevance in the development of the country the measure of its support for research through financial resources was generally weak although the university of nairobi provided a number of staff establishment positions for the research institutions like the bureau of educational research and the institute of development studies it provided very modest funds for research itself for example by the late seventies the funds in the research vote ostensibly earmarked for allocation by the deans research committee were absorbed into the general running of a financially stricken institution in the face of expanding enrolments and soaring costs university administrators inevitably gave priority to teaching rather than research needs of course the problem of financial resourcing was not entirely that of the university but of the government while the importance of research was very much emphasised in official pronouncements and echoed in the official documents like the development plans the practice was quite contrary to the official rhetoric hence the university was not allocated adequate funds for its key activities the position of the university progressively got worse both in material and goodwill termsfrom 1982 following the failed coup detat of august of that year which students and many academics seemed to welcome when faced with budgetary problems and the reordering of priorities therefore the university administrators made research grants the first casualties whether already allocated or not from the early 1980s the finance officer froze the deans research grants to members of staff this action virtually halted research production by members of the academic staff at the institute of development studies the universitys main centre for the conduct of social science research and one of the leading institutions in this particular area in africa serious research production by individual scholars or by the centre came to a complete standstill giving way instead to consultancies and shortterm contract research the research situation at nairobi was further exacerbated by continued budgetary cutbacks throughout the 1990s during which research virtually ceased being an important component of the institutions except for a few projects largely funded by donor agencies hence kenya like many other african countries ceded the strategic area of research under pressure from the international financial institutions donor community and its weak economic situation the deteriorating economic conditions combined with international donor agencies policy bias against public financing of higher education seriously contributed to the undersourcing of research the underfunding of these institutions has continued since 1990s public or private resources devoted to research and research capacity building have remained inadequate in kenya just like in many other african universities for example the association of african universities study found that by 19931994 none of the responding universities spent up to 4 per cent of their recurrent budgets on research research funding generally ranged between 033 and 378 per cent even then much of the research was funded through donor grants closely related to funding of research activities is the provision research infrastructure such as laboratories equipment libraries and an effective system of information storage retrieval and utilisation these include appropriate management systems and policies which facilitate and support research enterprise including incentives that recognise and reward high calibre research at the same time it is interesting to note that the provision of more revenue through parallel programmes in some universities especially in kenya has ignited an infrastructure construction boom in some of the public universities which had stalled since the 844 construction project in the 1980s due to public funding cutbacks especially for capital development kenyatta university for example has constructed a 5storey postmodern library a new administration block a graduate school centre among other facilities using internally generated resources while nairobi university is constructing a multistorey plaza using similar resources as well as some external support in addition to purchasing some properties for academic use in nairobi the two universities have also used additional revenues to undertake repairs and maintenance of physical facilities which generally were quite dilapidated as a result of underfunding by the exchequer they also now look much neater and better maintained than a few years back but little finding has been tailored towards research however they continue to face some serious challenges with regard to the provision of equipment and specialised teaching and learning resources due to very high student enrolments among other key challenges of the research enterprise in african universities is the management of postgraduate programmes on the whole there are serious weaknesses in postgraduate programmes of most african universities which strongly limits institutional research capacity and development while there is a general lack of relevant data which makes it difficult to confirm the actual numbers of postgraduate students in the various universities the association of african universities mentioned above found out that in the early 1990s the proportion of graduate students out of the total enrolment at the responding institutions was between 7 and 1 per cent at a francophone university with enrolment exceeding 40000 students at the university of nairobi for example postgraduate research also became a casualty of government financial cutbacks in higher education in the early 1980s both the government and university suspended funding postgraduate students the government also followed by scrapping scholarships for graduate studies the main effect of these decisions was to change the nature of the postgraduate programmes in the revenue earning faculties and schools the withdrawal of state funding of postgraduate education left only two alternatives for faculties and schools which wanted to initiate them they were either to turn to donor support to continue with researchbased postgraduate programmes or launch course workbased postgraduate degrees which required no research and could be funded on the basis of tuition from feepaying students the general trend has been that only a few strategic departments and units can secure donor funding to continue with researchbased postgraduate programmes however most faculties and schools opted for nonresearch postgraduate programmes the nonresearch programmes are intended to meet the market demands in addition the increasing number of postgraduate students poses a major challenge of supervision given the limited number of qualified staff the poor state of postgraduate programmes is a reflection of their underfunding as well as poor research content the graduate stipend was withdrawn in most institutions and where it is still provided it is not enough to support fulltime study while the job market to a large extent does not adequately reward advanced study apart from the failure to ensure the training of adequate teaching staff the inadequate numbers of graduate students at any one time in any institution implies not only the absence the natural foot soldiers of any research enterprise but also a severe shortage of potential teaching assistants required to help the release of more of the time for senior faculty staff for undertaking research however while the university of nairobi and other public universities in kenya have put in place research policy documents which places considerable emphasis on the role of research for development and established units for coordination of research work as well as establishing the office of the deputy vicechancellor in charge of research innovation and outreach what seems unclear from such research policies is how resources will be mobilised to implement them as continued reliance on the government makes such lofty plans a pipe dream although these universities are commended for making efforts to generate funds for research locally the funding has generally remained inadequate in comparison to their expenditure on infrastructure development the university of nairobi for example was recently reported to have raised around 8 billion kenya shillings for research in the last ten years and has undertaken a good number of research projects with the help of donor funding part of the key research challenges is not only the nonavailability of resources but also the lack of the research culture among the academic staff a vicechancellor is on record to have observed that despite the considerable amount of ongoing research at the university of nairobi most academic staff seem to view research largely as a vehicle for upward mobility on the academic ladder consequently often after one has been promoted to the level of full professor there appears to be reduced interest in research and publications due to lack of incentive for it as munene and otieno have pointed out kenyan universities shift towards lowcost highdemand teaching programmes puts at risk a fundamental role of universities in knowledge production through a culture of quality research this is a serious threat to the reputation of these institutions this is because as the demand for twining academic programmes to the labour markets immediate requirements increases and as government subsidies to public universities continue to dwindle the temptation to expand this type of knowledge production will continue to be irresistible the implication of this is that the countrys public universities will be failing increasingly in fulfilling their role as producers and disseminators of research knowledge this is because budgetary allocations for research both internally and externally have declined considerably and undertaking research is no longer considered to be a key function in the operations of public universities in the country summary and conclusion with some specific examples from kenyan universities this paper has reviewed the role of the postindependence african university in research and development and the effect of neoliberalism and the funding on these activities it was established that since their inception in the colonial era the academic purpose of universities in africa has remained essentially the same with other universities the world over namely to teach and advance knowledge by disinterested research and to maintain standards of teaching at a level which could be clearly related to those established in other countries following the achievement of independence universities were designated as development universities which meant they were expected to undertake research and participate in the development of their respective countries these expectations stressed the key responsibility of the university as an institution serving its society in direct immediate and practical ways that could lead to the improved wellbeing of the people most african universities tried in a variety of ways to fulfil this notion of the development university however due to inherent internal structures as well as the prevailing political climate they failed to emerge as development universities however such challenges to the development university did not did not totally eradicate the central role of the african universities in research and development much is expected of universities of the twentyfirst century in all countries african universities like others all over the world are required to respond to a variety of needs and fulfil sometimes incompatible objectives and this is not a matter of external demands but of a multifaceted commitment rooted in the traditions of the universities themselves and of the academic profession the paper further demonstrates that the neoliberal ideology was responsible for the significant withdrawal of the state in social provision through drastic reductions in social expenditure including the funding of education this has contributed to a drastic reduction in public expenditure in higher education the reduction in funding has had a farreaching effect on the quantity and quality of research in most african universities this virtual lack of research has a serious implication on the role of the university it means that public universities in africa are increasingly losing out on their role as producers and disseminators of researched knowledge for the development of their countries

with some specific examples from kenyan universities this article reviews the role of the postindependence african university in research and development and the effect of neoliberalism and funding on these activities it was established that since their inception in the colonial era the academic purpose of universities in africa was essentially similar to that of universities the world over to teach and advance knowledge by disinterested research and to maintain standards of teaching at a level which could be clearly related to those established in other countries following the achievement of independence universities were designated as development universities which meant they were expected to undertake research and participate in the development of their respective countries most african universities tried in a variety of ways to further the idea of the development university but due to inherent internal structures as well as the prevailing political climate it failed to emerge as a development university however such challenges to the development university did not diminish the central role of the african universities in research and development african universities as others the world over are required to respond to a variety of needs and fulfil many aims and this is not a matter of external demands but of the multifaceted commitment rooted in the traditions of the universities themselves and of the academic profession this article demonstrates that the neoliberal ideology which required a significant withdrawal of the state in social provision through drastic reductions in social expenditure which includes education contributed to drastic reduction in

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introduction oral health disparities are a significant public health concern particularly among tribal populations 1 these disparities are influenced by a range of factors including limited access to dental care cultural beliefs poverty and lack of oral health education addressing these disparities requires a multifaceted approach that takes into account the unique needs and circumstances of the tribal population 2 in this context a combined implementation of focus group discussion mobile technology networking and creating a supportive environment is an effective strategy that can improve oral health outcomes among the tribal population by identifying the population and their oral health needs developing an oral health promotion program implementing the program through a communitybased approach and creating a supportive environment this strategy can help participants adopt healthy oral hygiene habits and adhere to oral health recommendations 3 this approach has the potential to improve the oral health of tribal populations and reduce the oral health disparities that exist within these communities 4 regular evaluation of the program is also essential to ensure its effectiveness and sustainability literature has data on the oral health status of various tribal communities in india 5 6 7 but none exist on the gond tribes in the raisin district area these represent a sect who are isolated from the hustles of city life health education interaction done at a single point and by a socratic approach cannot effectively retain the learned behavior fgd is a form of research methodology that brings together a group of people to respond to questions in a moderated environment it will give them a chance to put forth their views and problems and help bring in suitable solutions this form of discussion is totally different from that of mass education wherein the health educator only speaks and there is minimal or literally no interaction at all mobile phones are extensively used even in remote areas of community dwellings presenting short messages in mobiles on a regular basis will further reinforce what was discussed during fgd making healthier choices the easier choices is the baseline of creating supportive ecology in health in our context it was achieved by educating the tribals about appropriate use of indigenous oral hygiene aids generally changes in oral health bought after interactive sessions are subjectively measured which always has a hidden element of bias this study is the first of its kind that assesses oral health changes brought about by the combined implementation objectively by reliable quantitative indices thus eliminating any errors hence the present study was undertaken to answer the research question is there an improvement in gingival and oral hygiene status after implementing the combined model of fgd mobile networking and creating a supportive environment using indigenous oral hygiene aids in a tribal population materials and methods the study design was a communityled trial using a convergent parallel mixed method model ethical clearance to conduct the study was obtained from the institutional ethical committee of peoples college of dental sciences and research centre bhopal informed consent from all 100 tribal volunteers was taken after explaining the study details confidentiality of every subject was maintained sample size and technique a convenient sampling technique was employed to recruit the study participants random recruitment was difficult in our study as we needed participants who were willing to actively participate and respond in a group convenience sampling is a nonprobability sampling technique commonly used in pilot studies and exploratory research the researcher selects participants based on their convenience or proximity to the research setting a total of 100 tribal volunteers were chosen for the study the study population was recruited from village habitats of tribes in raisin district madhya pradesh a set of 10 fgd teams were made with 10 in each group the samples were conveniently chosen after checking for their eligibility criteria eligibility criteria participants between 18 and 45 years of age of both genders who remained in their tribal habitats throughout life were recruited the respondents were chosen only when they were willing to participate in fgds and engage with mtn three examiners who were calibrated for codes and criteria of the indices conducted the clinical examination the kappa score showed an interexaminer reliability of 087 and an intraexaminer reliability of 091 suggesting good agreement in scoring the codes method of intervention it included both quantitative and qualitative aspects clinical examinations for the gingival status made up for the quantitative evaluation while fgd was categorized as the qualitative assessment data collection was conducted in three phases the first phase included the evaluation of the gingival status of all included participants through gingival indices the second phase constituted regular and systematic fgds and mobile networking fgd was conducted by the examiners who performed clinical evaluation in the last phase gingival health status was reevaluated quantitative phase or oral health status examination or first phase gingival and oral hygiene status outcomes were measured using the gingival index 8 and oral hygiene indexsimplified 9 the gingival index was scored as 0 normal gingiva 1 mild inflammation 2 moderate inflammation and 3 severe inflammation oral hygiene indexsimplified was scored as 0 12 good 13 30 fair and 31 60 poor qualitative phase or second phase participants were categorized into groups of 10 groups were arranged to include similar gender and age ranges for better discussion the facilitator conducted the discussion in the local language to ensure that the participants were comfortable and could express their opinions freely fgd aimed at topics such as oral health habits oral health education access to dental care community oral health oral health and overall health oral health and technology these questions and concepts guided a productive discussion on oral health in a focus group setting the themes or topics of fgd were put forth to all groups and open discussion was encouraged for a session of 45 60 minutes discussions were done regularly at monthly intervals for a period of three months a social media platform group was also formed of all the participants subsequently videos related to oral health and appropriate oral hygiene practices were shown and shared with all via mobile phones following the fgd session demonstration of appropriate use of indigenous oral hygiene aids such as datun sticks and plain mouth water rinsing were taught by the authors the collected data were analyzed using ibm spss statistics for windows version 25 oral hygiene levels and gingivitis before and after intervention were measured by applying the paired ttest at p 005 results all 100 study participants completed the intervention fgd was conducted twice in the threemonth span the mean age of the participants was 3604 1011 years a clear female predilection was noted the majority of them were into agricultural farming followed by poultry and craft work it was observed during the study that participants were enthusiastic and keenly interacted with the facilitator table 1 enlists the various sections of fgd the questions in each section and the themes deduced from the discussion 938 of the sample felt that oral health was not related to general health suggesting poor dental health awareness oral hygiene practices in the family did not differ between its members neither technology was not thought to improve oral health nor the significance of diet was known to the study respondents the tribal population was clueless about mental health awareness and its relation to oral health each theme of fgd was elaborately discussed and the main deduction was noted down fgd identified that oral health awareness was compromised in the tribal sect evaluated overall tribals were not well aware of oral health and the factors associated with it themes deductions oral hygiene habits half of the population used twigs and neem sticks to clean their teeth a negligible portion used a toothbrush and paste oral health education oral hygiene practices were learnt from family members in all the participants though mobile phones were used commonly they did not influence their knowledge or practice of oral hygiene access to dental care there was no access to dental care in their habitats distance and cost were the major reasons for avoidance of dental treatment community oral health the importance of oral health was not considered at par with general health by 938 of the tribal population challenges to oral health elderly members complained of compromised mastication and nutrition due to edentulousness young adults and females were more concerned about aesthetics oral health and technology none of them thought technology could be used to improve oral health oral health and diet none in the target population were aware of the role of diet in improving oral health role of mental health in oral health role of sound mind in maintaining their oral health was first heard from the facilitator of fgd table 1 themes and deductions of fgd fgd focus group discussion table 2 presents the findings of oral hygiene practices in tribal samples fiftyfour percent of the population used neem sticks and datun to clean their teeth and only 21 used toothpaste charcoal was also used in 13 this suggests that oral hygiene practices of the tribals were subpar thirtyseven percent of the study sample brushed lesser than once daily while a majority brushed once a day thus highlighting the lack of appropriate oral hygiene practices discussion the present study was conducted on 100 gond tribal volunteers of the raisin district and is the first of its kind it was noted that 54 of the sample used neem twigs for oral hygiene maintenance suggesting decreased accessibility to oral health care products knowledge levels regarding dental health were also lesser with only 21 of the population using toothpaste a definite improvement in gingival health was noted with the decrease in both oral hygiene indexsimplified and gingival index scores suggesting the effectiveness of the combined intervention strategy fgd aimed to understand the oral health knowledge attitudes beliefs and practices of the population fgd was facilitated in the local language to ensure that participants were comfortable and could express their opinions freely a volunteer from their habitat during fgd helped us to easily integrate the program into the community the use of mtn was integrated into the program to ensure that the participants received ongoing support and reminders practices such as appropriate use of datun sticks and mouth rinsing with water after every meal remains crucial to sustaining oral health promotion by creating a supportive environment participants are more likely to adopt healthy oral hygiene habits and adhere to oral health recommendations the findings from this study might help in the development of an oral health promotion program that addresses the specific needs of the population our study reported that greater than half of the population used neem sticks and twigs to clean their teeth the study by asif et al reported similar findings with only 22 of koya tribes and 3080 of lambada tribes using toothpaste and a good number using sand and charcoal 7 similar outcomes were observed in the rural population of the gambia in west africa by jordan where a large proportion of people utilized chew sticks and toothbrushes 10 in contrast naheeda et al observed that the majority of the population used a toothbrush and toothpaste and brushed their teeth once per day in their study conducted among tribals of the khammam district 11 considering the economic constraints of this population a simple toothbrush and paste were also difficult to afford by most of them for those who were already using a toothbrush and paste they were strongly encouraged to follow the same the sect of the population who could absolutely not afford was taught the rightful usage of neem sticks and datun ohi s ratings reduced from fair to good which was significant at p0000 the positive change in oral health bought by the combined strategy can be well appreciated as the study design in itself is novel we could only compare our prefgd with existing literature prefgd scores of ohis were in accordance with the study by asif et al who also reported fair score for koya and lambada tribes 7 this is also in concordance with tribals residing in telangana 12 kumar et al showed 570 of their study respondents showed poor oral hygiene the oral health disparities of the tribal population can be attributed to various factors such as limited access to dental services lack of oral health education poverty and cultural beliefs 13 seeking prompt dental treatment and proper oral hygiene practices enhances oral health improving oral health can have a significant positive impact on oral healthrelated quality of life 14 while the combined implementation is an effective strategy to address oral health disparities among tribal populations there are some limitations to this approach one limitation is the availability of resources to implement the program the implementation of this approach requires significant financial material and human resources which may not be available in all settings additionally the programs sustainability may be affected if these resources are not sustained in the long term another limitation is the language barrier the approach requires conducting the fgd and providing oral health education in the local language which may be challenging if there is no standard written language or if the language is not widely spoken this limitation can be overcome by employing interpreters or utilizing bilingual staff the approach may also be limited by cultural beliefs and practices that may influence oral health behaviors some cultures may not prioritize oral health or traditional practices may contradict modern oral health recommendations addressing these cultural beliefs and practices requires sensitivity and cultural competency on the part of the program implementers though the combined implementation is an effective strategy to address oral health disparities among tribal populations it is essential to consider these limitations and tailor the program to the specific needs and circumstances of the population the utilization of fgd allowed us to gain indepth insights into the oral health challenges faced by the tribal population it provided a platform for open discussions allowing community members to express their concerns beliefs and knowledge regarding oral health the fgd sessions helped us understand the specific needs and priorities of the community the integration of mtn played a pivotal role in enhancing access to oral health information and services mtn has the advantage of reaching a larger population even those in remote areas it also provides educational materials oral hygiene tips and appointment reminders empowering individuals to take charge of their oral health in fact it can act as a facilitated communication between healthcare providers and community members enabling timely consultations and referrals creating a supportive environment can indeed be a crucial aspect of an intervention aimed at addressing oral health disparities in a tribal population a supportive environment plays a significant role in promoting positive oral health behaviors and outcomes based on the current literature and the experience of implementing the research several recommendations can be made for future efforts in this area • in order to identify service gaps and enhance the efficacy of the strategy it is crucial to frequently examine the oral health needs of indigenous groups periodic surveys focus groups and communitybased participatory research are effective ways to accomplish this • there is a need to expand relationships between public health organizations tribal administrations and academic institutions in order to increase the resources available for putting the strategy into practice • further research on the use of mobile technologies is warranted especially in terms of reaching out to tribal populations that have little access to oral health care this can involve the use of mobile applications for oral health education and support text message reminders and telehealth services 15 • in order to make oral health promotion programs more acceptable to these tribals and culturally suitable it is necessary to incorporate traditional knowledge and practices this can be done by carefully collaborating with local community leaders and healers to incorporate ancient practices into current oral health recommendations conclusions our combined approach of fgd mtn and creating a supportive environment yielded promising results we observed improved gingival health among the intervened tribal population furthermore there was a notable reduction in oral health disparities as evidenced by improved oral health outcomes among the tribal population however it is important to acknowledge that addressing oral health disparities is an ongoing process and there are still challenges to overcome sustaining the interventions and ensuring their longterm impact will require continued support from healthcare providers policymakers and community stakeholders additionally further research is needed to evaluate the longterm effectiveness and costeffectiveness of the interventions as well as to explore other potential factors contributing to oral health disparities in the tribal population additional information disclosures human subjects consent was obtained or waived by all participants in this study peoples college of dental sciences and research centre bhopal issued approval ec202111 the institutional ethical committee in its complete perspective and is of the conscientious opinion that the above study can be conducted without any legal moral or ethical encumbrances animal subjects all authors have confirmed that this study did not involve animal subjects or tissue conflicts of interest in compliance with the icmje uniform disclosure form all authors declare the following paymentservices info all authors have declared that no financial support was received from any organization for the submitted work financial relationships all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work other relationships all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work

background and objective oral health disparities generally exist among tribal populations prompting creative solutions to tackle these challenges by using a combined implementation strategy of including focus group discussion fgd mobile technology networking mtn and creating a supportive environment this study aims to assess and bring positive changes in oral health in these populations methods the current study employed a mixedmethod approach on a sample of 100 tribal volunteers qualitative assessment included fgd conducted regularly for three months based on themes such as oral hygiene habits access to oral health technology in oral health the relationship of oral health to general health and the role of diet in oral health quantitative evaluation included recording of the oral hygiene indexsimplified and gingival index to measure gingival status messages on oral health were routinely posted to mobile phones to reinforce oral health education appropriate use of indigenous oral hygiene aids neem and datun was also taught during the discussion session clinical examinations were compared before and after fgd data were analyzed using ibm spss statistics for windows version 25 released 2017 ibm corp armonk new york united states a paired t test was used to find significant differences in gingival status at p 005 results the fgd sessions deduced observations such as limited access to dental care inadequate oral hygiene practices such as usage of neem sticks and twigs and lack of oral health awareness the implementation of mtn facilitated the dissemination of oral health information and enhanced communication between community members and healthcare providers the gingival index score significantly improved from prefgd to postfgd with a mean difference of 041700 significant at p0000 oral hygiene of the target population shifted from fair oral hygiene status to good oral hygiene statusthe combined implementation of fgd mtn and creation of a supportive environment demonstrated promising results in addressing oral health disparities among the tribal population the interventions led to improved gingival status and better utilization of oral hygiene practices these findings highlight the importance of tailored interventions community engagement and mobile technology in addressing oral health disparities in tribal populations ongoing support sustainability and further research are necessary to ensure the longterm impact and effectiveness of these interventions

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introduction mental health is gaining recognition as one of the priority areas in health policies worldwide and has also been included in sustainable development goals 12 nevertheless most countries globally are exposed to multiple psychosocial stress factors nowadays 3 for this reason mental disorders are a high priority in healthcare as major contributors to the global burden of disability especially in developing countries 45 estimates of the 12month prevalence of mental disorders vary between 274 and 382 in the general european adult population 67 due to the inclusion of new disorders and of new european member states in fact european countries show that they suffer relatively more from mental health disorders than the rest of the world although these may be significantly underdiagnosed in many countries 8 9 10 common mental disorders refer especially to anxiety and mood disorders which are highly prevalent in the global population with a range from 36 to 198 for anxiety disorders 7 11 12 13 and from 54 to 78 for mood disorders 71213 approximately one in five adults experience a cmd yearly and 292 at one point in their lifetime 12 in spain the prevalence of cmd in adults ranges from 16 to 22 14 15 16 cmds not only pose a threat to peoples quality of life but they also pose serious challenges for health systems and entail considerable societal and financial costs 1718 therefore both researchers and policymakers have identified decreasing the prevalence rates of cmd and disability costs as a key priority 7 19 20 21 it seems that the factors associated with a high prevalence of cmd include sociodemographic and economic conditions lifestyle habits and clinical variables 2223 another characteristic which must be taken into account is the gender differences in relation to cmd whereby women are more prone to experience cmd than men in most countries 1224 nevertheless these factors are not the only ones that influence the mental health of individuals 25 which also depends on the environmental context in which people are born are raised and live their lives 26 27 28 in short there is a growing consensus that buildings and the natural and social environments where people live can affect mental health 2829 conversely certain environmental factors such as green areas could reduce stress and exert protective effects against mental disorders 3031 in contrast air pollution and traffic noise have often been linked with poor mental health 32 moreover stressful places such as overcrowded urban areas contribute to psychological stress 28 in addition echeverría et al 33 and barnes et al 34 analyzed peoples subjective perception about environmental problems and how it relates to mental health and concluded that selfreports may be used as a good source of information even when they differ from objective measures in fact selfreport perception of the environment is a more relevant measure of cmd than objectivelymeasured environmental factors since the majority of studies assess environmental factors that could be related to cmds jointly 35 36 37 making it impossible to know how each factor contributes to the presence or absence of cmd the present study aims to investigate numerous different sociodemographic clinical lifestyle characteristics and environmental problems independently and simultaneously in a large representative sample of spanish population the main objectives of the present study were to report the prevalence of cmd among the adult population in spain to analyze time trends from 2006 to 2017 and to explore the associations between cmd and gender in regard to both perceived environmental problems and sociodemographic clinical and lifestyle factors materials and methods study design a quantitative observational nationwide crosssectional study carried out from december 2019 to april 2020 data source and study population data were obtained from the personalized interviews of the spanish national health survey 2006 38 20112012 39 and 2017 40 the snhss are interviewbased surveys of the noninstitutionalized population carried out by the ministry of health consumer affairs and social welfare in partnership with the national institute of statistics the sampling design was multistage probabilistic stratified by census areas family homes and individuals for the purpose of this work we limited our study to people aged 16 to 64 years living in spain the initial sample consisted of 52469 subjects but due to a lack of data for some of the variables studied 3964 individuals were excluded when the descriptive bivariate and multivariate statistical analyses were carried out based on the sociodemographic clinical lifestyle and environmental variables and the presence of cmd the subjects we excluded did not differ systematically from the rest of sample therefore the study was finally based on 48505 participants as follows 19868 in snhs 2006 13798 in snhs 20112012 and 14839 in snhs 2017 variables dependent variable the dependent variable was the presence of common mental disorders this variable was evaluated using the general health questionnaire validated in spain 41 42 43 the ghq12 scored on a likertlike scale from 0 to 3 these answer categories were scored according to the original ghq method 44 with the first two response options having a score of 0 and the last two having a score of 1 in other words in bimodal fashion the points were added up make to a global score ranging from 0 to 12 points the ghq12 scoring method with a cutoff at ≥3 points was used so that the final score is a dichotomized measurement of common mental disorders absence of cmd and presence of cmd the latter being used to indicate risk for psychological distress sociodemographic variables the independent variables such as the sociodemographic variables were year of survey gender age group marital status level of education nationality size of town of residence and employment situation using the international labour organization criteria 45 social class was assigned according to the categories proposed by the spanish society of epidemiology 46 this independent variable was classified into class i class ii athletes and artists class iii class iv class v class vi in this study these six original classes were formed into three groups lifestyle behavior lifestyle behavior included physical activity during leisure time clinical variables the clinical variables were evaluated using a selfdeveloped questionnaire proposed by the spanish ministry of health consumer affairs and social welfare 47 48 49 and included selfperceived health status and limitations due to a health problem for at least 6 months another clinical characteristic was type of chronic disease as assessed by a physician this variable was classified as number of chronic conditions the chronic diseases included in the present study were hypertension myocardial infarction angina pectoriscoronary disease other heart diseases varicose veins in the legs osteoarthritis chronic back pain chronic back pain chronic allergy asthma chronic bronchitisemphysemachronic obstructive pulmonary disease diabetes stomach ulcerduodenum ulcer urinary incontinenceproblems controlling urine high cholesterol cataracts chronic skin problems chronic constipation cirrhosisliver dysfunction depression chronic anxiety other mental problems stroke migrainefrequent headaches hemorrhoids malignant tumors osteoporosis thyroid problems kidney problems prostate problems and menopausal problems social support to collect perceived personal social support information as an independent variable the dukeunc11 questionnaire 50 validated in spain 5152 was used this scale includes 11 items which are scored on a likertlike scale ranging from 1 to 5 the overall perceived social support is obtained by adding the scores of the 11 items the results range from 11 to 55 points the final score is a dichotomized measurement of the perceived social support classified into optimal support and supoptimal support perception of environmental problems this variable was derived from the section problems the person has with the environment of their dwelling 53 54 55 this section includes the following problems noise from outside bothers you bad smells coming from outside drinking water is of poor quality little street cleaning air pollution caused by a nearby industry increased air contamination by other causes lack of green areas presence of animals that could be a nuisance each is problem scored on a likertlike scale from 0 to 2 in addition the number of environmental problems perceived was collected this number was obtained by adding together all the environmental factors ethical aspects the data obtained from these surveys are available on the national institute of statistics and ministry of health consumer affairs and social welfare websites 38 39 40 in the form of anonymized microdata no special authorizations are therefore required for their use according to the snhs methodology the microdata files are anonymous and are available to the public in accordance with spanish legislation when secondary data are used there is no need for approval from an ethics committee the research data are available as a supplementary file statistical analysis a descriptive analysis was performed by calculating the counts and percentages for the categorical variables and the continuous variables by calculating the arithmetic mean and standard deviation differences in the prevalence of cmd within the three time points were compared using the chisquare test for contingency tables or fishers exact test if the number of expected frequencies was greater than 5 linear regression models were used to identify statistically significant trends in the prevalence of cmd sociodemographic clinical lifestyle characteristics and the perception of environmental problems in the period of 20062017 the regression coefficient and the coefficient of determination were calculated to assess the direction average magnitude of the change and performance of the models in addition a logistic regression was performed to identify the variables associated with cmd by gender all variables with a significant association in the bivariate analysis were included in the multivariate analysis crude and adjusted odds ratios were obtained for all sociodemographic clinical and lifestyle habits variables and perception of environmental problems with 95 confidence intervals the wald statistic was used to exclude one by one from the model any variables with a p ≥ 015 all the hypothesis contrasts were bilateral and in all the statistical tests those with a 95 ci were considered significant values the statistical analysis was carried out using ibm spss statistics version 25 results sociodemographic clinical and lifestyle habits variables the study population included 48505 individuals of whom 26462 were women and 22043 were men between 16 and 64 years old the most frequent sociodemographic clinical and lifestyle characteristics of the participants were that they were married spanish and employed belonged to middleclass families had secondary or professional training lived in towns with a population of over 100000 inhabitants had a good selfperceived health status had one or two chronic conditions had not reported any limitations due to a health problem for at least 6 months did physical activity during their leisure time and had normal social support perception of environmental problems according to figure 1 the vast majority of participants had not perceived environmental problems furthermore within those who did perceive them the most common environmental problems were distressing levels of noise from outside the home poor quality drinking water and dirty streets results sociodemographic clinical and lifestyle habits variables the study population included 48505 individuals of whom 26462 were women and 22043 were men between 16 and 64 years old the most frequent sociodemographic clinical and lifestyle characteristics of the participants were that they were married spanish and employed belonged to middleclass families had secondary or professional training lived in towns with a population of over 100000 inhabitants had a good selfperceived health status had one or two chronic conditions had not reported any limitations due to a health problem for at least 6 months did physical activity during their leisure time and had normal social support perception of environmental problems according to figure 1 the vast majority of participants had not perceived environmental problems furthermore within those who did perceive them the most common environmental problems were distressing levels of noise from outside the home poor quality drinking water and dirty streets common mental disorders the overall prevalence of cmd was 194 over the different years of the study the prevalence of cmd was 204 in 2006 208 in 20112012 and 169 in 2017 by gender the prevalence of cmd in women was 245 in 2006 241 in 20112012 and 201 in 2017 and in men was 144 in 2006 174 in 20112012 and 135 in 2017 evolution of sociodemographic clinical and lifestyle habits variables and perception of environmental problems as regards the sociodemographic clinical and lifestyle habits variables of the sample according to the year of the survey a decrease in the number of people who were between 25 and 44 years old was seen there was also an increase in separated or divorced people 2006 63 20112012 76 2017 90 β common mental disorders the overall prevalence of cmd was 194 over the different years of the study the prevalence of cmd was 204 in 2006 208 in 20112012 and 169 in 2017 by gender the prevalence of cmd in women was 245 in 2006 241 in 20112012 and 201 in 2017 and in men was 144 in 2006 174 in 20112012 and 135 in 2017 evolution of sociodemographic clinical and lifestyle habits variables and perception of environmental problems as regards the sociodemographic clinical and lifestyle habits variables of the sample according to the year of the survey a decrease in the number of people who were between 25 and 44 years old was seen there was also an increase in separated or divorced people 2006 63 20112012 76 2017 90 the overall number of environmental problems perceived was 210 in addition it should be noted that there was an increase of participants who did not perceive any noise from outside the home association between sociodemographic clinical and lifestyle habits variables perception of environmental problems and common mental disorders in women the adjusted logistic regression model showed that the probability of having cmd was higher in those who were widowed separated or divorced foreigners unemployed did no physical activity during their leisure time and perceived a low social support in addition the probability of having cmd was greater as the distress caused by noise from outside the home increased as perceived health was worse and the number of chronic conditions increased moreover for each increase in a perceived environmental problem the probability of cmd increased 129 times by contrast the probability of cmd decreased in women who were not limited by a health problem in men the probability of having cmd increased in those who were foreigners unemployed did no physical activity during their leisure time and perceived a low social support furthermore the probability of having cmd was greater as perceived health was worse and the number of chronic conditions increased ≥3 or 170 95 ci 151192 in addition for each increase in a perceived environmental problem the odds of cmd increased 118 times on the contrary the probability of having cmd decreased as the level of education increased and in those who were not limited by a health problem discussion main findings the results of this study based on a large and representative adult population between 1664 years old in spain are unique in showing the relationship between perception of environmental problems sociodemographic clinical and lifestyle characteristics and cmd from 2006 to 2017 taking into account potential gender differences the overall prevalence of cmd was higher among women than men these percentages were similar when compared to previous studies conducted among the general and noninstitutionalized population living in spain which ranged from 18 to 30 in women and 9 to 18 in men 14 15 16 56 57 58 59 60 61 although the causes of these differences are still not understood completely 62 the variation observed may be due to multiple potential factors such as hormone mechanisms 63 genderbased violence 64 traditional gender roles 65 discrimination in the workplace or during professional careers 66 low social support 67 and more likelihood of them being willing to talk about their feelings and to seek help from healthcare services 6869 particular attention should be given to the socioeconomic situation in the european region which has deteriorated markedly since 20072008 70 for this reason the economic crisis had a particularly adverse impact in spain negatively affecting mental health 71 72 73 this confirms our results which showed higher percentages of cmd in 2006 and 20112012 nonetheless from 2015 as the spanish economy improved 74 the consequences of the previous recession were felt not the same by everybody 75 in other words unemployed individuals and people without studies suffered a more detrimental effect on their mental health from the economic crisis 76 77 78 for that reason the low percentage of cmd obtained in 2017 compared to previous years may be explained by the higher percentages of people who had a job and a high level of education in the same year during the economic crisis in spain workers who had lost their jobs decided to return to education 79 perhaps because some men held traditional views about their role as the family bread winner 6077 this corroborates the results obtained in which the probability of having cmd decreased as the level of education increased in men among the higher educated more rational coping strategies allow the individual to raise questions solve problems and progress in their lives 80 it was found that people with a low level of perceived social support had an increased probability of suffering from cmd in line with other studies in spain 1558618182 perceived social support refers to peoples beliefs about how much support is potentially available from their relationships and social contacts and about the quality of this support 8384 its beneficial effects for health are either direct allowing the individual to enjoy a sense of general wellness or indirect as a stressbuffering process 8586 foreigners had an increased likelihood of suffering from cmd there may be many reasons for this the emotional burden of the migratory process unfavorable living conditions general ignorance of the country of residence a precarious socioeconomic situation the difficulty of learning and communicating in a new language family upheaval or the strong cultural shock they experience 87 88 89 in the present study in both genders the likelihood of suffering from cmd was higher when the selfperceived health status was worse as concluded by henaresmontiel et al 16 moreover low selfperceived health can lead to problems of physical functional status and concurrent problems with certain chronic diseases 9091 similarly our results showed that adults without limitations due to a health problem had less probability of having cmd and those with at least one chronic condition were more likely to suffer cmd as shown in other studies 586181 limitations due to a health problem are a serious source of strain and have a direct influence on cmd 92 on the other hand there is a broad consensus in the scientific literature regarding the association between the presence of some chronic disease and poor mental health 93 94 95 there are many reasons for this including chronic pain restrictions on social life or somatic discomfort which are common consequences of chronic diseases that increase the risk of mental problems 96 regarding marital status women who were widowed or separateddivorced had more probability of suffering from cmd as is also reflected in the extensive body of literature 97 98 99 marital disruption can be an extremely stressful event 100 and may result in poorer mental health 101 102 103 in this context the level of psychological anxiety among divorcees and widowers is on average 36 higher compared to people whose marital status has not changed 104 gender differences in the impact of separation or divorce are driven by womens poorer prospects of remarriage given that the decline in the probability of remarriage after separation or divorce with increasing age is steeper and starts earlier for women than for men this potential source of gender differences is relatively pronounced among separated and divorced individuals 105 on the other hand the results of research show that the worse mental health status for widowed women is caused by the decline of socioeconomic status after a spouses death 104 it was found that the probability of suffering from cmd was higher in women who perceived a great deal of or somewhat noise from outside the home than in men in general women show higher levels of impaired mental health when exposed to all noise sources and annoyance levels than men 106 nevertheless no gender differences have been found in relation to noise sensitivity 107 although some studies have shown that it was higher in women 108 109 110 in fact our results may be explained by attitudes towards noise women are more attentive to the risk of hearing loss especially when exposed to loud noise and are four times more prone to use protective devices 108 in this study distressing levels of noise from outside the home were a common environmental problem perceived by participants it has been hypothesized that the quality of a persons environment has been linked to their levels of psychological distress which entails a reduction of cmd 111 although there are disparities in the results 112 distressing levels of noise from outside the home are associated with impaired mental health 113 114 115 besides the damage to hearing caused by loud sounds noise can lead to extraauditory effects such as stress reactions or can interfere with communication or concentration 116 noise from outside the home is usually caused by nearby traffic while distressing noise inside the home is usually caused by home appliances heating ventilation and air conditioning systems 110117 this noise impacts on sleep patterns therefore adversely affecting health 118 in fact several studies have documented the relationship between distressing noise and sleep disturbance 119 120 121 122 and the latter is considered a risk factor for cmd 123 moreover longterm exposure to distressing noise at home could also lead to several health problems such as mental illness 117 strengths and limitations some limitations to this study need to be recognized firstly due to the crosssectional design it was not possible to assign causality between the sociodemographic clinical and lifestyle characteristics perception of environmental problems and cmd secondly it should be noted that our indicators of mental health were constructed from selfreported survey questions which can be affected by memory andor social desirability bias nevertheless the recall period is the past 12 months which is relatively short for the dependent variables in ghq12 thirdly all participants were living at home we do not possess data on institutionalized populations furthermore it should be noted that people aged over 65 years were not included in this study and therefore the sample was not representative of all spanish adults on the other hand one strength of our study is that since the data were derived from a national survey they were obtained using a carefully planned methodology including sampling welldesigned forms preparation of the survey participants supervision of the survey and filtering of the data all of which guarantee a representative sample of the population between 1664 years old and lead to a greater understanding of this problem in todays society in this study we identified vulnerable groups such as unemployed people foreigners or those who were limited due to a health problem nevertheless longitudinal studies are needed to determine the best ways to reduce and prevent cmd in these groups finally further prospective studies using experimental methods are needed to study the effects of distressing noise level and their consequences on the mental health of the population for example studies using sound meters to measure noise from outside the home implications for research and practice this large representative sample of the spanish population between 16 and 64 years old enabled us to investigate a considerable number of associations with factors from different domains simultaneously thus this research provides valuable insights which will be useful for conducting future studies our findings show that the prevalence of cmd in noninstitutionalized people in spain from 2006 to 2017 was higher among women than in men furthermore the overall prevalence of cmd was lower in 2017 compared to 2006 and 20112012 which represents a 4 decrease even so further studies are needed to try to explain these gender differences in mental health in order to reduce them and promote equality our results show that foreigners those with limitations due to health problems or chronic conditions and unemployed individuals were more likely to suffer from cmd in both women and men these findings suggest that mental health policies should focus on vulnerable groups in spain and apply health measures to prevent or reduce mental disorders for example workor schoolbased mental health prevention programs could be implemented to promote physical activity and healthy nutrition 1 moreover it would be desirable to offer training programs for unemployed people on coping strategies to help to reduce stress while job hunting 124125 it is equally important to pay sufficient attention to social support for people with common mental disorders because learning about its beneficial effects may help these people to seek support from the healthcare services 126 in fact social activities are often overlooked in health consultations despite the recent growing demand to investigate social factors in mental health 127 in addition effective plans to promote social support in policy guidance are required 128 finally our results confirm the negative impact of noise from outside the home on womens mental health it is necessary to adopt political and social measures to try to reduce distressing noise levels for example creating more green areas which play an important role in reducing noise and contribute to mental health wellbeing 129 conclusions the overall prevalence of cmd in the adult population living in spain is 1943 with a decrease in cmd in this population from 2006 to 2017 the probability of having cmd decreases as the level of education increases in men in women the probability of having cmd is higher in widowed and separateddivorced women compared with single participants and lower as the perception of distressing noise levels from outside the home decreases in both groups there is a clear increasing gradient in the probability of having cmd in adult foreigners and in those with some sort of limitation due to a health problem and also when the selfperceived health is worse and the number of chronic conditions increases by contrast the likelihood of suffering from cmd decreases in employed people in those who do physical activity during their leisure time and in those who perceive a normal level of social support supplementary materials the following are available online at file s1 research data

common mental disorders cmd represent a serious growing public health concern especially in women the aims of this study were to report the prevalence of cmd among the adult population in spain to analyze the time trends from 2006 to 2017 and to explore the associations between cmd and gender in relation to the perceived environmental and sociodemographic problems and clinical factors a nationwide crosssectional study was conducted including 48505 participants aged 16 to 64 years old who had participated in the spanish national health surveys in 2006 20112012 and 2017 a logistic regression analysis was performed to identify the variables associated with cmd by gender the prevalence of cmd was 204 in 2006cmd was 204 in 208 in 2011cmd was 204 in 2012cmd was 204 in and 169 in 2017 p 036 p 036 in women the probability of having a cmd was higher in widowed or separateddivorced compared with single individuals and as the perception of distressing noise levels from outside the home increased the probability of cmd was lower as the level of education increased in men foreigners and those with limitations due to health problems chronic conditions and worse perceived health were more likely to suffer from a cmd in both women and men

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introduction social fragmentation caused by widening differences among constituents has recently become a highly relevant issue to our modern society as various forms of gaps and conflicts are emerging from cultural political economic ethnic religious linguistic and other driving factors researchers have developed theoretical models of social fragmentation using the adaptive network framework 1 2 3 4 5 where the topologies of social ties between constituents and their states coevolve simultaneously through homophily social contagion andor other social processes such adaptive social network models are known to either converge to a homogeneous wellconnected network or fragment into many disconnected subnetworks with distinct states from a viewpoint of social capital and innovation however neither of these two social states would be desirable because the former would mean the loss of information and the latter the loss of communication in order to keep our society active and innovative we should maintain culturalinformational diversity within our society high while also maintain information exchange and communication actively ongoing this can be conceptualized as a structurally wellconnected network with diverse node states earlier theoretical models of adaptive social network dynamics did not succeed in demonstrating how such outcomes could occur we note that those earlier models typically used stylized assumptions that behavioral attributes of social constituents were spatially homogeneous and therefore they may not have fully reproduced richer macroscopic outcomes such as potential coexistence of diverse cultures within a connected network structure to overcome this limitation here we introduced the diversities of behavioral attributes among social constituents into an adaptive social network model and computationally investigated their effects on social network evolution the rest of the paper is organized as follows section 2 describes our networked agentbased simulation model section 3 describes the design of our computational experiments and outcome measures section 4 summarizes the results section 5 concludes the paper with a brief discussion on the implications of the results for relevant research fields and realworld sociocultural dynamics model for the purpose of this study we developed a computational adaptive social network model of cultural diffusion dynamics by using our previous work on cultural integration in corporate merger 67 as the basis and implementing some revisions to it to allow representation of social constituent diversity in this model we simulate the dynamics of an adaptive social network made of two initially distant cultural groups each consisting of 50 individual constituents individuals are connected to each other through directed weighted edges which represent the direction and intensity of cultural information flow constituents within each group and across the two groups are initially connected randomly with 20 and 2 edge densities respectively to represent initially modularized social structure edge weights are initially random with weights sampled from a uniform distribution between 0 and 1 this initial network structure captures the state of two groups that is distant from each other both structurally and culturally each individual constituent has its cultural state as a vector in a 10dimensional continuous cultural space based on previous empirical studies on measuring organizational cultural dimensions 89 the distance between two cultures is characterized by the euclidean distance between their two vectors in the cultural space the cultural distributions among individual constituents are initialized as follows first two cultural center vectors are created for the two groups separated by 30 in the cultural space then individual cultural vectors are created for individuals in each group by adding a random number drawn from a normal distribution with a mean of 0 and a standard deviation of 01 to each component of the cultural center vector of that group this creates an initial condition in which the average betweengroup cultural difference is approximately seven times larger than the average withingroup cultural difference such an initial condition made of two distant distinct cultural clusters may not be a popular choice for models studied in complex systems network science and statistical physics where more randomized homogeneous initial conditions are typically preferred however such random homogeneous conditions are extremely rare and unrealistic in real society even for initial conditions rather largescale social systems emerge and evolve through numerous encounters and interactions between multiple smaller communities that are often culturally distinct from each other at the beginning the heterogeneous clustered initial conditions adopted in our study were intended to capture such social encounter situations with the aim to increase the realism and applicability of our model and results in view of actual social selforganization and evolution each iteration in simulation consists of simulating actions for all individual constituents in a sequential order in its turn to take actions an individual first selects an information source from its local inneighbors with 99 probability or with 1 probability from anyone in the connected component to which the focal individual belongs if there is no edge in the latter case a new directed edge is created from the source to the focal individual with a minimal edge weight 001 then the individual decides to either accept or reject the sources cultural vector based on the distance between the received cultural vector and its own the probability of cultural acceptance pa is an exponentially decreasing function of the cultural distance defined as 𝑃 where vi and vj are the cultural vectors of the individuals own and of the selected source respectively and d is the cultural tolerance or the characteristic cultural distance at which pa becomes 50 if the received culture is accepted the individuals cultural vector is updated as 𝑣 → 𝑣 𝑟 𝑣 2 where rs is the rate of cultural state change and the edge weight from the source to the focal individual wij is updated as 𝑤 → logistic logit 𝑤 𝑟 3 where rw is the rate of edge weight change or if the received culture is rejected no change occurs to the focal individuals culture but the edge weight is updated in an opposite direction as 𝑤 → logistic logit 𝑤 𝑟 4 the above formula that combines logit and logistic functions guarantees that the updated edge weight is always constrained between 0 and 1 when the edge weight falls below 001 the edge is considered insignificant and is removed from the network additional details of these model assumptions parameter settings and their rationale can be found in our earlier work 67 in the present study we use d 05 rs 05 and rw 05 as their mean values within the social network and we systematically vary their variances among social constituents as the key experimental parameters more details are given in the following section experiments we computationally investigated how the resulting social network states and topologies would change as social constituents behavioral attributes were systematically diversified within the simulated society the standard deviations of d rs and rw were varied from 0 to 05 at interval 01 which makes the total number of parameter value combinations 0 01 02 03 04 05 3 6 3 216 we ran 100 independent simulation runs for each specific combination of parameter values each run was simulated for 500 iterations after each simulation run was completed the following two quantities were measured as outcome variables on the final network configuration  average cultural distance between constituents in the initially distant two groups  average shortest path length within the whole network in these two measures social fragmentation transitions can be captured as a positively correlated increase or decrease of both quantities namely implies social fragmentation while implies social assimilation with loss of cultural diversity results figure 1 shows the baseline behaviors of the proposed model in the low behavioral diversity parameter region in which previously reported social fragmentation transitions are clearly observed as transitions between and behaviors meanwhile none of the simulation results showed behaviors when social constituents were behaviorally homogeneous figure 2 shows the same plots for different standard deviations of d rs and rw it is seen that greater diversity of d and rs helps maintain at higher levels in addition greater diversity of d also helps lower more which corresponds to the behavior that was not previously recognized in the literature meanwhile the effect of diversity of rw is not as clearly seen in this visualization compared to the other two parameters these results strongly imply that having a broad distribution of cultural tolerance levels within society can help promote the coexistence of cultural diversity and structural connectivity figure 3 shows typical final network configurations for two experimental settings in a situation where culturally heterogeneous constituents remain connected constituents with different levels of cultural tolerance typically occupy different positions in the network for example less tolerating constituents tend to form clusters of their own acting as cultural memory while more tolerating ones tend to act as a glue to connect such culturally distinct clusters serving as bridges we also conducted linear regression analysis to regress each of the two outcome variables onto the three experimental parameters and their interactions results are given in equations and and their anova tables are shown in tables 1 and2 the linear terms in eq imply that the average cultural distance is maintained by having the diversities of d and rs while the diversity of rw has a negative effect on the cultural distance meanwhile the linear terms in eq indicate that the average shortest path length is reduced by having the diversities of d and rw while the diversity of rs has only a marginal effect on the average shortest path length table 2 anova table of linear regression of shown in eq all terms were statistically extremely significant there were several simulation runs in which some individual nodes became disconnected and such cases were excluded from the calculation the nonlinear interaction terms in eqs and imply that the interaction between the diversities of d and rs has a negative effect on both outcome measures while other interaction terms generally have positive effects on them their interactions were visualized in more detail in the 3d scattersurface plots shown in fig 4 these plots illustrate that the interactions of diversity parameters are much more significant on than on and that greater diversity of either d or rs maintain consistently at a higher level sum of among all the terms included in these regression models the only term whose coefficients point to the direction is the diversity of cultural tolerance this result suggests that enhancing the diversity of cultural tolerance has the single most effective way to achieve the social state that maintain high cultural diversity and high structural connectivity simultaneously conclusions in this brief paper we computationally studied the effects of behavioral diversities of social constituents on the resulting cultural diversity and social connectivity using a networked agentbased simulation model our results indicated that allowing cultural tolerance levels to differ broadly within society helps promote the coexistence of cultural diversity and structural connectivity which is a novel macroscopic state of the adaptive social network models that was previously not known in the literature our key finding above is interesting and relevant to network science complex systems and socialorganizational sciences in a couple of distinct ways first it offers a clear demonstration of the risk in assuming that agents in a social system are identical and homogeneous in view of the complexity of realworld systems such a simplification is apparently wrong but it is still widely used in many complex systemsnetwork models of social dynamics our results show that inclusion of variations in individual attributes even in the simplest manner may already have huge impacts on the macroscopic outcomes of the systems evolution second our results point out the importance of behavioral diversity not demographic or other surfacelevel diversities that are often discussed in the context of social organizational and political studies in contrast to demographic properties that cannot be altered easily behaviors of people are by a large part acquired traits and therefore they can be trained and modified through proper intervention this indicates that our finding may eventually lead to some educationintervention strategies to promote the maintenance of informational diversity and communication possibly enhancing the creativity and innovation of our society as a whole third we note that our finding indicates the importance of the diversity of cultural tolerance levels and not the tolerance itself in todays sociopolitical climate cultural tolerance is highly encouraged but our model does not imply that simply increasing the cultural tolerance levels globally within the social network would lead to beneficial outcomes additional experiments with globally enhanced cultural tolerance levels of all the constituents did not generate the same outcome as presented in this paper because such a condition would quickly lead to a loss of cultural diversity this implies that at least from the perspective of enhancing both informational diversity and communication telling people to be just tolerating does not produce the desired outcomes these findings and implications collectively illustrate the highly nontrivial nature of the cultural dynamics in our society this study is still far from completion and there are several future tasks to conduct one obvious limitation of our present model is that it is fairly complicated and is not suitable for mathematical analysis we plan to develop a much more simplified model of the same adaptive social network dynamics so that its behavior can be analyzed and explained mathematically the other important direction of future research is to compare the dynamics of these adaptive social network models with realworld data of information exchange in order to validate and revise the model assumptions for this purpose we are currently working on collecting empirical data of cultural dynamics from social media and other onlineoffline sources recent machine learning tools for content analysis 1011 allow researchers to quantify similarities and differences between contents posted by users and this information can be examined with regard to its potential correlation with temporal changes of future contents posted by the same users as well as their social relationships 12 our future goal is to use such empirical data to determine the role and importance of individual behavioral heterogeneity in realworld adaptive social networks as predicted in the theoretical model presented in this paper

social fragmentation caused by widening differences among constituents has recently become a highly relevant issue to our modern society theoretical models of social fragmentation using the adaptive network framework have been proposed and studied in earlier literature which are known to either converge to a homogeneous wellconnected network or fragment into many disconnected subnetworks with distinct states here we introduced the diversities of behavioral attributes among social constituents and studied their effects on social network evolution we investigated using a networked agentbased simulation model how the resulting network states and topologies would be affected when individual constituents cultural tolerance cultural state change rate and edge weight change rate were systematically diversified the results showed that the diversity of cultural tolerance had the most direct effect to keep the cultural diversity within the society high and simultaneously reduce the average shortest path length of the social network which was not previously reported in the earlier literature diversities of other behavioral attributes also had effects on final states of the social network with some nonlinear interactions our results suggest that having a broad distribution of cultural tolerance levels within society can help promote the coexistence of cultural diversity and structural connectivity

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introduction globalization technological advancement and market openness have created an entrepreneurial ecosystem where more and more immigrants are launching their business ventures challenging job market in the host country have also pushed many immigrants into entrepreneurial activities wage earning employment for immigrants in the current job market becomes uncertain and they constantly seek out new opportunities to become entrepreneurs the formation of immigrants entrepreneurial intention is a process that starts with an awareness of and initial interest in entrepreneurship and culminates in starting that new venture there are both pull and push factors of iei along with need of learning skills and knowledge to function effectively in new business ecosystem iei is a learning process in which an individual learns the appropriate norms and behaviours to function better in the business culture of the host country this involves an active willingness to learn and understand the host entrepreneurial culture take risks to try out new and uncertain entrepreneurial activities although over the last two decades the study of ei in general has received great attention studies on iei in particular have been rather scarce moreover studies on how immigrant entrepreneurs think and how they develop their ei and their decision to become an entrepreneur have been lacking immigrants come from a different socioeconomic and cultural background with various types of experiences and skills their thought process might be different and need an indepth analysis to enhance our understanding as well as for policy formulation to better integrate them into the host society this study addresses this research gap by exploring antecedents of iei formation process which is different from ei of local entrepreneurs there are several studies with a greater focus on understanding the factors influencing peoples intention to start a new business venture they have been explored from different perspectives including the presence of economic and social dimensions that influence the level of total earlystage entrepreneurial activity the individual and psychological dimensions of market participants and the processual dimension while those works had contributed significantly to enhance our understanding the question of whether the generic determinants of ei can be generalized to all categories of individuals is still relevant specifically immigrant entrepreneurs are seen as distinct from local entrepreneurs and deserve more attention from researchers and policy makers understanding how they think perceive business opportunities and make decisions to start and succeed in entrepreneurial ventures requires the development of an integrative models and consideration of specific factors that are being dispersedly addressed in current literature in this study we are exploring the factors that contribute to developing iei from a holistic perspective immigrant entrepreneurship is described as the process by which an immigrant establishes a business in a country of residence which is different from their country of origin immigrant entrepreneurship can also be an important way of integrating into the socioeconomic life in the adopted country which is also the objective of public policy in the host country from the sociocultural perspective immigrants face various challenging situations that make them to be psychologically and cognitively distinct thus since individuals make up their own minds holistically considering that individual factors or contextual conditions alone is inadequate in studying their entrepreneurial intention to better understand their intentions and behaviours it is necessary to broaden the scope of antecedents that are commonly taken into consideration in entrepreneurship research by incorporating specific factors that appropriately contextualize it this could help to deepen the understanding of iei construct what are the particular factors that are relevant to the immigrant entrepreneurship context what are the effects of the selected determinants on immigrants entrepreneurial intention these are the questions that we attempt to address in this study an indepth understanding of the determinants of iei is important since immigrants and their descendants can play an important economic role through the creation of new businesses and jobs although many studies have identified the influence of culture on iei models those studies did not explain how a culture gap impacts peoples propensity to start a new business this is a weakness of the way culture was conceptualized in those models by an extensive use of cultural dimension grid designed to examine cultural differences between nations in a migration context exposure to different ideas and environments can affect and even transform cultural beliefs given the increased migration and socioprofessional integration problems it becomes necessary to understand how the difference between the entrepreneurship culture of both the home country and host country influences iei the study intends to make following significant contributions first addressing the concerns of authors such as fayolle and liñán krueger and day and liñán and fayolle on the paucity of iei research this paper extends the theory of planned behaviour by adding more variables that are essential for immigrant entrepreneurship intention beyond individual factors the cultural distance between the country of origin and host country as perceived by immigrants as well as institutional supports for entrepreneurship have an impact on the development of the iei moreover distinct from the models of cultural value dimensions the cognitive approach enabled us to verify that immigrants perceive cultural distance through a cognitive prism of planned behaviour that stimulates the feasibility of their entrepreneurship project in addition the existing literature lays emphasis on psychological factors such as risk perception by integrating psychological and economic dimensions our findings advance the contextualized approach in immigrant entrepreneurship and illustrate that the integrative effects of individual and contextual factors is critical for improving the quality of iei therefore we advance the research on the value of contextualizing ei and on the role of cognition in explaining this process secondly we conceptualize the learningbased entrepreneurial intention following the study of douglas thus it can assist scholars in empirically studying immigrant entrepreneurship intention in a way that is consistent with the crosscultural understanding that reflects the reality of their research finally this learning approach enables us to consider entrepreneurial culture as a shared liability issue the liability of foreignness which requires immigrants to learn the local entrepreneurial culture and the liability of the host country which consists of finding effective mechanisms that can overcome liabilities of foreignness of newcomers to entrepreneurship the article proceeds as follows in the next section we develop its theoretical basis and the hypotheses then we go further to test the hypotheses by using data from 250 participating immigrants thereafter we discuss the results by highlighting the important contributions and limitations of the study before drawing a conclusion theoretical foundations and hypotheses the process of iei development is not a linear phenomenon some immigrant entrepreneurs are forced to establish their own businesses as an economic survival strategy some others engage in ethnic enclave business and serve people from similar backgrounds and experience as them and some other immigrant entrepreneurs belong to specific ethnic minority community that do not share the characteristics of the majority local population our study employs the principle of tpb and extends it by including additional predictors moreover ajzen states that the approach offered by the tpb provides a conceptual framework for thinking about the determinants of the behaviour under consideration ie immigrant entrepreneurship intention and which can be submitted to empirical test however there is scarce research attaching importance to integrating these conditions into the holistic framework of immigrants entrepreneurial intention formation process theories in immigrant entrepreneurship early research described immigrant entrepreneurship as the process by which an immigrant establishes a business in the country of settlement different from his or her country of origin several studies have addressed the importance of entrepreneurship on the social and economic integration of immigrants immigrant entrepreneurship refers to the process whereby immigrants identify create and exploit economic opportunities to start new ventures in their host nations conceptual understanding of immigrant entrepreneurship implies to pin down several frameworks and models that extant research provides these theoretical views allowed researchers to explore the particularities of factors enabling or impeding immigrants to start a business venture rather than suggest monocausal and then multicausal approaches to make the bill consistent peroni et al classified theories that seek to explain the relationship between immigration and entrepreneurial involvement into two broad groups the first group focuses on the specific characteristics of immigrants for explaining differences in the propensity to start a business compared to nonimmigrants the second group relies on the institutional and cultural environment of the host country theories in the first group spotlight higher probabilities that make immigrants to start a new business due to several forms of disadvantages in the host country pushing them to necessity of selfemployment instead of low paid jobs cultural traits that immigrants inherit from their home countries driving them to use ethnic resources in areas where they run business belonging to the same ethnic group role played by certain immigrants seen as foreign traders specifically middlemen or intermediaries between market actors among this group the second theory has received considerable attention through the fact of maintaining networks and connections with the country of origin theories in the second group focus on the interaction between individual characteristics of immigrants and the institutions and features of the hosting societies and markets the interactive model explains immigrants involvement in entrepreneurship as the outcome of the interaction between their own resources and societies opportunity structures so immigrants mobilize their specific characteristics called ethnic strategies to access these opportunity structures the latter are historically shaped circumstances such as market conditions that do not require mass production or distribution characterised by decreasing return to scale in which ethnic goods are in demand one decade later kloosterman and rath refined the former model to account for countryspecific institutional frameworks their socalled mixed embeddedness suggests that immigrants are not solely belonging to ethnic networks they are also embedded in specific market conditions socioeconomic and politicoinstitutional environments by and large most scholars in the field of immigrant entrepreneurship research base their arguments on the mixed embeddedness theoretical approach however the conceptualization of this approach did not take into account the effects of countries of origin yet immigrants are in a unique position to create opportunities by combining and adapting ideas products and processes from different sociocultural contexts including but not limited to the host country accordingly while scholars found immigrant entrepreneurs to be embedded in multiple contexts literature has ignored the need to focus on the embedding process itself disregarding the learning which is necessary to achieve the embeddedness personal attitude subjective norms and perceived behavioural control and immigrant entrepreneurship intention entrepreneurship crystallizes the business creation process to understand this entrepreneurial process authors such as bird and krueger and carsrud identify ei as the link between ideas and action that therefore makes it so crucial in this process for ajzen intention captures how people exhibit their motivation and willingness to carry out the desired behaviour intention is one of the best predictors of planned behaviours however understanding the consequences of intention requires an understanding of intentions antecedents there are various theoretical frameworks for ei proposed by previous studies each of them claims that every entrepreneurial behaviour is preceded by the intention to develop such behaviour and that several specific different factors influence this intention the tpb is probably the most applied widely supported and robust intention model the theory suggests three factors that contribute to forming entrepreneurial intention attitude towards behaviour subjective norms and perceived behavioural control attitude towards behaviour is defined as the individuals evaluative effect towards creating a new business the subjective norms suggest that individuals are more likely to adopt a family and close friends or mentors behaviours andor behaviours that these reference individualsgroups approve perceived behavioural control reflects the perceived ease or difficulty of engaging in that behaviour control factors include along with many others skills and abilities experience cooperation by other people money and other resources the immigrant is supposed to have acquired or learned several previous studies in various countries and contexts have shown the vital role played by ei using the tpb other studies have empirically analysed and adequately shown the positive impact each of these three antecedents has on ei according to urban and chantson the beleifs values and capabilities of an individual influence the choices and decisions they make immigrants who believe and know that they can succeed in their entrepreneurial drive will do the needful to succeed immigrants with greater control of exhibiting a behaviour will have a greater intention or efforts to achieve that goal or behaviour attitudes subjective norms and perceived behavioural controls collectively form behavioural intentions and so lead to actual behaviours based on the results of these studies we formulate the following hypotheses h1a immigrants personal attitude positively impacts their entrepreneurial intention h1b immigrants subjective norms positively impact their entrepreneurial intention h1c immigrants perceived behavioural control positively impacts their entrepreneurial intention our model aligns with the tpb on two grounds firstly that there is an interaction between subjective norms and personal attitude on the one hand and behavioural control on the other hand huichen et al found a positive impact of personal attitude and perceived behavioural control on subjective norms still this effect was not significant on ei however although the predictors of intentions are conceptually independent empirically they are free to correlate with each other consequently we assume an effect of personal attitude and perceived behavioural control on subjective norms theoretically attitude is conceived as personal in nature and subjective norms reflect external social influence however attitudes have two components personal attitude and social attitude behavioural outcomes can be social in addition to personal because an immigrant entrepreneurs behaviour often has consequences for other people subjective norms is different from social attitude and deals with what reference groups think about the behaviour itself put together social attitude and subjective norms refer to a persons behaviour in relation to other people and show the relatedness of social attitude to subjective norms immigrants are considered high in selfconsciousness and selfmonitoring social attitudes significantly and positively influence their behavioural measures it implies that a positive attitude towards entrepreneurship of the immigrant and his own perceived feasibility of the project can contribute to the increase of perceived social pressure to engage in the entrepreneurship this leads us to formulate the following hypothesis h2a immigrants personal attitude positively impacts their subjective norms h2b immigrants perceived behavioural control positively affects their subjective norms secondly it aligns with the tpb in that those external factors such as demographic or environmental characteristics do not directly influence intentions but are mediated by the three antecedents of intentions furthermore in light of ajzen this study theorizes that the degree to which immigrants have control over the entrepreneurial behaviour will depend on their ability to overcome entrepreneurial culture distance and on the presence of such facilitating factors as past experience and assistance provided by social networks and institutional context individual variables and the antecedents of immigrant entrepreneurship intention entrepreneurial experience economic integration of immigrants depends on human capital which needs to be demonstrated by official qualifications bureaucratic red tape and difference in international qualifications make it difficult for immigrants to assert their human capital based on foreign qualifications to overcome this impasse some entrepreneurs are likely to use their previous experience to carry out the entrepreneurial process building on their learning experienced entrepreneurs can identify more opportunities and generally explore more innovative opportunities with more potential for wealth creation than unexperienced entrepreneurs because experience improves their capacity to deal with liabilities of newness effectual reasoning and attitudes towards failure experienced entrepreneurs must rely on it to make informed and effective decisions entrepreneurial experience can have a critical value in the host market as entrepreneurial learning transpires through and is emergent from practices and their relations prior entrepreneurial experience is expected to play a crucial role in the formation of entrepreneurial intention this view has been empirically supported by several studies wiklund and shepherd argue that both ei and behaviours can be conceptualized in entrepreneurs capabilities knowledge and accumulated skills of each entrepreneur are in fact predictors of entrepreneurial activity such is the case with experience whether direct or indirect which is part of human behaviour and stimulates ei work experience is even seen as a factor that attracts people to selfemployment because it can motivate varied wellperceived and approved initiatives the diversity of experience may benefit startuppers since it increases the probability of being a habitual businessperson with setting up more than one entreprise based on the above and considering ajzens view about background factors in the tpb as assumed to influence intentions and behaviour indirectly by affecting its determinants we expect that experienced immigrants will exhibit higher personal attitude subjective norms and perceived behavioural control to induce the intention to start a business thus we formulate the following hypothesis h3 immigrants experience positively impacts their personal attitude subjective norms and perceived behavioural control towards undertaking an entrepreneurial venture perceived risk and immigrant entrepreneurship intention among the personality traits considered as an antecedent of intention the notion of risk is of particular importance risk is defined as the probability of a substantial financial loss but the same dollar amount of possible loss could be more severe for one entrepreneur than another while risk may also involve nonfinancial threats like damage to reputation it is our view that high risk seen as a threat among immigrants may arouse their own epistemic curiosity generally risk perception has been conceptualized as an assessment of risk by the decisionmaker in a given situation it is perceived as a determinant of risky behaviour and entrepreneurial decisionmaking despite the importance of risk on entrepreneurial intention relatively few studies have addressed this issue perceived risk plays an important role in the course of undertaking an entrepreneurial venture by immigrants in a new environment of their newly adopted country of residence they must assess their abilities as well as the environment in which to create and develop the new business the idea inherent in the evaluation process is that individuals evaluate stressful situations in terms of their wellbeing and especially risk it is important to understand to what extent perceived risk influences the formation of entrepreneurship intention we can only assess the risk and even anticipate it when we know it and are exposed to it then we can have a conscious approach called risk taking when forming entrepreneurial intention risk taking allows the potential entrepreneur to temper overoptimism by determining the rate at which it will influence performance risk perception is considered as something that slows down entrepreneurial activity as it might create perception of potential losses from business activities thus risk perception will negatively affect the immigrant entrepreneurial intention immigrants willingness to take risks should be very high early in the entrepreneurial process or they would never get started then this willingness may decline over time probably when they will realize that entrepreneurial projects are exposed to many risks that require entrepreneurs to deal with and manage in addition to the assessment of possible damage and loss it is the fact of being a foreigner that creates the additional risk a new approach to risk in business creation argues that risk perception is contextdependent and multidimensional with two meanings risk as a threat and risk as an opportunity the results of a recent empirical study in a recessionary economic context indicate that both types significantly influence ei it means that perceptions of risk as an opportunity tend to increase ei but few empirical studies have supported it on the other hand it is widely believed that perceptions of risk as threat tend to reduce ei a similar line of reasoning can be applied to immigrant entrepreneurs who should perceive risk more as a threat than an opportunity in the host country this can weaken the desirability and feasibility of launching such a new venture moreover personality traits are background factors that are assumed to indirectly affect behavioural normative and control beliefs hence the following hypothesis h4 immigrants perception of risk as a threat hurts their personal attitude subjective norms and perceived behavioural control towards undertaking an entrepreneurial venture contextual variables and the antecedents of immigrant entrepreneurship intention social network context is a multifaceted concept its social dimension reflects both the perspective of social network as well as household and family integration turkina and thai define social network as a set of actors and their links both social and cultural factors may be important in the creation of entrepreneurial events and are most felt in the establishing of individual values systems generally an entrepreneur considers his entrepreneurial social network to be a medium through which he may gain access to different resources links in social networks are often divided into two types close or strong ties are intimate bonds that exist between an entrepreneur and family members very close friends or other members of ethnic group and loose or weak ties form social ties that are more diffuse less intense and often shortlived than is true for close or strong ties bonding social networks emphasizes on the density and tightness of the existing social network of an individual while bridging social networks concentrate on an individuals scope and type of social network ties and their impact on the several outcomes including venture creation and nascent behaviour literature on immigrant entrepreneurship insists on the propensity of entrepreneurs to rely on ethnic networks to mobilize resources that are useful for the creation of their business this understanding enlightens granovetters use of the social embeddedness concept to measure the effects of social networks on economic behaviour the cultural anchoring of immigrants would facilitate the mobilization of ethnic resources as well as a vertical integration with coethnic producers resellers and customers this vertical social embeddedness provides physical and emotional support through internal interactions and promotes trust among internal ethnic group members by sharing information beyond the kinshipbased connections in the host country highquality social relationships are supposed to be built and nurtured with purpose what we think of as horizontal social embeddedness facilitates entrepreneurs to obtain accurate information from outside the community and identify opportunities in the wider society as well as gain decisionmaking advantages for this purpose healthy entrepreneurial bridging social networks should provide contacts and relationships to improve entrepreneurial capability building nowadays following the sobriety of ethnic enclaves and the boom phenomenon of entrepreneurial digital social networks this can allow immigrants to update information about new markets and opportunities leading them to a more adequate decision ultimately what is important is the strong entrepreneurial awareness to which the interaction of the role of potential entrepreneurs and the social context leads moreover since mobilities are applied to immigrant entrepreneurship to investigate the ways immigrants build links and bridges through spaces and places such horizontal social embeddedness is beneficial for immigrants particularly in establishing reputation improving performance and enhancing legitimacy different levels of networks can promote the circulation and exchange of resources research evidence suggests a statistically significant relationship between bonding social capital and perceived desirability bridging social capital and perceived feasibility and entrepreneurial intentions and both perceived desirability and perceived feasibility current research on bridging social capital derived from entrepreneurs social networks indicates that it indirectly influenced ei through the positive mediation of entrepreneurial selfefficacy with strong significant relationships between it and entrepreneurial selfefficacy following the above literature and drawing on the tpb apart from the internal coethnic network we postulate that external network which goes beyond ethnicity will have positive impact on personal attitude subjective norms and perceived behavioural control translating into higher level of iei those who develop diverse outwardly oriented networks will be more likely to show higher intentions than their counterparts who have less or no such network within the social system the following hypothesis is then formulated cultural difference institutional context which draws on the concept of formal and informal institutions as coined by north in terms of the rules of the game in a society are humanly designed systems that shape human interaction when it comes to informal institutions the strand of literature studies its influence on relationship to entrepreneurship such research draws attention to the impact of culture culture has been described as the interactive set of common characteristics that influence the response of a human group to its environment international entrepreneurship scholars argue that a countrys values beliefs and norms affect its residents entrepreneurial orientation therefore entrepreneurs effectual behaviour differs due to their national cultural traits regarding entrepreneurial culture it is seen as one that values the personal characteristics associated with entrepreneurship hence conceptualization manifestations and consequences of entrepreneurial culture are inherently central to entrepreneurial intention research from a microlevel standpoint this concept refers to an organizational culture embodying and upholding entrepreneurial attributes and characteristics from a macrolevel viewpoint entrepreneurial culture is found as a component of national culture that enables the success of economic growth accordingly gem reports on canada experts opinion claim that cultural environment is one of the most favorable conditions for entrepreneurship in the country many developed and developing economies have allocated and spent vast amounts to promote and cultivate entrepreneurial culture a valuable entrepreneurial ecosystem dimension for institutions to foster the entrepreneurial spirit among people seeking to enter business it becomes important to do so by focusing on empowering the individuals to carry out their entrepreneurial tasks we consider entrepreneurial culture as an important factor in forming and promoting immigrants entrepreneurial behaviour and their integration in the entrepreneurial ecosystem of the host country thus immigrants entrepreneurial acculturation should be placed in a lifelong perspective and started before business creation moreover if foreignness is inherent to mobility distinguishing between entrepreneurial cultures is central to immigrant entrepreneurship where culture is seen to be a liability issue as with the liability of foreignness which depends mainly on the social relational and institutional factors the difference in entrepreneurial cultures of the home and host countries can give rise to unfamiliarity and lack of embeddedness discrimination by host country actors and relational hazards for immigrants in their host countries lack of social legitimacy associated with information asymmetry and economic nationalism in host countries can give rise to a lack of trust in immigrants entrepreneurial ventures and sometimes even discrimination against them on the other hand in a new country immigrants might have certain emotions visàvis this environment hofstede et al suggest that the tension created by the differences between the cultural dimensions and the countrys institutions can also be a source of dissatisfaction generally this perspective suggests that dissatisfaction among individuals who do not conform to the predominant cultural dimensions at the country level would induce the tendency to start their own business dissatisfaction could arise when there is a cultural clash between the immigrant and the informal environment of his host society missing the cultural embeddedness boat some immigrants may feel that they are not affected by some of the values and practices that underpin the social fabric of their host country overall this distancing could somehow influence the entrepreneurial decision in the same theoretical and empirical logic as in the recent studies results the former confirmed the importance of entrepreneurial culture and education to promote entrepreneurial selfefficacy and then develop ei the latter revealed entrepreneurial culture has a positive influence on attitude based on the foregoing we assume that the perceived culture distance will decrease the iei levels by lowering the effects of personal attitudes subjective norms and perceived behavioural control instead of leveraging ei it will hold a negative impact on both attitude subjective norms and perceived control the following hypothesis is therefore formulated h6 immigrants perceptions of distance in entrepreneurial culture lower their personal attitude subjective norms and perceived behavioural control to undertake an entrepreneurial venture formal institutions when it comes to formal institutions the critical role that institutional context plays in venture creation process has been welldocumented in the wider entrepreneurship literature formal institutions as political and economyrelated rules which create or restrict opportunity areas for entrepreneurship provide the framework and structure to facilitate some types of exchange and the framework in which people have confidence in determining outcomes they reduce uncertainty by providing a stable platform for human interaction and affect the costs of interactions in such an environment by providing incentives for some behaviours and discouragement for others the availability and quality of institutional context that produce human capital through education training andor learningbydoing should be likely to generate a strong propensity for new businesses therefore in this study we argue that institutional support for entrepreneurship has established itself as a critical policy direction to address the structural issue of the lack of employment opportunities particularly in a hostile or corrosive environment of immigrants the literature conceptualizes formal institutions in terms of the financial and educational support attributed or attributable to entrepreneurship and related regulations and the perception of corruption these factors that motivate entrepreneurship are generally evoked from either a positive angle or a negative angle according to zhang et al government support falls into two categories to give policy support and to provide service support for solving problems in this vein entrepreneurship training program as examined by lyons and zhang is informative the authors found that the effect of such program was small for minorities in the short run more pronounced for minorities likelihood of longer run startup activity whereas for nonminorities the effect was small and statistically insignificant entrepreneurial supports have a positive influence on entrepreneurial intention the more an immigrant perceives an institutional support and the more training he receives the more entrepreneurial attitude he will have thus drawing on the tpb we expect institutional support for immigrant entrepreneurship will positively influence both attitude subjective norms and perceived control of the immigrants for their entrepreneurial career intention based on the above it can be inferred that immigrant entrepreneurs who have favorable perceptions of formal institutional environment and supports for entrepreneurship will have higher ei the following hypothesis is then formulated h7 immigrants perceptions of entrepreneurial supports have a positive impact on their personal attitude subjective norms and perceived behavioural control towards undertaking an entrepreneurial venture methodology empirical setting this study focuses on immigrants living in canada regardless of their countries of origin recently innovations in the gem methodology have made it possible to assess the quality of an economys entrepreneurial ecosystem or the entrepreneurship environment graded over 10 points according to the 2019 neci out of the 5 participating economies that we consider as traditional countries of immigration canada is the second country with the most favorable environment for entrepreneurship after the united states of america moreover in its 2019 budget the government of canada extended its support for inclusive entrepreneurship with the proven success of economicclass immigrants in entrepreneurial activities it is clear that this economy has an environment that is the most conducive this is the reason why we decided to base our work on immigrants in canada the following procedure and instruments were known to and approved by the ethics committee of the laval university sample and procedure our data draw from a survey conducted from june 2018 to july 2019 through the following sampling procedure we were able to contact the immigrants through mifi where we accessed the tcri to obtain a list of immigrant associations registered in their database the list enabled us to contact the presidents of several african european latincaribbean and asian immigrant associations with the help of the associations presidents we were able to send our questionnaire to a total of 444 participants the questionnaire was developed in english and french the two official languages of canada to administer it to the participants we combined two data collection techniques namely an online survey via an electronic link and manual completion of printed copies of the questionnaire for the online survey an email with the electronic link to the survey was sent to association presidents who then forwarded it to their respective members printed copies of the questionnaire were distributed to participants during association gatherings such as community fairs general meetings and open events the questionnaire items were formulated in such a way as to minimize social desirability bias also respondents were assured of the anonymity of their responses out of the 444 distributed questionnaires 275 were returned by respondents out of these 275 returned questionnaires we had to reject 25 based on incomplete answers therefore 250 valid questionnaires were finally retained this sample of 250 respondents was made up of 54 africans 26 europeans 10 latincaribbeans and 10 asians from a gender perspective the sample was made up of 27 men and 73 women as for the sectors of activity envisaged for their future businesses among the 101 participants who answered this question 18 targeted restaurants 15 groceries 12 services related to new technologies and 9 retail sales measurement of the variables measurement of ei and its antecedents entrepreneurial intention and its antecedents were measured using the items developed by liñán and chen on a 7point likert scale ranging from 1 to 7 thus a set of 4 items including statements such as i am ready to do anything to be an entrepreneur and my professional goal is to become an entrepreneur were used to measure respondents ei an analysis of this constructs reliability shows that it has good internal consistency with a cronbachs alpha of 077 the immigrants attitude towards entrepreneurship was measured using four items indicating their attractiveness and the level of benefits they perceive for entrepreneurship these items include statements such as being an entrepreneur would give me great satisfaction and a career as an entrepreneur is attractive to me this construct has a cronbachs alpha of 068 to measure subjective norms we used four items including statements such as my immediate family would approve of my decision to start a business and my friends would approve of my decision to start a business cronbachs alpha associated with this construct is 075 perceived behavioural control was measured with three items including statements such as if i tried to start a firm i would have a high probability of succeeding and i know how to develop an entrepreneurial project with a cronbachs alpha value of 072 frontiers in psychology 09 frontiersinorg measurement of individual variables two variables risk perception and entrepreneurial experience were used to analyze individual factors effect on immigrants ei we adapted the items developed by nabi and liñán to measure the perception of risk as a threat on a 7point likert scale ranging from 1 to 7 these items include statements such as starting a new business is very risky and the probability of a new venture doing poorly is very high giving us a cronbachs alpha of 068 to measure entrepreneurial experience we asked respondents to indicate the number of years they have already spent doing business in canada measurement of contextual variables to analyze the effect of contextual factors on immigrants ei we used three variables social network distance of entrepreneurial culture and institutional context social network was measured using three items adapted from lancee on a 7point likert scale ranging from 1 to 7 lancee identifies two types of networks bonding network and bridging network however in the present study bonding network items do not have an excellent internal coherence we therefore had to select only bridging network which enables us to assess the extent of immigrants weak social ties with the host society the items used include statements such as i establish relationship more with native canadians than with my ethnic group and the constructs internal reliability test shows a cronbachs alpha of 069 we used four items from stjean and duhamel in terms of distance of entrepreneurial culture they postulate that entrepreneurial culture can be perceived through the media coverage given to entrepreneurship and entrepreneurs social status the other two items are from langford et al for whom a societys entrepreneurial culture can be perceived through the entrepreneurial spirit and propensity to risk that characterizes individuals and their creativity and ability to innovate since our focus in this work is the difference in entrepreneurial culture between canada and the immigrants countries of origin we adapted the items developed by stjean and duhamel and those of langford et al in the same manner as saha et al who studied the role of cultural distance in the medical field thus we asked respondents to indicate the magnitude of the difference they perceive between canadas entrepreneurial culture and that of their countries of origin on a 7point likert scale ranging from 1 to 7 items used include statements such as media attention towards entrepreneurship in canada and my country is… and the way status is accorded to successful entrepreneurs in canada and my country is… with a cronbachs alpha of 088 formal institution variable was measured by asking respondents to indicate their perception of entrepreneurs assistance by formal institutions a set of five items was used to measure this variable on a 7point likert scale ranging from 1 to 7 these items relate to several aspects of institutional support such as access to funding support for innovation networking arrangement etc for example the items used include statements such as in canada training to be an entrepreneur makes funding available for business startup and in canada support structures enable joining or developing social networks for this construct the internal reliability test shows a cronbachs alpha of 074 results validating the measurements we tested the different scales used to ensure their convergent validity discriminant validity and reliability to this end an exploratory factorial analysis was carried out on all the items making up each of the multiitem variables used in our iei model we first verified the relevance of the factorial analysis by using the kaisermeyerolkin test to evaluate the homogeneity of the items the results presented in table 2 below show that there is a factorial solution for each of the variables because the kmo values are more significant than 05 in addition the factor analysis confirmed the unidimensional structure of the scales used because for each of the variables only one eigenvalue is greater than 1 the proportion of the total variance explained by each factor is also consistent with the recommendations in the literature in addition to the exploratory factorial analysis we used cronbachs alpha to examine the internal reliability of each of the constructs used in our model the results of this test reveal that the different constructs have an acceptable level of internal consistency in addition the mean standard deviations and bivariate correlations between the independent and dependent variables are presented in table 3 in this study correlations analysis confirmed a statistically significant relationship between ei and all its three antecedents according to the tpb there is also a statistically significant relationship between some exogenous variables and ei antecedents testing further for structural validity the square root of the variance shared between the constructs and their measures was analysed path models test it should be stated from the outset that we tested two models in succession one with a social network and the other without a social network since social network ties were all found to be insignificant this variable and all other insignificant relations were removed from the initial model to test whether the adjustment would at best improve or at worst be maintained the results presented in table 4 below show that the structural model proposed without considering the network is overall well fitted and can therefore be used to test our different research hypotheses all the models were tested with mplus 61 the criteria used to assess the fit quality of this model are the chisquare ratio to the degree of freedom the root mean square error of approximation 0040 the comparative fit index 0968 and the tuckerlewis index 0923 a comparison of these different indicators values with those recommended in the literature χ2df ≤ 3 rmsea ≤01 cfi ≥ 090 tli ≥ 090 shows that the estimated model is well fitted moreover chisquare is insignificant in addition most of the estimated relationships are significant except for h1c and h2b all the other research hypotheses are validated thus our results show that immigrants attitudes toward entrepreneurship and their perception of subjective norms positively affect their ei hypotheses 1a and 1b are therefore validated the results also indicate that h3c h4a and h4b on the relationships between individual variables and the antecedents of intention are validated similarly the hypotheses on the relationships between contextual variables and perceived behavioural control are validated as for the relationships between ei antecedents hypothesis 2a which postulates that attitudes towards entrepreneurship positively affect subjective norms has been validated the results of model 1 are also presented in table 3 they show that the structural model incorporating social networks is generally wellfitted as was the previous model the adjustment indices show that the model fits well with the data the chisquare ratio to the degree of freedom 1296 the root mean square error of approximation 0034 the comparative fit index 0967 and the tuckerlewis index 0934 apart from the hypotheses about bridging social networks which appear to have no significant effect all relationships in the model maintained their significance level figure 2 summarizes the results of the final empirical model with all the relationships tested when comparing the standardised coefficients represented in this figure it is clear that the magnitudes of the standardised coefficients differ perceived risk as a threat was related to personal attitude and subjective norms confirming h4a and h4b respectively entrepreneurial experience was related to perceived behavioural control which partially confirms h3 cultural difference in entrepreneurship was related to perceived behavioural control which partially confirms h6 institutional entrepreneurial support offered by formal institution was linked to perceived behavioural control which partly confirms h7 discussion on findings of this study in this article we studied the antecedents of immigrants entrepreneurial intention by testing a model that combines previous research on entrepreneurship immigrant entrepreneurship and psychological factors that form immigrant entrepreneurship intention more specifically we studied individual variables and contextual variables as indirect antecedents as well as attitudes subjective norms and perceived behavioural control as direct antecedents of iei we expected that individual and contextual variables would show indirect effects via attitudes subjective norms and perceived behavioural control direct impact on subjective norms was also being expected from attitudes and perceived behavioural control regarding the direct antecedents of intention described by the personal attitudes subjective norms and perceived behavioural control only perceived behavioural control was not conclusive in predicting iei while this result contradicts previous literature which proposed that individuals decision to start their own business is influenced by the perceived feasibility judgment particularly among immigrants this result confirms experience as a source of selfefficacy in line with banduras work moreover as long as the perceived risk does not undermine the perceived feasibility of their business idea immigrant entrepreneurs can create value for themselves with more or less risk in the host country this risk mitigation is suggestive of their potential entrepreneurial resilience regarding contextual variables among the three tpb factors only perceived behavioural control was affected by direct effects of distance in entrepreneurial culture and institutional supports for entrepreneurship and not by network support as for cultural distance any confusion among immigrants is likely to reduce perceived feasibility which contributes to the feeling of ineffectiveness whereas for perceived support it confirms verbal persuasion as a source of selfefficacy in line with banduras work the dynamic narratives of programs and other peoples experience tend to persuade the immigrant audience that they can competently carry out any entrepreneurial activity if they try the extraethnic social network of the immigrants appears not much helpful for their career plan this emphasizes the lack of integration of immigrants in local networks although the reality of an ethnic enclave needs to be nuanced nowadays this point nevertheless suggests that ethnic resources remain an asset the strong ties of networks operating within the communities are a determinant factor for an ethnic business startup serving the communities with the similar tastes and preferences in a nutshell our results show that tpb partially accounts for overall indirect effects individual factors indicators of experience and perceived risk all appear to operate within the broader framework of tpb in that they are linked to the iei on the other hand the seemingly unsuccessful indirect effects of entrepreneurial culture distance and institutional supports for entrepreneurship are probably due to the cognitive nature of both distance and support on feasibility the result of social networks which seems counterintuitive rather calls for doing things differently while attitudes and perceived behavioural control are understood as the two strongest antecedents of immigrant entrepreneurship intentions how can we understand the indirect effects of individual and contextual factors lack of transmission to the final intention two explanations seem plausible first the possibility of reverse causality has been raised in the previous literature it has been suggested that an increase in iei may affect desirability and feasibility elfving et al report that the idea of such reciprocal causality is reasonable this suggests that the intention formation process would be iterative and therefore evolutionary unfortunately our sample did not allow us to test such a mechanism secondly the result seems to challenge the performance of the entrepreneurial support of which some immigrants are beneficiaries discovering the gap between the entrepreneurial culture of their country of origin and that of the host country creates a constant tension a source of dissatisfaction which looks like a doubleedged sword on the one hand that dissatisfaction pushes them to start their business as individuals who do not conform to the predominant or mainstream direction of the countrys cultural dimensions at the same time on the other hand the tension created by cultural differences is likely to limit the effect of perceived behavioural control on intention because when an important informal institution is different the gap which undermines efficient and effective transactions of productive markets can be construed as informal institutional void this tension can only be mitigated by institutional supports for entrepreneurship this is the mission that entrepreneurial support structures should fulfill with immigrants in their entrepreneurial emergence process otherwise the potential immigrant entrepreneur procrastinates even has mental blockages and gives up in the face of obstacles therefore the immigrants should use the opportunity of their mixed embeddedness in institutional context theoretical implications theoretically this study makes several important contributions to immigrant entrepreneurship first we connect immigration with entrepreneurship to integrate mixed embeddedness with the tpb both conceptually and empirically on a cognitive level based on our assessment both tpb and mixed embeddedness logics are important to understand the relevance of the iei formation process this indicates new theoretical linkages that have rich potential for theory and research in immigrant entrepreneurship this study extends the tpb by contributing significantly to the limited literature on factors driving the immigrants intention process to become entrepreneurs in their host country in this article we are concerned with the antecedent drivers of iei and whether these are different from the drivers of traditional ei since both immigrant and traditional entrepreneurship are desirable for economic growth global competitiveness and entrepreneurship diversity it is important to understand how both types of entrepreneurships behaviour emerge this empirical study confirms the plausibility of tpb in understanding the antecedents of intention to start a business by immigrants it has clearly shown the importance of several factors that are often overlooked in previous works on iei the goodness of fit of the model validates the inclusion of these factors in the tpb when predicting ei of immigrants moreover while the evidence from the literature shows that the tpb variables have been extensively studied in the decisions of individuals to engage with an intention to start a business in various contexts studies that engage immigrant entrepreneurs intention formation process are rare the inclusion of such previously unexplored factors fills important knowledge gaps and enriches the understanding of their effects on the ei of immigrants in host countries under a holistic decisionmaking process second it also enriches the theory by comforting the tpb against the problem of inclined abstainers individuals who form an intention and subsequently fail to act that has been a recognized limitation of the tpb third it improves the understanding of the mixed embeddedness approach by adding the effects of country of origin a neglected aspect that recently drew criticism the approach is a waldinger et al s interactive model refined by adding new elements limited to the host countryspecific institutional frameworks finally to the best of our knowledge entrepreneurial culture distance in entrepreneurship research has not been adequately addressed previously in doing so this study advances theoretical conceptualization in the field of immigrant entrepreneurship furthermore the iei formation process cannot be adequately described without addressing the factors holistically through learning and cultural sensitivity this logical argument that underpins this study helped us to identify which factors should be studied as well as how and why they are interlinked empirical implications the operationalization of cultural distance of entrepreneurship concept is intended as an empirical contribution to existing knowledge on immigrant entrepreneurship this study empirically tests an entrepreneurial model based on the relationship of beliefattitudeintention framework developed by several authors such as krueger we present an integrative model integrating individual and contextual dimensions along with psychological factors that jointly form the immigrant entrepreneurship intention formation process this study differs from the study of zhu et al where variables like entrepreneurial cultural differences were absent practical implications the importance of our research lies first in the fact it provides a valuable piece of information to those in charge of entrepreneurial support and decisionmakers who seek to further promote the emergence of entrepreneurial activity in immigration context immigrants cannot claim to become entrepreneurs merely on the basis of an identity as entrepreneurship is a learning process even more so is entrepreneurial intention itself we argue that ei is also a learning process with regards to the way enterprises are doing business second analysis across the worlds entrepreneurial ecosystems displays common challenges posed by an entrepreneurial culture to develop and transmit and how to ensure that individuals who wish to start a business actually take action the study affords clear implications of theory for problemsolving in immigrant integration situations immigrants should learn to undertake for ensuring progress in the process rather than developing rigid policy instruments our results allude to the importance of encouraging the entrepreneurial mindset and network of immigrants the problem is not just taking action but rather persisting in action this requires integral embeddedness we therefore support and plead for formal experiencebased training third if our results show that perceived risk can weaken the passion for entrepreneurship entrepreneurial behaviour reality and contexts require individuals to get familiar with local entrepreneurial culture examining culture at a more granular level than previous research reveals that entrepreneurial culture is a shared liability issue the liability of foreignness behoves the immigrant to learn the local entrepreneurial culture whereas the liability of the host country consists of cultivating such culture in a way that allows learning it to boost the entrepreneurial mindset empowering immigrants entrepreneurial intention through entrepreneurial culture is the key policy makers should take action to help their entrepreneurial ecosystems to thrive by strengthening human capital addressing localnational inequalities through promoting cohesive inclusive and sustainable entrepreneurship to support integration through entrepreneurship destination countries should help the immigrants in improving their human and social capital consequently this would lessen the disadvantage they face in their host countries finally in international business literature several recent studies have begun to focus on the joint effect of formal and informal institutions the results of our study are consistent with this and call for institutional complementarity in the support to be offered to immigrant entrepreneurs conclusion although it is not always easy to work at the intersection of two disciplines this study could attest to the benefits of combining economic and psychological perspectives in examining iei it is challenging to appreciate how the cognitive perspective in which we have embedded this work has served as an interface to integrate several theoretical approaches this has led to a deeper understanding of the process of iei the difficulties and obstacles being encountered by immigrants in starting and developing their businesses are often those that they should have paid attention to during the entrepreneurial intention phase as the saying goes trees with deep roots are those that grow high the challenges that are not identified at this stage can persist and jeopardize the career that is chosen out of opportunity or necessity while perceived risk only affected intentions via the tpbs desirability factors the formal and informal context only had direct effects on the feasibility factor of the tpb framework particularly future studies could focus more on a longitudinal analysis of these direct effects by and large therefore we conclude that the interaction between individual factors and contextual factors plays an important role in the transition of immigrants from the employability world to that of selfemployment and that future research should continue to shed light on this interaction preferably in an interdisciplinary manner and especially using longitudinal designs this will contribute to a better understanding of immigrants ei for engaging in entrepreneurship moreover the use of a structural equation model has confirmed that the distance between the host countrys entrepreneurial culture and that of the country of origin acts as a reducing factor in perceived feasibility in contrast entrepreneurial support should serve as an amplifier of the latter to maximize ei and without further delay move on to real entrepreneurial action there would be a compromise in the perception of feasibility of a business project between entrepreneurial cognitive mechanisms particularly between the distance of entrepreneurial culture and institutional entrepreneurial support this study calls for an adaptation of the ad hoc structures to the actual support needs it should be noted that this study has several limitations although the hypothetical path model is based on wellestablished theories unfortunately the correlational design of our study does not allow for strictly causal interpretations another limitation is the fact that our data was collected from a single source the immigrants canadian experience of immigrants was only assessed using the 10 3389fpsyg20231153142 frontiers in psychology 15 frontiersinorg singleitem measure while it is important to limit the number of items that respondents must complete future research could also use multiple item instruments for this construct finally iei is a psychological state of mind and there are many more individual and social variables that could also be integrated into the model we have also assumed canada as a given background of space and place in relation to immigrant entrepreneurship except the entrepreneurial cultural difference institutional supports and personal network in the host market future studies on iei might consider other individual and contextual variables related to canadian space and place that facilitate or create constraints in the iei formation process future study might also consider variables such as the duration of stay in canada and visatype of immigrant entrepreneurs for the iei formation process data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors frontiers in psychology 12 frontiersinorg and vozikis 1994 it however corroborates subsequent studies by these same authors who see entrepreneurial selfefficacy as another cognition also with intentional qualities as derived from social learning theory as an alternative to the direct effects of antecedents on entrepreneurial intention only personal attitudes show an immediate effect on subjective norms while the impact of perceived behavioural control on subjective norms is not confirmed this suggests that an immigrants selfefficacy does not seem to convince his or her reference group in this study the effect of the reference groups social norms is difficult to identify due to the samples cultural diversity il can also imply that the need for starting an entrepreneurial venture for survival in a new country was so dire that immigrants entrepreneurs do not put that much important on the effect of subjective norms of their reference group however it cannot be excluded that we are dealing with some individuals with low selfefficacy beliefs pessimistic selfefficacy beliefs are likely to affect behaviour particularly thinking and decisionmaking quality pertaining to individual variables the three psychological factors have helped to better understand the effect of these variables on immigrants intention to engage in entrepreneurship they add an important perspective to the study on immigrant entrepreneurship by addressing why individual variables might be necessary for immigrants transition to entrepreneurship in this vein our study final empirical model for predicting immigrant entrepreneurial intentions ethics statement the studies involving human participants were reviewed and approved by the research ethics committee of laval university 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

economic integration of everincreasing number of immigrants in the host country is a challenge both for the immigrant and their host government immigrant entrepreneurship can be one of the solutions to this challenge however little is known about how immigrant entrepreneurship intention formation process takes place immigrants face various challenging situations that make them psychologically and cognitively distinct this study models from a holistic perspective the dimensions of individual and contextual variables as antecedents of immigrants entrepreneurial intention iei the study aims to identify the key factors responsible for developing ei of immigrants with an implementation intent crosssectional data from canada is examined using a sample of 250 immigrants the analysis adopts a structural equation modelling approach in addition to risk perception bridging social network and experience we postulate that the perceived distance of entrepreneurial culture country of origin versus host country and entrepreneurial support are crucial factors that influence iei empirical analyses based on survey data partially confirmed our hypotheses the results show the role of psychological and cognitive factors in determining immigrants intention to start a new business we extend the theory of planned behaviour tpb by identifying certain understudied determinants in the literature and presenting a holistic decisionmaking process in the context of immigrationentrepreneurship nexus examining specific factors that appropriately contextualize immigrant entrepreneurship research and relativize the ei through a learningbased approach advances current literature it offers insights to policymakers and practitioners to contemplate entrepreneurial culture as a shared liability issue foreignness host country and adapt their entrepreneurship guidance accordingly thus this study opens the way to a better understanding of the business behaviour of immigrants their impact matters for the entrepreneurial diversity that resilient ecosystems need

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introduction stunting is an ongoing issue in many lowand middleincome countries unicefwho and the world bank 1 indicate that the number of stunted children is approximately 151 million accounting for 222 of the children in the world moreover the proportion of stunted children is concentrated in lowincome and lowermiddleincome countries compared to uppermiddleincome and highincome countries 1 approximately 838 million stunted children live in asia mainly in southern and southeastern asia 587 million in africa and 51 million in latin america and the caribbean indonesia is one of the countries with a high burden of malnutrition including stunting 1 child health outcomes are poor even though the indonesian economy is the largest in southeast asia and the 17 th largest in the world 2 data published by the ministry of health show that the incidence of stunting among children aged five years and below remains high at 308 3 the world bank 4 noted that indonesia has underperformed in terms of reducing the level of stunting compared to other uppermiddleincome countries and other countries in the region given the high prevalence of stunting and its impact on childrens cognitive development the productivity level of indonesias next generation is predicted to be half of its potential 4 therefore tackling child stunting remains a major government commitment as asserted in the indonesia medium development goals 20152019 and 20202024 56 the wider literature on stunting reveals that various child parental householdand communitylevel characteristics are associated with stunting 7 8 9 10 11 12 13 at the parental and household levels several dietary and socioeconomic factors have been shown to be correlated with the risk of stunting with regard to risk factors beal et al 7 for example established that the risk of stunting in indonesia is higher in households that have no access to safe drinking water household wealth status is another significant predictor as children coming from poor households are more likely to be stunted 1112 meanwhile at the community level the prevalence of stunting has been shown to be higher in communities that lack access to health care 7 in terms of protective factors for stunting previous studies have shown that the likelihood of stunting is lower in communities where antenatal care services and integrated health and nutrition services are available 8913 in addition consumption of diverse food within the household has also been found to lower the likelihood of stunting 14 furthermore parental education has been shown to be significant with children raised by educated parents having a lower risk of being stunted semba et al 11 explored the channels through which parental education impacts stunting and argued that educated parents provide more care which would in turn lower the risk of stunting the prevalence of stunting in indonesia varies by region as illustrated in fig 1 below 3 it improved across all provinces between 2013 and 2018 except in east kalimantan the capital city of jakarta province had the lowest prevalence in 2018 at 177 whereas east nusa tenggara recorded the highest at 426 provinces in the eastern part of indonesia where many development indicators lag behind other regions have a higher prevalence of stunting the world bank 4 has also highlighted the regional variation in the incidence of stunting in indonesia and further noted that the risk of stunting was higher in poor and populous districts where access to basic infrastructure of water sanitation and hygiene was lacking this paper examines the individual household subdistrictand provinciallevel determinants of stunting using a multilevel mixed effects model methodologically this is an improvement over most of the previous literature in the field see for example 13 14 15 as earlier studies examined the determinants of stunting in indonesia using logistic and probit regressions a multilevel model was appropriate for our analysis because of the hierarchical or clustered structure of our data young children living in the same household and community can be expected to have more similar stunting risks compared to those living in different households and communities 111215 furthermore children in the same province are more likely to have the same risk of being stunted because they have similar access to health care services and other infrastructure 8913 in addition parental characteristics and household socioeconomic background have an influence on childrens eating habits and nutritional status 1415 multilevel modeling enables us to investigate individual heterogeneities and the heterogeneities between clusters and improves the estimation techniques used in previous stunting studies see for example 13 14 15 in addition taking into account the clustering in the data generates more reliable standard errors of regression coefficients 16 this paper addresses two main research questions do variations at the province subdistrict household and individual levels explain childhood stunting in indonesia what are the multilevel determinants of childhood stunting in indonesia the remaining parts of the paper are organized as follows section 2 discusses the data and methodology used in the paper including the outcome variables and various control variables included in the estimation section 3 presents and discusses the results of our estimation the last section presents the conclusions and provides policy recommendations based on the findings of the study data and methods data source an open access and rich dataset from the indonesian family life survey was used to estimate the multilevel determinants of stunting across households subdistricts and provinces in indonesia the ifls is a longitudinal survey representing 83 of the indonesian population in 1993 the survey has five waves of data collected in 1993 1997 2000 20072008 and 20142015 the survey was conducted by the rand institute with the cooperation of local universities and research centers in indonesia the first wave of the survey covered only 13 provinces but the number was broadened to include more than 20 provinces in the last round to capture respondents mobility to other provinces ethical clearances for the surveys were provided by institutional review boards in the united states and gadjah mada university for ifls waves 3 4 and 5 and by the university of indonesia for ifls waves 1 and 2 this particular study focuses on the last two waves of iflswave 4 and wave 5 analyzed as repeated crosssectional surveys there were 13500 households and 43000 individuals interviewed in the fourth wave of the study the number of respondents increased in the fifth wave to 15900 households and more than 50000 individuals this study only covers young children aged five years old and below the dataset includes a total of 8290 young children with 4142 in wave 4 and 4148 in wave 5 using child anthropometry information we excluded children identified as having biologically implausible values based on zscores of height following the world health organization child growth standard which reduced the number of children to 8105 in addition we removed young children for whom complete information on household and community characteristics was not available hence the number of young children included in our final analysis was 8045 the proportion of respondents with missing values was insignificant four hierarchical levels were considered in our analysis individual household subdistrict and province children were nested within households there were 6437 households with 8045 children aged 5 and below in the two waves of the ifls approximately 20 of the total households had more than one child aged 5 and below households were nested within subdistricts there were 1332 subdistricts recorded in the two waves of the survey we considered the subdistrict as the third level in our model as service provision and quality of care in primary health centers or puskesmas are determined at the subdistrict level the fourth level was the province within which subdistricts were nested we considered provinces as the highest level in our analysis there were 21 provinces in the two waves of the ifls used in our study the ifls provides a wide range of information including data on birth history anthropometry of children clinical and subclinical infection dietary habits and demographic characteristics child health status data include both a selfreported measure of general health status and a biomarker measurement conducted by a nurse furthermore the household data consist of information on parental education and parental anthropometry antenatal care during pregnancy consumption and wealth and household access to wash finally the ifls also includes other communitylevel data consisting of access to nutritionspecific intervention programs in the phcs in childrens neighborhoods outcome variable according to the 2005 world health organization child growth standard and indonesian ministry of health guidelines 17 stunting is a measure of childrens nutritional status based on their height nutritional status is determined by comparing the height of children with their peers of the same age height was measured during the survey by trained interviewers then the zscore of height was calculated using the height of children and the corresponding median and standard deviation for children of the same age which were obtained from the anthropometry guidelines we then further grouped nutritional status into four categories using the calculated zscore values the first group consists of severely stunted children whose heightforage zscores are more than three standard deviations below the world health organization child growth standards median the second group consists of stunted children whose heightforage zscores are more than two standard deviations below the who child growth standards median the third group is considered to have normal nutritional status and their zscore is within two standard deviations of the who child growth standards median the last group consists of children who are considered to have above normal nutritional status with zscores more than two standard deviations above the who child growth standards median as the focus of our analysis in this research is stunted children for our regression analysis we categorized children into two groupsstunted and not stunted the stunted group consisted of children who were severely stunted and was represented by a dummy variable equal to one the remaining children were categorized as not stunted and were represented by a dummy variable equal to zero individuallevel variables one of this studys particular aims was to assess the impact of childrens dietary habits on stunting the ifls dataset provides data on dietary diversity and consumption frequency in the one week prior to the survey for each child in the family studies have suggested that adequate dietary diversity lowers the odds of stunting whereas the consumption of unhealthy snacks raises it 14 18 19 20 we constructed a binary variable capturing the intensity of unhealthy snacking as a measure of childrens dietary habits following wang et al 21 the dummy variable for unhealthy snacking took the value of 1 for children consuming unhealthy snacks more than 7 times a week and took the value of 0 for those with lower consumption frequency snacks in the ifls survey include instant noodles fast food carbonated beverages and sweet snacks that are usually high in salt fat and sugar and low in micronutrient content however unhealthy snack data are only available in ifls wave 5 therefore we conducted two estimations our first estimation used both waves of the ifls and excluded the unhealthy snack variable whereas our second estimation used only the ifls wave 5 and included the unhealthy snack variable demographic characteristics of children such as gender have also been considered predictors of stunting 152223 a dummy variable was constructed to test whether male children have a higher risk of being stunted as earlier studies have found 152223 the study also included neonatal weight as one of the predictors of stunting as suggested by tiwari et al 23 and de silva and sumarto 15 according to the world health organization 24 a newborn baby weighing fewer than 25 kg is considered a small baby our dummy variable assumed a value of 1 if the neonatal weight was fewer than 25 kg and 0 otherwise infections such as enteric infections and diarrhea contribute to stunting 25 the ifls dataset has information on childrens acute morbidity in the four weeks prior to the survey including the occurrence of diarrhea we constructed a dummy variable that assumed a value of 1 for children who had experienced acute diarrhea and 0 otherwise householdlevel variables householdlevel variables consisted of both parentaland householdlevel factors that have been found to affect stunting in the wider literature previous studies have indicated that maternal education is associated with a lower risk of stunting 71523 mothers are primary caregivers in most indonesian households and we controlled for maternal education using years of schooling we also included the mothers height in our model to control for maternal stature in line with previous literature 111526 according to beal et al 7 a short mother has a higher risk of having stunted children therefore we created a dummy variable equal to 1 for mothers whose height was fewer than 145 cm and 0 otherwise previous studies have shown a strong association between stunting and socioeconomic background de silva and sumarto 15 and mani 27 presented evidence that higher household consumption expenditure per capita and greater wealth lower the prevalence of stunting among children the ifls dataset provides detailed information on food and nonfood consumption food expenditure consists of spending on staples vegetables dried foods meat and fish beverages and prepared food the expenditure on nonfood items includes spending on education electricity water telephone household items recreation entertainment clothing and medical costs we used the quartile of total consumption expenditure per capita as a measure of household wealth categorizing the expenditure data as quartiles labeled q1 to q4 with q1 being the lowest quartile of expenditure we included three dummy variables that identified poor households in the bottom quartile of the consumption expenditure distribution as a base compared with the higher quartiles of q2 q3 and q4 to account for possible differences in health service delivery between rural and urban areas we included a dummy variable for place of residence which equaled 1 for children living in rural areas and 0 for those living in urban areas some earlier studies have suggested that childhood stunting is more prevalent in rural areas 152328 and we examined whether this also held true for indonesia finally this study also examined the contribution of household access to wash previous studies have underlined the importance of sanitation and access to health services in lowering the risk of stunting 12152930 this study considered the association between access to clean wash and the risk of stunting three dummy variables were introduced in the empirical model to capture wash variables the main source of drinking water in households was coded as 1 if the source of drinking water was either tap water or mineral water and 0 otherwise the availability of a toilet was coded as 1 if there was a toilet with its own septic tank for sanitation and 0 otherwise additionally the disposal of garbage was coded as 1 if garbage was disposed into a trash can that is collected by a sanitation service and 0 otherwise communitylevel variables we examined the effect of nutritionspecific intervention programs in phcs in young childrens neighborhoods the ifls dataset provides information on access to three nutritionspecific services provided by phcs growth and development monitoring additional treatment for malnutrition and additional nutrition for the poor a dummy variable was created to differentiate between young children who have access to all three nutritionspecific services and those who do not statistical methodology the study examined the individual household communityand provincelevel determinants of stunting using a multilevel mixed effects logistic model multilevel models allowed us to take into account the hierarchical structure in our data and calculate residual components at each level in the hierarchy the individuallevel variables we controlled for included childrens demographic characteristics birthweight history of diarrhea and dietary habits the familylevel variables included mothers education mothers stature and family consumption we also included contextual variables at the community and district levels in the form of access to clean water hygiene and sanitation availability of nutritional services and area of residence the adjusted odds ratio of the fixed effects reflects the likelihood of stunting in children the intraclass correlation coefficient measures the degree of homogeneity within clusters in the risk of stunting the partitioning of the residual components at each level enables us to see the effect of unobserved provinceand communitylevel characteristics on stunting another advantage of multilevel models is that they allow simultaneous estimation of group effects and the effect of grouplevel predictors we started our estimation by running mixed effects logit null models without covariates the first null model introduced a random intercept term at level 4 the second null model included an additional random intercept term at level 3 additionally the third null model included an additional random intercept term at level 2 the null models provided an indication of how much variation in stunting each additional cluster accounts for predictors were introduced in a stepwise manner starting with childlevel covariates and followed by familyor householdand communitylevel covariates the table also shows that more than half of the children consumed unhealthy snacks frequently based on wave 5 data in terms of gender composition 52 of the children were boys moreover the proportion of children who suffered from acute diarrhea was 1546 however only 4 had been small at birth with a weight of less than 25 kg results characteristics of study participants mothers in our sample had on average 8 years of education which is equivalent to reaching the second year of junior high school in indonesia in terms of stature 4517 were fewer than 145 cm tall and were therefore classified as short following beal et al 7 for householdlevel variables the data revealed that the monthly average household consumption expenditure per capita increases as we move from the bottom quartile to the top quartile the average for the bottom quartile was 230947 rupiah compared to 23 million rupiah in the top quartile the proportion of children living in rural areas was 4416 from the descriptive statistics for access to wash facilities we can see that more than 96 of households had access to clean water only 688 had access to sanitation and an even lower proportion had access to hygiene last the data show that 27 of families had access to all three nutritionrelated services from phcs multilevel analyses of stunting determinants we present the results from the estimation of our three null models in table 2 as noted previously the first null model includes random effects at the province level the second null model includes random effects at both the province and the subdistrict levels and the third null model includes random effects at the province subdistrict and household levels we can see from the table that the likelihood ratio test statistic is highly significant for all three null models this shows that multilevel models are a better fit to the data than a singlelevel model moreover we also conducted likelihood ratio tests comparing the fourlevel model with threeor twolevel models and found that the fourlevel model was a better fit for the data thus stunting in indonesia varies by province subdistrict and household and analysis of stunting needs to take into account variations at all these levels fig 2 below shows a caterpillar plot of the residuals from all 1332 subdistricts in the sample with 95 percent confidence intervals the residual shows the departure of the risk of stunting for subdistricts from the average the graph reveals that for a substantial number of subdistricts the 95 confidence interval does not overlap with the horizontal line at zero indicating that stunting in these subdistricts is significantly above average or below average table 2 also presents the intraclass correlation coefficient which measures the degree of homogeneity in the risk of stunting within clusters a higher icc indicates a stronger correlation in the risk of stunting within a cluster we can see from model 3 that the level4 intraclass correlation at the province level is 0031 whereas the level3 intraclass correlation at the subdistrictwithinprovince level is 0127 and the level2 intraclass correlation at the householdwithinsubdistrict level is 0297 this indicates that withinsubdistrict differences are more important in explaining the variation in the risk of stunting in indonesia than differences between subdistricts and provinces we can also calculate the variance partition coefficients to see the contribution of unobserved cluster characteristics to the risk of stunting at each level in our model the vpcs indicate that 3 of the variation in stunting is due to differences between provinces whereas 10 is due to differences between subdistricts differences between households account for 17 of the variation whereas individual differences between children account for 70 of the variation in stunting we present our estimation results in table 3 our most comprehensive model controls for householdand individual childlevel covariates and communitylevel contextual characteristics two main estimates are generated from the stepwise regression in s1 appendix as discussed in the methodology section the first estimation employs two complete waves of the dataset these results are presented in columns 1 and 2 of table 3 the second estimation relies on the latest wave of data as information about dietary habits particularly unhealthy snacking behavior is only available in wave 5 these results are presented in table 3 columns 3 and 4 for the individual variables our findings indicate that a high frequency of snack consumption is associated with a higher risk of children being stunted in terms of magnitude frequent snacking increases the risk of being stunted by 30 as shown in table 3 1828 30 31 32 34 additionally our results indicate that boys have a higher risk of being stunted than girls a finding that is consistent with previous studies the likelihood of stunting was higher by 17 for boys than girls using two waves of data and by 26 using the wave 5 dataset 32 33 34 35 another individuallevel factor that is associated with a higher risk of stunting is neonatal weight this study found that small babies weighing fewer than 25 kg at birth have a 2 times higher risk of being stunted than babies of normal weight according to our model utilizing both waves of data the odds of stunting for a small baby were 229 the final individuallevel predictor of stunting is infection with diarrhea the estimations revealed that suffering from acute diarrhea in the four weeks prior to the survey is associated with a higher risk of being stunted with an odds ratio of 127 in the model using wave 4 data and an odds ratio of 130 in the model using waves 4 and 5 our results also indicate that maternal characteristics such as maternal stature and years of schooling and household characteristics such as household wealth quartile place of residence and access to basic infrastructure are significantly associated with stunting children whose mothers are shorter than 145 cm have a 19 greater risk of being stunted moreover the number of maternal years of schooling lowered the risk of being stunted our results also suggest that children from poor households have a higher risk of being stunted the risk of stunting decreased by 23 for children in the second quartile of the wealth distribution the risk of stunting was further lowered for children in the fourth quartile by 44 it is apparent from our results that children living in rural areas have 19 greater odds of being stunted than children living in urban areas this study also found that having no access to clean water increases the risk of being an odds ratio is statistically significant at either 1 percent 5 percent or 10 percent of the confidence intervals stunted by 36 similarly having no access to sanitation was associated with a 27 higher risk of being stunted a higher risk of stunting was also associated with a lack of access to hygiene at 52 the stepwise estimation using the multilevel mixed effects model shows that the risk of stunting is higher if the children have no access to nutrition services programs in phcs but this association is not statistically significant finally the estimation shows that the odds of being stunted for young children in 2014 was higher than that for young children in 2007 the data show that the proportions of stunted children in 2007 and 2014 were 24 and 29 respectively discussion our analysis found that stunting is associated with several individual familyhouseholdand communitylevel variables frequent unhealthy snacking male sex low birthweight and diarrhea increase the risk of being stunted family characteristics that contribute to stunting risk include short maternal stature and having a family with a low socioeconomic status in terms of community characteristics this study found that living in rural areas increases the risk of stunting by 19 the risk of stunting is also higher for children living in a community with a lack of access to clean wash the results show that there is a positive association between a high frequency of snack consumption and the risk of children being stunted studies have indicated that snacking is becoming more prevalent in indonesia both in rural and in urban areas a study by sekiyama et al 19 showed that onethird of food consumed by young children in west java indonesia can be categorized as snack food high snack consumption has a detrimental effect on childrens development because snacks contain mostly fat and energy but have a lower density of protein and micronutrients black et al 31 and tarwotjo et al 32 suggested that a lack of micronutrient intake such as calcium and vitamin a adversely affects childrens linear growth the world health organization has reported that chronic deficiencies in micronutrients are experienced by more than 2 billion people worldwide 29 micronutrients are vital for childrens development because they have a significant role in bone formation long bone growth and intrauterine femur length increase 33 34 35 the importance of micronutrients for children has also been established by other studies measuring the effect of the school feeding program on childrens development 36 37 38 a quasiexperimental study by metwally et al 36 revealed that feeding children pie made of flour fortified with vitamins and minerals has a positive effect on cognitive development nevertheless the effect of sfp on nutritional status takes a longer time to manifest so the effect is not statistically significant another study of sfp in rural kenya showed that the intake of minerals such as zinc and iron and vitamins may increase childrens appetite muscle growth and physical activity 37 the importance of micronutritients on childrens diet has also been found in the impact evaluation of sfp programs in rural uganda 38 it was found that children fed one or two eggs per day gained more height and weight because eggs are a source of 13 essential micronutritients and protein which are essential for childrens development our finding that boys have a higher risk of being stunted than girls is consistent with previous studies adair and guilkey 35 moestue 34 and wamani et al 33 for example found that the heightforage zscore for girls is higher than that for boys thus girls have a lower prevalence of stunting in subsaharan africa and china the literature suggests that higher stunting prevalence among boys may be explained by complementary feeding practices boys receive premature complementary foods as parents perceive that breastfeeding is not sufficient to fulfil the greater energy intake they believe is required for baby boys 18 a study by tumilowicz et al 39 showed that among guatemalan children more boys than girls aged 23 months are fed complementary foods the ifls dataset for young indonesian children also shows that complementary feeding is initiated for boys earlier than for girls on average complementary feeding for indonesian young children in the ifls data of waves 4 and 5 started at 1974 weeks for baby girls and 1891 weeks for baby boys the difference was statistically significant in a ttest in addition these complementary feeding practices do not benefit boys because they are more likely to be fed more meals than girls tumilowicz et al 39 presented evidence that baby boys are fed two more meals than girls in a 24hour period premature complementary feeding practices have a detrimental effect on young children because they pose a greater risk of catching infectious diseases 4041 in addition early introduction of food before babies reach 6 months of age has no significant effect on childrens length or weight development 23 as presented in the results section we found that babies of lower birth weight have a two times higher risk of being stunted than babies of normal birthweight this finding is consistent with a study by tiwari et al 23 which found that average and above average weight newborn babies have lower odds of being stunted than smaller babies furthermore a saleemi 42 and varelasilva et al 43 also showed that the risk of smaller babies being stunted is three times higher than that for other babies according to schmidt et al 26 neonatal weight and particularly length are good indicators of the status of childrens nutrition in the future low neonatal weight and short length may be an indication of intrauterine growth restriction meaning that babies are not growing at a normal rate inside the womb during pregnancy lower neonatal weight and height may also be related to maternal malnutrition during pregnancy which in turn influences the development of the baby 23 moreover small babies may also have been born prematurely which means they may not have fully developed during pregnancy 23 in the long run iugr may lead to numerous developmental issues such as growth retardation lower cognitive ability development and poor neurodevelopmental outcomes in terms of infection with diarrhea our findings are consistent with previous studies by bardosono et al 44 beal et al 7 and tiwari et al 23 these authors also found that diarrhea is associated with stunting according to richard et al 45 diarrhea is a particularly common health issue in developing countries as households lack access to clean water and sanitation drinking from unimproved water sources and drinking untreated water increase the risk of diarrhea due to intestinal infections from a variety of bacteria parasites and viruses richard et al 45 suggest that the impact of diarrhea on linear growth is particularly strong when young children suffer from multiple episodes of diarrhea in the first 24 months of their lives furthermore diarrhea may lead to growth retardation if the occurrence of diarrhea coincides with a lack of goodquality food and poor access to health care diarrhea has a detrimental effect on linear and ponderal growth as it lowers dietary intake escalates metabolic demands and lessens nutrient absorption in the gut 45 our analysis found a strong association between maternal stature and childhood stunting semba et al 11 similarly established a strong association between maternal stature and stunting and schmidt et al 26 contended that maternal stature and neonatal weight are the strongest predictors of child stunting maternal stature is perceived to be a good indicator of intragenerational undernutrition prendergast and humphrey 46 argued that having a stunted mother is relevant in explaining stunting prevalence in children because of the importance of the nutritional status of the mother on childrens stunting mothers suffering from undernutrition may have a higher risk of having stunted children because of their significant influence especially in the first 500 days of a childs life the association between maternal years of schooling and risk of stunting is also supported by previous studies see for instance 81941 a better educated caregiver is perceived as having appropriate maternal nutritional knowledge 44 furthermore semba et al 11 found that better educated parents tend to engage in more protective caregiving for example they may do this by ensuring that their children receive vitamin a capsules are fully immunized have access to better sanitation and consume iodized salt the results also provide evidence that children from poor households are at higher risk of being stunted the strong association we found between family wealth and stunting has been established in the literature 7111327 47 48 49 50 bardosono sastroamidjoo and lukito 44 argued that poor families lack the resources to consume highquality nutritional foods and access health care our result shows the positive association between living in rural areas and the risk of being stunted previous studies support the finding that children living in rural areas have a higher risk of stunting than their peers in urban areas see for instance 152328 according to mahendradata et al 51 and mulyanto kurst and kringos 52 both the demand and the supply of health care vary between urban and rural areas people living in urban areas have more access to health care and other related infrastructure such as roads that reduce the travel time to health care facilities meanwhile access to health services in rural areas is more limited according to sparrow and vothknecht 53 63 of subdistricts in indonesia have no access to phcs these districts are mostly in rural areas outside java island furthermore their study reported that 42 of phcs in rural areas have no physician serving in health facilities physical health infrastructure such as working incubators lab facilities and outpatient polyclinics is also more limited in rural areas another study by schmidt et al 26 suggested that a higher prevalence of stunting in rural areas compared with urban areas is related to a greater sensitivity to changes in food prices families in rural areas are more sensitive to food price increases because they allocate twofifths of their budget for staple needs as the price of foods increases the purchasing power of rural families declines making it harder to fulfil the essential nutritional requirements of their children our results also show that a lack of access to wash is associated with stunting among young children in indonesia secure access to wash infrastructure is critical young children are more prone to diarrhea intestinal worm infection and environmental enteropathy when households have poor wash facilities 9 these infections may lead to nutritional issues for example children may lose their appetites so they might consume less food than they need in addition these types of infections can lead to the malabsorption of nutrition and chronic immune activation finally infections may induce fever which requires the body to burn more food and exert energy to fight the infection instead of using it for physical development the insignificant association we found between stunting and access to nutrition services in phcs may be due to the limited capacity of the indonesian nutrition program as shown in a report by unicef 54 in terms of coverage of the nutritionspecific interventions recommended by the lancet 55 the indonesian government has only adopted 4 out of 10 of the remaining six programs four are partially covered and two are not included in terms of health infrastructure the proportion of nutritionists per head in the population is low in indonesia and varies across regions in the larger provinces on java island such as in central java the number of nutritionists to every 1000 people was as high as 4314 in 2017 however the number was much lower in the provinces outside java island for example in east nusa tenggara one of the provinces with a high prevalence of stunting the number was only 1204 our results also show that the risk of stunting for young children was higher in 2014 than in 2007 previous studies have revealed that after a significant decline in stunting prevalence in indonesia in the 1990s and early 2000s 28 the prevalence remained unchanged in the 2000s 56 our finding aligns with national data from the indonesia socioeconomic survey and basic health survey which shows that stunting prevalence was higher in 2013 than in 2007 a world bank publication acknowledges the important role that nutrition programming and surveillance at the village level in the 1980s played in reducing the prevalence of malnutrition in indonesia however this massive program has experienced setbacks and lost the close attention of the government furthermore indonesia has undergone decentralization which has reduced the effectiveness of nutrition programs in improving childrens nutritional status due to weak management and poor governance 57 study limitations and strengths this study highlights the importance of familyand communitylevel variables in stunting in addition to individual characteristics the assessment of the different levels of clusters in this study facilitates understanding of how contextual factors contribute to stunting in children hence our study demonstrates the urgency of addressing not only personalor individuallevel factors but also householdand communitylevel factors to reduce stunting prevalence the limitations of this study are listed here first regarding the source of the data the two waves of the ifls data used in our paper are representative of approximately 83 of the indonesian population covering 21 provinces thus some areas of eastern indonesia were excluded from our analysis additionally ifls wave 4 data do not capture unhealthy snacking behavior among young children this variable is considered an important proxy for measuring childrens dietary habits therefore we used only wave 5 data to examine this issue second from a methodological perspective the crosssectional nature of our analyses limited our ability to infer causation moreover some data were based on selfreported information for example the birth weight of the children and thus may be susceptible to measurement error in addition our study did not control for the random slope component in the model the assessment of nutritional services was conducted from the supply side however we adjusted for several important confounders and took into account some unobserved characteristics through multilevel modeling conclusion stunting remains a development issue in indonesia with approximately 30 of young children being stunted this study examined the multilevel determinants of stunting among young children in indonesia at the contextual level the icc showed that there is a correlation in the risk of stunting for children living in the same province the correlation becomes stronger for children living in the same subdistricts finally the strongest correlation of the risk of stunting was found among children living in the same household moreover the likelihood ratio tests revealed that stunting in indonesia varies by province subdistrict and household level and analysis of stunting needs to consider variations at all these levels at the child and family levels our results identified several statistically significant determinants of childhood stunting in terms of individual characteristics being a boy having a low neonatal weight and experiencing acute diarrhea were associated with stunting in terms of family characteristics we found that mothers characteristics specifically maternal stature and maternal education were associated with stunting in contrast living in a family with a higher socioeconomic status lowered the risk of stunting and the risk of stunting was much lower for children in the highest quartile of the wealth distribution finally in terms of community characteristics we found that living in rural areas increased the risk of stunting by 20 the risk of stunting was also higher for children living in a community with lack of access to clean wash from a policy perspective our findings suggest that tackling stunting in indonesia requires substantial effort to create spaces that assist policy implementation in establishing supportive multilevel conditions these include addressing both individualand householdlevel factors that support good child nutrition and development healthy eating habits mothers education and awareness socioeconomic characteristics and the availability of wash matter the data are available in a public repository from the orgwellbeingsocialandbehavioralpolicydata flsiflsdownloadhtml universitas sebelas maret grant contract number 452un2721pn2020 url the funders had no role in study design data collection and analysis decision to publish or preparation of the manuscript

stunting is still a major public health problem in lowand middleincome countries including indonesia previous studies have reported the complexities associated with understanding the determinants of stunting this study aimed to examine the household subdistrictand provincelevel determinants of stunting in indonesia using a multilevel hierarchical mixed effects modelwe analyzed data for 8045 children taken from the 2007 and 2014 waves of the indonesian family and life surveys ifls we included individual familyhouseholdand communitylevel variables in the analyses a multilevel mixed effects model was employed to take into account the hierarchical structure of the data moreover the model captured the effect of unobserved household subdistrictand provincelevel characteristics on the probability of children being stuntedour findings showed that the odds of childhood stunting vary significantly not only by individual childand householdlevel characteristics but also by provinceand subdistrictlevel characteristics among the childlevel covariates included in our model dietary habits neonatal weight a history of infection and sex significantly affected the risk of stunting household wealth status and parental education are significant householdlevel covariates associated with a higher risk of stunting finally the risk of stunting is higher for children living in communities without access to water sanitation and hygiene

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introduction the desire to have a child is based both on psychological and social reasons assisted reproduction treatments have made it possible for many individualscouples to have a family even when sperm and oocytes are reduced or lacking large numbers of children are born following donor conception and there is an increasing demand for donor conception worldwide depending on legislation and regulations treatment with donor sperm oocytes and embryos is available to various groups of recipients including heterosexual couples lesbian couples and single women donor conception has traditionally been performed with anonymous donors while it has been less common to use a donor who is known to the recipient most often a female relative who donated oocytes there is a global trend towards programmes using donors that are identifiable to the resulting offspring at maturity commonly labelled identityrelease or openidentity donors the use of identityrelease donors implies that the donor is anonymous to the recipients although they may receive some nonidentifying information about the donor upon request from a donorconceived child that has reached mature age the donors identity is released to the child legislation on identityrelease gamete donation was first introduced in 1985 in sweden and later in other jurisdictions donor conception creates families where the genetic linkage between family members is varying and where there are genetic links to individuals outside the family unit the presence andor absence of genetic linkage may have psychosocial consequences for all involved parties ie for the donor and hisher family as well as for the recipient the donorconceived child and their larger family there is a relatively large body of research on the psychosocial aspects of anonymous donor conception and to a lesser extent on known donation systematic reviews in the field show that both oocyte and sperm donors psychosocial wellbeing was good throughout all donor groups and families created through the use of donor gametes appeared to be welladjusted during recent years the attitude towards disclosure in gamete donation has shifted from secrecy to openness and disclosure is now strongly encouraged by the ethics committee of the american society of reproductive medicine a recent systematic review focussing on donorconceived offspring showed that genetic ties are perceived as important especially during adolescence and adulthood and that many were interested in receiving more information about the donor and for potential contact in contrast to the relatively large body of research on anonymous and known gamete donation research on the psychosocial aspects of conception with gametes from identityrelease donors is more limited mostly due to the fact that this type of donor conception has been less common the purpose of the present review is to summarize the available research on psychosocial aspects of identityrelease gamete donation furthermore we want to present an overview of the specific perspectives of donors recipients and offspring including motivations for participating in this type of donor conception as well as perceptions of disclosure issues and potential contact between donor and offspring family pubmed and psycinfo databases were used in order to search for relevant empirical studies due to the diverse use of terminology for this type of donation it is possible that some studies including relevant groups were missed this overview covers only studies that specifically noted the inclusion of donors recipients or offspring involved in identityrelease donation but does not include studies on surrogacy although such arrangements frequently include donor gametes in several studies a small subset of participants concerned identityrelease donation such studies were included provided that they presented results from these groups separately and were otherwise excluded eg not surprisingly the largest number of identified studies was performed in sweden where identityrelease gamete donation has been mandatory since 1985 and the remaining studies were conducted in other european countries and in the usa perspectives of identityrelease donors motives and characteristics by definition the term donation implies altruism and both male and female donors who agree that their identity may be released to offspring at maturity have been found to donate primarily or solely based on altruistic reasons ie they want to help involuntarily childless people however also other motives such as receiving confirmation of ones own fertility potential spreading ones good genes and donating as a way to have a childchildren in the future have been reported with sperm donors more often reporting spreading their genes as a salient motive compared to oocyte donors although the dominant motive for donating was altruistic two small survey studies found that a subgroup of identityrelease sperm donors also reported financial motives a danish interview study with sperm donors five of whom had opted for identityrelease status found that financial compensation was a factor for the decision to allow more information about them to be made available to recipients but the childs wellbeing was also considered when providing extended information about oneself also in a large finnish study of oocyte donors one in four reported that the financial compensation had at least some influence on their decision to donate in contrast in a recent interview study including 24 oocyte and sperm donors in the uk all rejected the idea that they had been financially motivated and it was particularly important for sperm donors to frame their donation as a purely altruistic gift as a financial motive was perceived to be incompatible with a beneficial potential relationship with offspring from their donation oocyte donors on the other hand were more comfortable to incorporate the fact that they received financial compensation in the narrative of their donation as a gift to recipients longing for a child the personalities and characters of gamete donors are of interest for the recipients but also for the resulting offspring in a swedish national study the temperament and character inventory was used to assess both oocyte and sperm donors the sperm donors were found to all be in the normal range of character which means that the donors perceived themselves as autonomous individuals with capacity to take responsibility and with the ability to behave in a goaloriented manner the sperm donors described themselves as persons well integrated in society and having a capacity for relatively high identification with and acceptance of other people concerning the personality and character of the oocyte donors it was evident that they described themselves as less worried shy and fatigued and as more persistent compared to a comparison group of women in fertile age these findings are reassuring for all involved both in the donation and treatment process and for the future families and suggest wellfunctioning screening procedures in a noncommercial donor programme openness about donating little is known about donors view of informing others such as partners and biological children about their donation in two swedish survey studies each including 30 sperm donors almost all had shared information with their partner about their intention to donate or of being a donor the involvement and support from the partner seemed to be important factors for the decision to donate sperm particularly among younger men many donors in the ekerhovd et al study planned to inform their own children of the donation particularly if the donation did result in a child similarly in a welldesigned finnish study almost all oocyte donors who were mothers either had or planned to share this information with their children thoughts about offspring and potential contact for identityrelease gamete donors the number of children conceived with their gametes is of particular interest since the offspring will be able to obtain the donors identity and may attempt to contact the donor however only one study was found investigating donors views regarding the number of children a donor may conceive about half of 235 oocyte and sperm donors 58 years after their donation regarded 110 children to be an acceptable number of offspring from one donor with oocyte donors more often supporting an upper limit than sperm donors following identityrelease donation a majority of both oocyte and sperm donors would like to be informed if their donation results in pregnancy and birth in a swedish followup study of gamete donors sperm donors reported a higher level of emotional involvement with offspring from their donation compared to oocyte donors this included wanting to know how the child fares in life and feeling responsibility for the child if anything happened to hisher parents in two swedish qualitative studies each including 30 sperm donors most of them were positive or neutral towards contact with adult offspring from their donation this finding was confirmed in a large followup study of sperm donors and oocyte donors 58 years postdonation ten percent of donors were negative towards being contacted by an offspring and some comments indicate that this was based on a desire that the child would feel no need for contact and be happy in their real family among oocyte donors in finland a majority stated that they were positive or neutral towards future contact with an offspring but they were more uncertain regarding potential contact between their own children and a donor offspring furthermore in a qualitative study of 11 oocyte donors from the uk women were happy to be contacted by offspring but some expressed concerns regarding potential negative impact of such contact on the offsprings parents and on the donors own family so far only one study has reported on identityrelease donors position when adult offspring from their donation seek information about them in that study from one sperm bank in the usa clinic staff contacted sperm donors when information about them was being requested and 39 out of 43 men responded that they were open for contact with their offspring satisfaction with the donation and need for counselling the experiences satisfaction and consequences of being an identityrelease gamete donor ie with respect to the medical care and treatment have been investigated in a few structured followup studies in a finnish followup study of 428 former oocyte donors 67 of which were identityrelease almost all were satisfied with their donation similarly in a swedish study of 300 oocyte and sperm donors most of them were satisfied with the donation those who expressed ambivalence before the donation reported lower satisfaction 2 months after their donation in a qualitative study from the netherlands male donors expressed a need for counselling in order to discuss the emotional consequences of their donation disclosure to their own children family and friends and potential future contact with an offspring in a swedish followup study of 210 oocyte and sperm donors several years following donating one in four donors reported a need for counselling about how to manage potential future contact with offspring from their donation more than half of these donors wanted to be notified when an offspring requested information about them in order to prepare for potential contact while onethird were negative to receiving such information partly to avoid potential disappointment if no contact attempts would follow in the abovementioned finnish study the oocyte donors indicated a high level of satisfaction with the support offered during the process and a relatively low need for additional support perspectives of recipients motivation for choosing identityrelease donation in general reasons for choosing treatment with donor gametes include having a biological tie to the child desiring to experience a pregnancy and to have a child who has a genetic link to at least one parent the most common reasons for choosing identityrelease sperm donation stated by heterosexualcouple lesbiancouple and singlewoman parents in a us study were that this gave the child the option of getting more information about the donor including his identity and the option to be able to meet him in a us study of 129 lesbian mothers most of them were satisfied with their choice of an anonymous known or identifiable donor those who had selected an openidentity donor were most satisfied with their choice both because they avoided potential custody conflicts andor involvement from a third person and because offspring would have access to information about the donor disclosure identityrelease donation gives the offspring an option to obtain identifying information about the donor however offspring can only make use of this option if heshe has been made aware of the donor conception most often by hisher parents in a swedish study of 148 heterosexual couples with children conceived through donor insemination in the years directly after the law was introduced only 11 had informed the child about the donor conception 46 planned to disclose later and onethird were unsure or planned not to disclose those who had disclosed did not regret their decision to disclose and thought that being open about the donor conception had been beneficial to the child in a followup interview study including 19 couples from the above study participants said that healthcare staff had influenced their thinking and a majority of those who had been encouraged to tell their children about the donation had done so another interview study of 31 heterosexualcouple parents with 1to 7yearold children conceived with donor sperm during 19972003 found that 75 already had or planned to talk with the child about the donation in a later swedish study of 111 heterosexual couples with 1to 4yearold children following oocyte or sperm donation 78 planned to disclose to the child about the donation and 16 had already started the disclosure process a subset of 30 heterosexual sperm recipients from that study also participated in an interview study when the child had reached 7 years of age the authors concluded that sharing information about donor conception with offspring was a complex process that involves different levels and in which parents beliefs and the childs responses serve as driving or impeding forces a uk study investigated disclosure to offspring among 31 heterosexual solo mothers and 47 heterosexualpartnered mothers with donorconceived children aged 48 about half of the solo mothers and onethird of the partnered mothers had already told the child about their conception with donor sperm among those who had not yet disclosed partnered mothers were significantly more reluctant or negative to disclose than solo mothers in line with this finding a us study showed that all single women and lesbian couples with adolescent offspring had disclosed their use of donor insemination to their children while this was the case for 70 of heterosexual couples disclosure did not seem to have any negative impact on the families regardless of the parents sexual orientation or relationship status several studies have found that large groups of recipients had told other persons about their use of gamete conception with no differences in disclosure behaviour with regard to sex or type of donation one stated reason to refrain from sharing this information with people outside a close circle of friends and family was that the child should learn about the donation before other people did among parents who plan not to share information about the donor conception with their child disclosure to others increases the risk of accidental disclosure managing family life when a couple conceives with donor oocytes or sperm this creates a family where the child has a genetic link to only one of the parents the presence andor absence of genetic linkage as well as the existence of an identifiable donor may have psychosocial consequences for the couple and the family two swedish interview studies of heterosexual couples following sperm donation concerned family life leeblundberg et al reported that some parents had worried that the lack of a genetic link to the father would create an unequal relationship with the child but these concerns had disappeared over time isaksson et al found that resemblance between child and parent was an important theme and parents were reported to navigate between the importance of genetic connectedness and of doing parenthood through social interactions nonresemblance between parent and child was described to bring the donor to the front and the donor constituted an absent presence as also described in a qualitative study of single mothers in the uk in the longitudinal swedish study of gamete donation recipient couples of donor oocytes and sperm were followed 25 years after treatment heterosexual couples that had been treated with sperm donation expressed satisfaction with their relationship and couples using oocyte donation treatment had a balanced and solid view of their relationship where having children or not after treatment had no effect on the nature of the relationship lesbian couples following sperm donation reported stable relationships and a high satisfaction with their relationship also after unsuccessful treatment they also reported less parenting stress compared to heterosexualcouple parents following ivf with their own gametes and parents following a spontaneous pregnancy while a previous study in the usa indicates that following donor insemination heterosexual couples lesbian couples and single women were positive about their decision and were quite open about the donor conception lesbiancouple families may face specific challenges related to their nontraditional family formation results from interviews with 20 femalepartnered mothers of young children indicate that participants had lacked psychological support in the process of planning and becoming a parent they expressed a desire to be treated as equally valid mothers and as a proper family by professionals at child healthcare services also the results from a web survey with 145 belgian and swedish participants 36 of whom had used identifiable donors showed that donorconceived families were challenged by cultural norms and values and responses from friends healthcare professionals and teachers when children conceived with gametes from identityreleased donors grow up parents need to deal with the question of disclosure to the child in a study of 111 heterosexual couples following oocyte and sperm donation onethird were not in agreement about what to disclose to their child about hisher conception and these couples reported a lower relationship quality than couples who agreed about disclosure however incomplete couple agreement about disclosure did not appear to have a negative impact on parental stress contact with donor and donorsiblings in a swedish study including 279 heterosexual recipient couples of donor oocytes or donor sperm about half believed that it was in the best interest of the child to be able to obtain identifying information about the donor while the remaining were unsure neutral or negative while few believed that contact between the child and the donor could be harmful for the offspring or family about onethird could not form an opinion about this in a subsequent qualitative study of 30 heterosexual parents with a 7yearold child some parents were curious about the sperm donor and hoped that the child would make contact in the future while other parents expressed concerns about potential contact between the child and the donor with openness about donor treatment both parents and offspring may want to get information and contact others who share the same donor the sperm bank of california has established a service that connects families who share the same donor and it has been used predominantly by families headed by lesbian couples and single women most of whom had used identityrelease donation these groups motivations for contact with other families who share the same sperm donor included to create a family for the child obtain support for their children andor themselves and to get information about shared traits and medical problems femalepartnered women most often described their own and their childrens relationship with linked families as a unique type of relationship a special bond an extended family or merely acquaintances perspectives of offspring there is a dearth of research including the perspectives of persons conceived with gametes from donors who originally chose to donate within an identityrelease programme and all concern persons conceived with donor sperm scheib and coworkers have presented several studies based on donors recipients and their offspring from one sperm bank that has offered identityrelease donors since 1983 one interview study included 29 adolescents conceived with sperm from openidentity donors from households led by lesbian couples single mothers and heterosexual couples a majority reported always knowing about their donor conception and were comfortable with their conception origins most also planned to request the donors identity and pursue contact in order to learn more about themselves these results are in line with two longitudinal studies of families headed by lesbian couples in the netherlands and the usa where half of adolescents conceived with sperm from an openidentity donor reported a desire to meet their donor and 67 of adolescents planned to contact the donor at the allowed age of 18 only one study was found that reported on the final step of an identityrelease donor programme ie requests and provision of identifying donor information to adult offspring in a followup study scheib et al reported on the first 10 years of this practice at one sperm bank during this period adult offspring from 256 families were eligible to receive such information and a total of 85 offspring contacted the clinic for this purpose being a female offspring and belonging to a singleparent household increased the probability of requesting donor information while having heterosexualcouple parents decreased the likelihood of a request a large majority of offspring contacted the clinic for information within the first three years after turning 18 the most common motivations for requesting the donors identity were to gain information about who the donor is as a person his motives for donating and medical or health information many believed that information about the donor would help them learn something about themselves and help to fill in the missing links while a majority expressed an interest in contacting the donor most had low or no specific expectations of a potential contact and very few expressed a desire for a close relationship four offspring were informed by the clinic that their donor was not open to contact and were reported to be very disappointed and upset discussion the aim of this review was to provide an overview of the perspectives of donors recipients and offspring involved in identityrelease donation identifiable donors of oocytes and sperm predominantly reported altruistic motives in line with motives reported for anonymous and known donors still the prospect of a potential future meeting with donor offspring may influence how donors reflect about and frame their motives for donating identityrelease oocyte and sperm donors were found to be mature and welladjusted individuals which is reassuring and indicates that the screening procedures are wellfunctioning the studies that have investigated longterm consequences of donating in an identityrelease donor programme indicate that most donors were satisfied with their decision and had positive or neutral attitudes towards being contacted by offspring from their donation however subgroups of donors expressed a need for support and counselling both to handle their own situation and to prepare for a potential situation when an offspring seeks contact while a recent review concluded that families following gamete donation in general are wellfunctioning conception with oocytes or sperm from a donor who will be identifiable to the child at maturity may have specific psychosocial consequences the present results indicate that recipients of gametes from identityrelease donors had stable relationships and were increasingly open about having used donor conception with femalepartnered and single women being most positive towards disclosure to the offspring parents were generally satisfied with their choice of an identityrelease donor as this gives their child the option to obtain more information about their genetic origin some parents had own interest in contact with the donor andor with families who had used the same donor concerning the perspectives of offspring conceived with gametes from identityrelease donors the present review highlighted the very limited knowledge base for this specific group only four studies were found all concerning adolescent and young adult offspring conceived with donor sperm the results indicate that about half of the offspring who are aware of their donor conception and have the possibility to obtain the identity of their donor plan to do so and many also intend to contact the donor their motivations for learning the donors identity and meeting the donor are in line with those reported by offspring conceived with gametes from anonymous donors the study by scheib et al is the first to report on the percentage of offspring eligible to receive identifying donor information who actually made such a request which was about onethird of the total sample also it was recently reported that only 5 of eligible adult offspring from heterosexualcouple families in sweden had requested donor information at the moment there is no information available about the large groups that have not requested information about their donor are they aware of their donor conception and the possibility to obtain the donors identity what is their level of interest in this information are there any practical issues concerns or considerations that impact their decision not to seek donor information in view of the relatively low disclosure rates reported by heterosexual couples who conceived with donor gametes in the 1980s and 1990s is it reasonable to assume that at least some of those offspring are unaware of their origin with donor gametes the studies covered in the present overview were performed in europe and the usa and included quantitative and qualitative studies with crosssectional retrospective and longitudinal designs studies of individuals involved in gamete donation are frequently based on single clinics and suffer from relatively low response rates which limits the generality of the findings research on donorconceived offspring is hampered by specific difficulties identifying this population as it is ethically only possible to approach individuals who are aware of their donor conception recruitment of participants through selfselection eg membership in networks for donor conception is feasible but introduces a selection bias thus there is a lack of knowledge about the perspectives of donors recipients and offspring who are not interested in seeking information about genetically related persons also the number of longterm followup studies in this field is limited and attrition is a matter of concern as in all longitudinal designs changes in legislation dnabased voluntary contact registers and directtoconsumer genetic tests constitute new challenges and may have great influence for the future for assisted reproduction with donor gametes the possibility of identification of genetically related individuals may have an impact not only on donors recipients and offspring but also on their extended families the need to ensure that all this information is handled with the best safety and privacy rights has been stressed however reflections on the future of genetic testing andor screening must be distinguished from the longstanding debate about disclosure of donor conception to children in conclusion donor conception creates families with varying genetic linkage between family members and where there are genetic links to individuals outside the family unit in the case of identityrelease donation the offspring has the opportunity to obtain identifying information about hisher donor existing research about the perspectives of donors and recipients involved in identityrelease donation indicates that both oocyte and sperm donors primarily have altruistic motivations and that recipients are increasingly open about having used donor conception furthermore several studies indicate that the offspring are interested in contact with the donor and most donors are open to such contacts keeping in mind the lifelong consequences of identityrelease donor conception recipient families and donors could benefit from support and counselling to increase their confidence in managing family life in view of the present findings as well as the rapid development and increasing use of resources to identify genetic relatives more highquality research is warranted on the longterm psychosocial consequences of gamete donation disclosure statement no potential conflict of interest was reported by the authors notes on contributors agneta skoog svanberg registered nursemidwife phd and professor in reproductive health department of womens and childrens health uppsala university uppsala sweden gunilla sydsj€ o certified psychotherapistma behavioural scientist phd and professor in psychosocial obstetrics and gynaecology department of obstetrics and gynaecology department of clinical and experimental medicine link€ oping university link€ oping sweden claudia lampic lic psychologist phd and associate professor in caring sciences department of womens and childrens health karolinska institutet stockholm sweden

donor conception creates families with varying genetic linkage between family members this may have shortterm as well as lifelong psychosocial consequences for all involved gamete donors have traditionally been anonymous to recipients and offspring but there is a growing trend towards identityrelease donor programmes that give offspring the right to obtain the donors identity this review aims to provide an overview of the perspectives of donors and recipients and offspring involved in identityrelease donation the results show that both oocyte and sperm donors have primarily altruistic motives and recipients in particular lesbian and single women are generally open about the donation to their offspring the few existing studies on offspring perspectives indicate that those who are aware of their donor conception appear to be interested in contact with the donor and most donors are open to such contact investigations of donors and recipients indicate a need for more counselling and support to manage family life with varying genetic linkage within and outside the family unit this includes preparing for and managing future contact between the donor and hisher family and donor offspring and their family as well as between donor siblings and their respective families

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introduction autism spectrum disorder is a neurodevelopmental disorder characterized by frequent highlevel behaviour problems 1 it is not clear what the exact cause of autism is however it is related to heredity and there is no known cure for autism although treatment has been suggested 2 caretakers of children with asd present various forms of stress including worries and feelings of helplessness to have a child who often portrays tantrums and violent behaviour leading to a feeling of humiliation and negative labels 3 usually children are 148 2 trained in toileting at two years old but this may not be the case with children with asd who are still aided in nearly all areas of their lives coupled with extra attention from their parents in zambia there are no exact figures for children living with asd although roughly there are indications of about 40000 cases of asd 4 5 with such estimates it cannot be ignored that the impact of asd exerts a significant influence on the individuals with the disorder and those around them this study explored the influence of asd on parents and shed light on what helps them cope with it among zambian parents a wealth of literature provides different experiences parents go through in their everyday lives conceivably parents experience much stress when they are told the results after the diagnosis of their asd child 6 literature reveals that negative coping by some parents of children with asd led to anger confusion avoidance distress and projection further parents sometimes encounter physical reactions such as fright trembling and loss of appetite 6 studies show that parents of children with asd suffer more from depression anxiety and stress than parents of normal developing children or those without disorders 7 8 studies by rafferty et al 9 and hastings and johnson 10 revealed that those parents require a vigorous and comprehensive level of parenting as children with asd need more time resources and management skills the literature mentioned above established that most marriages of parents of children with asd experience less sexual satisfaction and end in divorce more than families of typically developing children 8 11 rafferty et al 9 also investigated the social dynamics of parents when they inform their friends and relatives about the diagnosis the study found that parents generally experienced different responses positive and reassuring responses included expressions of love and support whereas negative responses included regret and an offer to help if needed it is also the case that parents will have experienced significant stress before the diagnosis because their child would have been displaying stimulating behavioural symptoms but the parents would not have understood why or how to deal with them 12 empirical analysis has also suggested that parental stress is related to the severity of the childs symptoms and behaviours 13 14 behaviors that are too difficult to manage require professional intervention and as such parents continually need to seek appropriate educational and training services 15 this can require a significant amount of administration by the parents as they spend much time looking after their children at home which can be a source of stress furthermore parents are expected to experience stress if the information and necessary access to resources are unavailable parents with insufficient information about the disorder will lack the understanding necessary to cope which can affect how they can meet the childs strains parents may also be unable to follow their interests or goals and mothers usually the primary caregivers can feel predominantly restricted economic circumstances resulting from having a child with a disability can also cause parental stress in different instances like when significant fees are required for private services 5 16 reviewed literature therefore shows the focus was on the stress children with asd go through challenges and opportunities experienced in learning and teaching children with asd and the psychological functioning of teachers handling children with asd without necessarily addressing parental stress as they interact with their children with autism the majority of such studies have involved children with asd with a focus on educational attainment instructional strategies and rehabilitation of such children 4 17 18 although these studies have been done and significantly have contributed to available knowledge on children with asd globally very little attention has been paid to how parents of children with asd cope with their childrens behaviours which causes them stress this study was therefore conducted to establish the trials of parents of children with asd pass through in coping mechanisms in the lusaka district in zambia the study therefore sought to answer two main research questions as follows how do parents get stress when working with their children with asd how do parents cope with the experiences of their children with asd methods this study employed a qualitative approach a phenomenological research design was used the study purposefully recruited ten parents aged 30 and 50 years old where six of the participants were mothers and four were fathers all from lusaka district the study used homogeneous sampling which helped to describe parents trials with their children with asd in the lusaka district in zambia the research design was suitable for this study because it helped understand how parents and guardians of children with asd coped with stressful situations through interviews nonverbal cues were observed and coded while what they said was recorded as verbatim excerpts evidence of fieldwork the study involved ten parents and guardians interviewed via facetoface interactions participants were four male and six female one of the participants was a grandmother who was caring for her daughter with asd participants were tapped from different professions while others were not working in the formal sector one of the participants had two children with autism which gave the study a different experience from those with one child with autism in their family facetoface indepth interviews were used to collect data from participants indepth interviews allowed flexibility in how the questions were asked with each interview taking an average of 30 minutes the interviews helped in asking additional questions and observing nonverbal cues interview questions covered the participants family life challenges stress and coping techniques data were analyzed via the identification of key themes that were guided by the research questions and emergent themes from discussions with participants a research practice supported by barriball and while 19 who contended that qualitative data might be analyzed through common and recurrent themes and that thematic analysis is a way of organizing qualitative data and involves the researcher identifying and making sense of the emerging themes 20 this study transcribed coded and categorized data according to themes it ensured that themes were consistent and well understood 20 the school of humanities of the university of zambia ethics committee approved the study participants agreed to take part in the study and signed ethical consent forms their identities in this study have been withheld to fulfil the ethical requirements of anonymity and confidentiality results and discussion the findings of this study have been presented and discussed according to the main themes derived from the research questions 31 ways in which parents get stress from their children with asd this study revealed several stressful situations for parents of children with asd more so the situations are not any different from parents in similar situations although the degree or severity of the condition also impacts the amount of stress on an individual parent stressful conditions of parents generally the findings showed that parents got stress from performing daily routine duties such as child care financial burdens communication barriers stigma and frequent discussions with professionals who endeavoured to help out the findings from the study are supported by pisula and kossakowska 16 who opined that parents become distressed and family functioning is impacted in numerous ways due to rearing a child with autism parents bear most of the emotional burden as caring for the child falls predominately upon them 7 stress from childcare duties stress also emanates from childcarerelated duties the findings of this study align with alnemary et al 5 according to alnemary et al 5 some parents lack knowledge of how to manage problem behaviour exhibited by a child with autism and end up being overly stressed the failure to know the condition creates pressure anxiety and stress to handle emerging behavioural challenges emitted by children with asd childcare duties create high transport costs for parents as they take their children to and from hospitals for treatment and consultations with medical doctors 2 according to the findings of this study it is not easy to care for a child with autism thus a gap emerges in this study that parents appear to have knowledge and skills in managing problem behaviour for children with autism 21 one of the parents says it is not that easy because you have to do everything for the child from waking up until he or she sleeps this wears me out said participant a5 children living with autism are usually inconsistent in terms of routines parents found caring for their children after school difficult without a helper or other family members parent participant a9 said it was challenging because i have changed nannies occasionally after all they become stressed and quickly relinquish their duties to look for other less demanding nanny duties this leaves me with many care responsibilities for the child yet i have to fend for the family overall childcare duties were stressful to parents as evidenced by the complaints of most parent participants members who had someone to help reported less stress for instance an elder sister would help to take the child to and from school this was not easy for single parents financial burden this showed that working parents who could afford financial resources found it easier to take care of their children with autism than those who did not have the resources this finding relates to wonani and muzata 4 who reported that parents complained about the financial burden or costs of having children with asd compared to those without therefore taking care of a child with autism was highly costly since parents needed to take their children to the hospital for medical checkups treatment and professional guidance on how to care for them in this study all parents complained that taking care of children with autism was expensive one of the parent participants a2 testified below i must confess that i find it costly to take care of my son who has autism especially since i am not married which means i have no husband to help me take care of this child i also have to shoulder all the costs by going to the hospital and performing home chores when he needs attention i usually take him to be scanned because it is routine according to how we were advised at the hospital and because it is routine you must pay consultation fees every time the other financialrelated burden reported by parents was transport parents shared that they have to always take and drop their children right at school so that their child is not ridiculed if allowed to walk to school alone or with peers parent participant a4 explains when using a public minibus you always worry about people you sit with because they make silly statements about the child additionally one participant a10 reported that she was unemployed and her husband could not continue supporting the child she narrates when my husband stopped supporting the child i could not take the child for treatment at the hospital as was a routine previously i cannot afford school fees at a private school these findings therefore appear to indicate that parents need financial and other forms of support to provide for their children and offset the adverse impact of such a child on the overall family needs institutions and organizations that support the vulnerable in society should take a keen interest in identifying persons in such circumstances parents of children with autism need financial support mental health support and training in skills to manage problem behaviour that comes with the condition communication barriers communication is a critical feature that aids child development mutual communication aids childrens development as they can quickly receive guidance and instructions from parents and they too can make requests and seek various services however it is now naturally accepted that children with autism lack communication for parents it was so stressful that they could engage in fruitful interaction with their children who had autism one of the extracted excerpts below speaks to this finding you know how important it is to communicate nevertheless in this case i can talk to my child even if i try i am not sure he understands me the worst part is that he cannot communicate back however some parents especially the older ones believed that communication with children gradually improved with time and patience parent participant a3 reported his experience as follows at the beginning it was rough but now the child can follow some instructions and we can also know what he wants at a particular time perhaps with time we will be communicating a3 stigma families of children with autism are more likely to feel socially isolated and stigmatized than families of children with no disability at all 22 studies by gray 12 and wonani and muzata 4 report that parents of children with asd may feel stigmatized in public places a9 reported that people always stigmatize us as parents and the child in places but you have to show love to your child however in a public place i have to explain to the person my child is seated next to so that he or she understands when my child behaves in a contrary way although parent a9 reported this not all parents had similar experiences some parents did not report any form of stigma one parent reported that people at a church were more supportive of her daughter with autism we receive positive attention from members of our church my child is engaged in different entertaining activities when we go to church however since i am always worried i try to check on her or sit with her in church constantly varied experiences of parents show the different orientations and attitudes in society when attitudes are negative the sources of negative attitudes need to be targeted with educational sensitization talks when positive attitudes linger there is a need to strengthen and utilize such societies to help turn other societies in the pursuit of supporting parents and children with autism and other disabilities coping strategies used by parents acceptance when parents realize their child has asd they may accept it put all other emotions behind them and focus on ways to better their and their childrens lives 5 however it does not come that easy parents must pass through various stages before they adapt and accept and deserve support through the journey to adaptation and acceptance the adaptation process may know no age although experience with children with asd in this study shows that elder parents tended to accept their condition and move on a little quickly parents who finally accept their childs condition would say like the parent a5 below i have to move on i do not need to keep on complaining so i need to find ways of paying attention to my childs needs and gradually the child improves until no one notices that the child has a disorder support groups the study discovered that a family raising children with asd with other family members needs support and assistance in dealing with their emotions in this study most parents received support from family members most help came from the grandparents of the child with autism ie the childs mother one middleaged parent participant responded that she generally cares for her baby but her biological mother assists her in every way possible in this study participants reported getting support from other family members and their families however a few others noted that they did not receive regular assistance from relatives or family members participant specified that her family provided psychological and emotional support my entire family supports me since i am the first to have an asd child surprisingly this study reveals that female participants received support from family while no male parent did not report this this calls for further investigations into the nature of support provided to parents of children with autism and establishes whether females receive more support than male parents yet harbour the same challenges generally the findings restrict support to the family level meaning that parents may not be aware of the relevance of a broader support system that can be created from the communities in which they live it is essential to introduce parents to other parents living with similar children so that they can appreciate and exchange knowledge skills and understanding of the trials they encounter when children with asd are raised support groups may include professional groups that may train children in social skills communication therapeutic activities and daily living skills parents need to be introduced to communities of hope that provide counselling and guidance on where to access financial help leisure outings another finding critical to coping with autism is the adoption and use of technology parents with access to information technology tools such as computers phones and games easily helped parents engage their children with autism in play and social behaviour regulation one of the parents narrates below i use technology at home to keep my child from throwing tantrums and give me free time to do my things i use phones and tablets which keep my child away from problems another contribution from participant a2 says i use television for my child to watch cartoons and showing my child pictures of new persons or places to enhance growth and understanding to know what is happening and if we want to go to a place unfamiliar to him although this finding was not prevalent for most parents for various reasons including lack of access to gadgets it is essential to explore the use of various technologies in helping regulate social behaviour for children with autism various games can entertain children through play but computer games can help train children in acceptable social behaviour what needs to be addressed is the issue of access for parents affordability and knowledge of the relevant software for behaviour regulation use of technology another finding critical to coping with autism is the adoption and use of technology parents with access to information technology tools such as computers and phones with games quickly helped parents engage their children with autism in play and social behaviour regulation one of the parents a4 narrates below at home we use phones and a tablet so we use games to help the child play and relax we use some cartoons to teach good behaviour how to ask for things say sorry etc occasionally we would ignore his demands as another way to control his behaviour we also explain by use of verbal explanations another participant a2 recounts we sometimes use stories and models and we show the child pictures of new places and people to help him understand what is in the environment we advise visitors to our home not to introduce aspects that trigger bad or aggressive behaviour in the child although this finding was not famous for most parents for various reasons including lack of access to gadgets it is essential to explore the use of various technologies in helping regulate social behaviour for children with autism various games can entertain children through play but computer games can help train children in acceptable social behaviour what needs to be addressed is access for parents affordability and knowledge of the relevant software for behaviour regulation safety and behavioral tokens parents used tokens to reward good behaviour for managing noncompliance and reducing stress for instance one parentparticipant a10 reported that i use the reward system when my child portrays a specific good behaviour i give him what he likes for example my boy loves pizza i go with him to buy to encourage the behaviour praising is also a coping strategy for my child to see good behaviour i also continue with routine demands various strategies and social stories despite my childs protests working with some of these strategies parents participant a7 submitted that our house is near the main road so we had mounted steel bars installed alarms and inserted many locks on doors and squeezed window frames to stop my son from going out and getting lost i am comforted and at peace he is in a familiar place this is another unpopular response that did not receive a higher coding but is relevant in regulating behaviour and reducing stress among caregivers of children with autismbehaviourists such as bf skinner edward thorndike and ivan pavlov noted the relevance of rewards in modifying behaviour 11 parents need to be helped to become aware of the nature of rewards and how often they can help their children regulate stressful behaviour in a surprise but real revelation of findings that most parents did not bring out one parent reported using physical punishment below is the attestation by participant a5 i lose it at times i beat the child when he shows unacceptable behaviour so i treat him like any other child in the house i do not give special treatment coming from a family of orders i beat him though he does not show any remorse another parent who used a yelling and shouting strategy at the child eventually realized it was not working she says i fail to tell what strategy to use for my child as a mother of five children i screamed roared and carried negative distress in return for violence or problem behaviour my effort to use time out did not work and the child would shout or leave me alone punishment to diminish unwanted behaviour is acknowledged in behavioural psychology but not supported in the current discourse of behaviour modification negative reinforcement should be discouraged especially in the current human rights discourse that children should enjoy daily supervision and monitoring of behavior modification schedules the responses from the parent participants adopted the supervision and monitoring model to help modify their childrens behaviour and reduce stressful occurrences if the children were left loose this means parents need to stay alert and ready to intervene always to avoid damage one parent participant a4 said my son has no fixed schedule he can sleep at 1400 hours and wake up at 2200 hours furthermore no one is allowed to sleep when he wakes up and he needs to be given extra attention to have pandemonium in the house he can sometimes sleep at 1800 hours and wake up at 0200 hours to us it is to be always ready and at times we distract him so that he does not sleep early but after 2000 hours so that he wakes up in the morning spiritually and religious strategies like banja and muzata 1 this study revealed that parents resorted to god or other religious figures they believed in to help them cope with their childs condition thus religion can mediate in parents coping trials an observation made by spector and steve 23 in an earlier study in this study the following excerpts reveal what parents said parent participant a6 said that i believe god cannot give me a problem i cannot handle i accepted that my children have a disorder and i always pray for strength that was a vital religious experience i began reading my bible wanting to know why i was given a child with a disorder and where i went wrong i keep asking myself this question and praying for gods miracle to heal my child participant a1 a father said it is essential to be patient and accept every child god has given someone because god rewards people in different ways as a christian i have accepted my child using verses in the bible that one day god will heal my child in his own time religion has a role in helping parents cope with the difficulties they face in life and this study therefore calls on religious leaders and organizations to play a role in helping parents adapt to the disability and manage the stress caused by having a child with asd conclusion this study explored the coping strategies parents of children with autism spectrum disorder in the lusaka district use to cope with the stressful behaviours of their children through a hermeneutic phenomenology ten parents participated in the studys sample size based on the findings of this study parents in lusaka need various services to adapt accept and support their children with asd parents must be provided with knowledge and skills on various methods to interact and cope with children with asd they must be linked to various service providers to access financial support counselling services and skills to live with a child with asd linking parents to support groups would help alleviate depressing feelings and improve mental health among parents living with children with autism the study was qualitative using ten parents of children with autism which means it is restricted in generalizability it would be necessary to upscale this study quantitatively to obtain more parents in the same situation to broaden service provision to all parents of children with asd in lusaka and zambia

this was a hermeneutical phenomenological qualitative study of the coping strategies parents of children with autism spectrum disorder asd use to cope with the demanding behaviours of their children in the lusaka districtin zambia parents as key caregivers of children with disabilities are likelier to develop unhappiness and worry than parents of classically developing children parental stress is usually associated with the severity of the asd disorder it was imperative to study how parents in lusaka district coped with children with asd daily interviews were used to collect data ten 10 parents of children with asd were purposively selected to participate in the study data analysis was done in themes that revealed extra worries for parents caused mainly by a lack of information about asd especially before diagnosis parents adopted specific strategies to cope with their childrens problematic behaviour in areas of social interaction further parents require much assistance developing interaction between them and specialists to acquire support services regarding coping strategies for their childrens behaviour

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introduction within the united states a disproportionate number of incident hiv infections and new diagnoses of hiv lie within men who have sex with men in los angeles for instance over 75 of all infections are attributable to msm 123 among msm in the united states latinos accounted for 20 of new infections and african americans accounted for 37 of new infections 4 to address the epidemic among atrisk populations researchers have requested innovative approaches for understanding and preventing sexual risk behaviors online technologies have been rapidly growing in use and may play a role in facilitating sexual risk behaviors especially among atrisk populations 56 internet use was previously used primarily among uppermiddleclass white populations however minority groups have increasingly used online technologies 7 for instance in the united states from 2005 to 2006 there was a 121 increase in the number of african american households with highspeed internet connections and a 46 increase in latino households with broadband usage with 56 of latinos using the internet on a daily basis 89 in fact englishspeaking latinos are almost identical to whites in their use of internet and home broadband 10 and african americans and latinos are more likely than whites to access the internet from mobile devices 11 social networking technologies platforms for virtual social communication have been the predominant factor for the growth in online technology use among minority groups social networking sites such as facebook grindr and twitter are online platforms designed for social communication through sharing of pictures messages and other forms of multimedia communication 12 african americans and englishspeaking latinos are almost 15 times more likely to use online social networking sites compared to the general adult population this trend is consistent in twitter usage online video usage and usage of locationbased devices 13 in addition gay lesbian and bisexual individuals use social networking technologies more often than heterosexual individuals 9 although research has explored the link between internet use and sexual risk behaviors 14151617 little work has focused on social networking use and sexual risk however it is especially important to study the relationship between social networking and sexual risk behaviors because these technologies were specifically designed for social communication and interaction 1218 research from internet studies suggest that compared to people who do not seek sex on the internet internet sex seekers tend to have more frequent anal sex more previously diagnosed stis more sexual exposure to men greater numbers of sex partners and higher numbers of sex partners known to be hiv positive 14 social networking users have a potentially increased risk as social networking technologies allow users to engage in realtime interaction that can be used to initiate rapid sexual encounters for example people can use locationbased mobile applications such as sexmap and grindr to search for potential sexual encounters with others in immediate geographic proximity it is therefore important to evaluate how social networking technologies might affect sexual risk behaviors especially among social networking users who are at highrisk for hiv such as msm this study seeks to determine the relationship between social networking use and sexual risk behaviors among minority msm specifically we assess 1 rates of using social networking technologies for sexseeking and 2 sexual risk behaviors associated with seeking sex on online social networks methods this study was conducted according to the principles expressed in the declaration of helsinki the ucla office of the human research protection program approved this study methods conform to recommended guidelines for using social networking technologies in hiv prevention research 19 participants provided a webbased informed consent over a period of 45 months 122 participants were recruited online from physical venues frequented by african american and latino msm and from direct referrals from study participants participants were paid 30 in gift cards to complete a survey four participants were found to have completed multiple surveys their second response was dropped leaving 118 participant responses six participants completed part of the survey their responses are included in this analysis participants were recruited online using the following methods paid targeted banner ads on social networking sites and setting up a fan page on facebook with information describing the study participants recruited using online methods were directed to a website where they could receive more information and enroll fliers placed in physical venues frequented by african american and latino msm described the study and provided a contact email address and a web link for participants to receive more information and enroll most fliers were culturally tailored including a picture of a male latino or african american stating that the study was looking for male participants who were 18 years of age or older african american or latino interested in men and had a facebook account fliers provided a contact email address and link to a website where participants could receive more information and enroll participants were informed that they could refer friends who were interested and fit the inclusion criteria participants were not paid additional incentives to refer friends potential participants visited the study website and were screened for eligibility eligible participants were males who were 18 years of age or older living in los angeles had had sex with a man in past 12 months and had a facebook account because we attempted to recruit a sample of predominantly minority msm we first recruited 70 of the sample from these populations and then opened recruitment to msm from other populations participants were excluded if they did not fit inclusion criteria a facebook connect application was used as a verification tool to ensure that each participant had a registered and unique facebook account if the eligible participant consented to the study he had to provide his facebook username and password through facebook connect once this connection method verified his status as a facebook participant he was asked to input his email address phone number and completed an online survey the 92item online survey took approximately 45 minutes and included a collection of items from previous research on sexual risk behaviors internet use as well as a number of novel items related to use of social networking technologies items focused on demographics raceethnicity income and education internet and social media usage and sexual health behaviors prior to responding to items related to social media use participants were given a definition of social networking sites along with a list of examples sites internet and social media usage items focused on the amount of time spent using the internet and social media reasons for using these technologies and comfort when using these technologies to talk about sexual risk behaviors for example after a description of the difference between general internet sites and social networking sites participants were asked about their use of social networking sites for seeking sex in the past 3 months how many sexual partners have you met on the internetsocial networking sites they were not asked to differentiate between general social networking websites and websites that were designed specifically for dating or seeking sex sexual risk behaviorrelated items focused on number and gender of sexual partners sexual behaviors and number of times exchanging sex for food drugs or a place to stay for example participants were asked in the past 3 months have you exchanged sex for food drugs or a place to stay chisquare tests were used to assess differences in population demographics internet and social media usage and sexual risk behaviors analysis of variance tests were used to assess differences in age between groups as well as to confirm chisquare differences on continuous variables multiple regression analysis was used to assess the relationship between number of sex partners met on the social networks and exchanged sex new sex partners sex with men and oral sex controlling for age race education and total number of sex partners total number of sex partners was added to control for the possibility that group differences in social networking sex partners could be accounted for by overall increases in sex partners analyses were performed on deidentified data using stata software 20 results as facebook connect was used to verify facebook status 100 of participants were current facebook users slightly less than half of the sample used myspace and twitter with a smaller portion using grindr and various sexseeking sites such as adam4adamcom and manhuntcom table s1 displays the demographic results between populations and in the overall sample participants were predominantly latino or african american the majority of participants had at least a high school education with over 60 of participants from the western united states almost all participants reported being either gay or bisexual and single the average age of the sample was just under 32 years of age with white participants on average being older than the rest of the sample group differences by population were found on education level birthplace and age the majority of participants had used the internet and online social networking technologies to meet new sex partners within the past 3 months on average participants met over 4 of their most recent sex partners using these technologies compared to african americans latinos on average more frequently used internet social networking technologies to meet sex partners table s4 presents results of a regression analysis looking at exchanged sex new sex partners sex with men and oral sex as outcomes controlling for age race education and total number of sex partners there was a significant positive relationship between number of sex partners met from online social networking technologies and 1 likelihood of having exchanged sex for food drugs or a place to stay 2 number of new sex partners within the past 3 months 3 number of male sex partners within the past 3 months and 4 likelihood of engaging in oral sex discussion results from an analysis of msm social networking users suggest that msm are using online social networking technologies for sexseeking and that meeting sexual partners from social networking sites is associated with increased likelihood of engaging in sexual risk behaviors those who met sexual partners from social networking sites were more likely than those who did not to have exchanged sex for food drugs or a place to stay have new sex partners within the past 3 months have had sex with a greater number of men and have engaged in oral sex these effects were not due to the possibility that people who engage in more frequent sexual encounters engage in more sexual risk behaviors but were unique to sexseeking on social networking sites these results are important because they suggests that social networking websites when used for sexseeking may be associated with transmission of hiv and other sexually transmitted infections the ability to recruit african american and latino msm facebook users for this study provides support that minority groups are actively and increasingly using social media technologies 1013 this study builds on those findings by suggesting that minority msm are actively using social networking technologies for seeking sex knowledge of these changing trends is useful for understanding both the locations and behaviors of atrisk groups so that these same technologies that could potentially facilitate hiv transmission could also be used for hiv prevention latino msm appear to be especially likely to use social networking technologies to search for sex partners this finding could be useful in helping latino msm researchers understand how to use social networking technologies for latino msm recruitment and for development of culturallytailored hiv prevention interventions this study builds on research on the relationship between internet use and hiv risk 14162122 by showing that number of sex partners met on social networking sites was associated with increased likelihood of engaging in sexual risk behaviors however number of sex partners from social networking sites was also associated with an increased likelihood of having had oral sex this finding may provide support that the social networking sites do not necessarily lead to increased hiv transmission as people using the technologies for sexseeking might be able to meet and have sex with more individuals but might engage in oral sex to mitigate these risks 23 this study provides new data on the use of social networking technologies among atrisk groups it is important to begin to understand how use of social networking technologies by way of promoting both social engagement and anonymity can affect hiv risk behaviors studying how social networking users engage other sex partners will be important in crafting hiv prevention interventions toward atrisk populations for example websites that track and integrate geolocation technologies are currently being used to initiate rapid sexseeking encounters as technology develops and can be used to facilitate sexseeking and sexual risk behaviors it becomes important that researchers and policymakers study and understand how these same technologies can be used to prevent the spread of hiv and other sexually transmitted infections policymakers and sexual health organizations have already begun using social media to reach atrisk populations and as research is furthered in this area it can be used to support models for improvements in sexual health policies and interventions study limitations are based primarily on the focused population and enrollment criteria first as the sample is based in los angeles it is possible that participants from other locations might not share the same population characteristics however high hiv rates in los angeles make los angeles an important area for hiv prevention research second although sexual risk behaviors presented in this study are associated with hiv transmission knowing the specific type of sexual behavior would help to more accurately determine the associated risk for example while exchanging sex for food and drugs is associated with sexual risk engaging in unprotected anal intercourse in exchange for drugs would be associated with greater risk than engaging in protected intercourse this study presents a first look at associations between social networking use and sexual risk behavior and future studies that identify the specific sexual behaviors may help to provide a more definitive link to hiv transmission next participants were not asked to report how they were recruited to the study future research can address this question to provide data on best recruitment methods finally it is possible that the present results might not generalize to groups other than msm or early technology adopters although social networking use is being studied among broader racial and ethnic populations of people living in the untied states 1013 research on the link between social networking and hiv risk has only recently been studied and has focused on populations at highrisk for hiv such as msm 1924 future research is encouraged to test whether these findings extend to other atrisk populations conclusion the present study suggests that african american and latino msm are using social networking technologies to search for and meet sex partners and those who use these technologies are more likely to engage in hiv risk behaviors understanding how atrisk populations use social networking technologies is important for crafting and scaling culturallytailored hiv prevention interventions supporting information

online social networking usage is growing rapidly especially among atrisk populations such as men who have sex with men msm however little research has studied the relationship between online social networking usage and sexual risk behaviors among atrisk populations one hundred and eighteen facebookregistered msm 601 latino 28 african american 119 other were recruited from online social networking websites and banner advertisements and offline local clinics restaurants and organizations venues frequented by minority msm inclusion criteria required participants to be men who were 18 years of age or older had had sex with a man in the past 12 months were living in los angeles and had a facebook account participants completed an online survey on their social media usage and sexual risk behaviors results from a multivariable regression suggest that number of sexual partners met from online social networking technologies is associated with increased 1 likelihood of having exchanged sex for food drugs or a place to stay within the past 3 months 2 number of new partners within the past 3 months 3 number of male sex partners within the past 3 months and 4 frequency of engaging in oral sex within the past 3 months controlling for age race education and total number of sexual partners understanding the relationship between social media sexseeking and sexual risk behaviors among atrisk populations will help inform populationfocused hiv prevention and treatment interventions

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historical process of womens rights womens rights and the role of women in society have emerged in different ways from the first human communities to the present day in the early ages of humanity before human beings settled down the family structure was matriarchal but with the transition to settled life it is thought that the patriarchal structure that is the maledominated social structure began to form instead of the matriarchal structure another view is that even matriarchal societies have a patriarchal structure and there are no situations where women are dominant 1 there are many documents showing the existence of these womens problems even in ancient documents these documents reveal the inequality between men and women in the societies of that period most researchers agree that genderbased discrimination is a deeply rooted form of discrimination 2 the role assigned to women throughout history has often been that of ruler this situation tells us that the inequality between men and women has continued to exist since antiquity varying according to time and place 3 one of the reasons why women started to be seen as less valuable than men is the developments in the field of production the fact that the tools used in production were invented by men caused the material power to be in the hands of men and the fact that the material power was in the hands of men put women in a lower position against men 4 when we look at the documents found from the earliest times of humanity it is not common for women to participate in social life to be educated and to work but it is possible to see examples narratives about prominent women physicians architects philosophers and women sages from ancient egypt ancient greek civilization or the roman empire have survived to the present day 5 although ancient egyptian society was patriarchal it is known that women had some special rights they had the right to buy property and to be tried equally with men in court however although it is known that there were female pharaohs it is understood from the documents that have survived to the present day that women were not brought to important places in the administration 6 the marginalization of women increased during the ancient greek period women were left at home and excluded from society they were seen as a commodity that could be traded however it was considered important for men in high positions to marry the daughters of wellknown families in order to give birth to a noble man the value of a womans social status remained dependent on giving birth to a noble child 7 according to the beliefs of the sumerians it was not the gods who created everything and owned everything but the goddesses that is women according to the surviving documents about the sumerians monogamy was practiced and it is understood that women and men had equal rights in a poem written during the sumerian period my mother is a light shining on the horizon a mountain deer a shining morning star an example of the value given to women appears in the line 89 the clay tablets written by the assyrians who lived in the borders of todays kayseri province show that anatolian women were free at that time during this period there were city states in anatolia women who took an active role in the administration of these states are described in these tablets it is known that women were also active in trade life 8 in the hittites who lived in the same region after the collapse of the assyrian trade colonies it is known that the powers of the queen and the king were equal 10 however since there are very few documents related to the family in this period there is not much information about the status of women in social life 11 nevertheless it is known from some documents that hittite laws did not discriminate between men and women in punishments and the same punishment was given for the same crime in the roman empire where the patriarchal structure was dominant the justice system worked in favor of men a serious pressure was created in social life by using concepts such as privacy and honor against women 12 in such an environment where women were pushed out of society christianity which promised equality and freedom was born in christian teachings it is accepted that all people are equal the place of women has been moved to a different position with the concept of family 13 however as seen in most religions religious teachings have been shaped according to the habits of the community in which they are found christianity fused with the social mindset and became a patriarchal faith the churches which were the enforcers of the law judged women more strictly than men 14 in the environment of the middle ages where fiefdoms ruled educational institutions gradually began to conform to the wishes of the church womens basic education became possible centuries later provided that their families made donations to the churches 5 the teachings of judaism are similar to the effects of christianitys degeneration over time on relations between men and women beliefs such as the idea that a woman was created from a mans rib the belief that the human race was expelled from paradise as a result of eve the first woman in most religious teachings eating the forbidden fruit have led to a deep prejudice against women in society as a result of all these women have been marginalized in society and made dependent on men 15 looking at the status of turkish women in asia in history it is known that women played important roles and had equal rights with men in addition to the signatures of khans the signatures of their wives hatuns also appear in state documents one of the important findings of the equality of men and women in turks is the word marriage the expression they got married is used instead of the man took the woman which is frequently encountered in old documents 16 regarding women in the ancient turks an order was not considered acceptable if it started with the khan says so it would be acceptable if it started with the words the khan and the khan are ordering the khan could not receive ambassadors of foreign states alone ambassadors could appear in front of both of them the khan on the right and the khatun on the left it is understood from this that the role of women in public services was as great as the khan the right of guardianship in the family belonged not only to the father but also to both parents there was no harem veil or age in the ancient turks women could enter any assembly 17 ancient turkish women could ride horses shoot arrows and fight when necessary 16 monogamy was the law in ancient turks in the light of all this information it can be said that the ancient turks had a democratic and feminine mindset 18 when we look at the historical development of womens rights turkish women were free and had equal rights with men in the preislamic period according to the conditions of the period religious beliefs of the period considered women sacred 18 the turks entered anatolia during the seljuk period the seljuks were under the influence of iran where they had lived before under the influence of the arabs since they accepted islam and under the influence of the byzantines living in the anatolian lands they came from during this period turks in anatolia had to act according to islamic rules while acting according to their own habits 8 with the teachings of islam women have gained importance they had rights over family life according to islamic teachings a married woman was given valuable goods called mahr this practice was done so that the woman could manage herself in case her husband died or the woman was left alone such as divorces however before islam the gifts given for the wedding were given to the womans family and the father would marry or sell his daughter to whomever he wanted in islam a womans refusal to marry meant that the marriage was void in preislamic arab society women began to receive their share of inheritance which they had not received in the past with the teachings of islam 19 however islam like other religions has changed by being mixed with the values of the society in which it was formed in islamic belief the differences in the creation of men and women have been determinant in social relations and this situation has caused inequality 20 for these reasons the social position of women changed radically after the adoption of islam the provisions of islamic law and its implementation in society limited womens space in public life women were trapped in family and home life obedience and submission were expected of women in islamic societies 21 in order to evaluate the relations between men and women of the period the position of women in preislamic society should be taken into consideration 22 when we look at the ottoman empire we see three statuses palace women mansion women and public women palace and mansion women had to live within the framework of islamic rules although some of the palace women had some works built the majority of them were women of other nationalities in general palace women lived a life similar to prison life public women on the other hand were almost all productive women they shouldered the burden of the ottoman empire they sent their husbands and children to military service worked in agriculture raised animals and produced food and clothing they gave some of their earnings to the state as taxes as a result although the economy of the state was almost entirely in the hands of women it is seen that girls in the ottoman empire were taken out of school when they were 89 years old and were confined to the house women were also restricted from going out on the streets in various ways during this period in some regions they were not allowed to walk or ride in cars or trams and actions such as walking around the grand bazaar sitting in a shop or talking in a group were also forbidden to women 8 during the war of independence our women worked with all their strength produced food and clothing and even took part in the front line for the liberation of our homeland from the enemy despite all these contributions the text of the law prepared by the parliamentarians who tried to enact a law on family law in 1923 included articles such as since the woman is mentally and religiously weak she must be under the protection of the man the man can take many women and divorce them as he wishes womens working outside disrupts social life and science destroys womens morals the text was not accepted in this form however months before the proclamation of the republic mustafa kemal in a speech spoke of freedom for women equal educational opportunities and a social position for women no different from that of men and said in konya the fact that our women who were under much less favorable conditions have become equal to men and in some cases even surpassed them is a proof of their extraordinary abilities and equality 23 with the adoption of the civil code and the abolition of islamic provisions and the granting of the right to vote and then to be elected turks began to return to their past in central asia and the seeds of the idea of equality between men and women were sown in the republican era thanks to atatürk women were able to step into the world of science for the first time before the republic it was impossible for women to go to university most of our first women scientists in the republican years were women who had received their education abroad after the establishment of the republic of turkey with the adoption of the law on unified education our education system changed and women and men were offered equal conditions in education with the dress code and the turkish civil code the place of women in society changed and women were granted equal rights with men 23 with the factorization brought about by the industrial revolution in europe women started to play a more frequent role in business life this situation played an important role in revealing the situation of women and the violence they were exposed to concepts such as equality justice and peace which began to be expressed with the french revolution also came to the agenda for women with the beginning of the age of enlightenment the idea of compulsory education covering the whole population began to spread whether or not girls should receive this compulsory education soon became a matter of debate 24 the right to citizenship was demanded for women and it was argued that women should also be able to receive vocational education that was only available to men for a century however women were not allowed to study at universities the reason for this situation was that women were considered physically weaker than men and that they were not suitable for such an education in terms of intellectual ability 524 by 1840 the first female students in europe began their education at the university of zurich despite all these developments many scientists living in those years who adopted the conventional perception of women argued that the idea of equality between men and women was unnecessary 25 today even in developed countries women are still not equal to men in social life and human rights in developed countries gender discrimination and the obstacles placed in front of women at every stage of their working life from admission to employment to promotion are the most common forms of this inequality in addition to the problems in developed countries problems in basic life situations such as being subjected to violence and being deprived of education are more common in developing countries violence against women for centuries violence against women as a violation of human rights and a form of discrimination continues to exist all over the world regardless of ethnicity class religion social status cultural economic and geographical boundaries according to the patriarchal mentality even if a woman is a victim of violence she is the one who harbors the cause of the crime considering that every woman victim of violence may have provoked the perpetrator her criminal behavior is questioned violence is defined by the un as all individual or collective acts that cause physical or mental harm to people by applying force and pressure 26 violence against women is defined by the world health organization as any behavior that results or is likely to result in physical sexual psychological economic harm to women including the prevention of freedom through coercion whether in public or private life 27 violence against women in the historical process archaeological studies trace the origin of womens experiences of physical violence back to 3000 years ago in ancient times while 920 of the bones of male mummies found in these studies were fractured this rate was 3050 in female mummies during the roman empire it is known that men could beat their wives and had the right to kill them for reasons such as adultery and drunkenness in england the law allowed men to beat their wives until 1887 in ancient indian traditions it is known that women whose husbands died were burned together with their husbands in preislamic arab geography girls were often buried alive because they were seen as a disgrace to society when the dates show march 8 1857 the incident in which 129 women workers died as a result of the police intervention against striking workers in a textile factory in new york the workers were locked in the factory and then the workers could not escape in the fire that broke out is one of the biggest examples of violence against women in our recent history march 8 was first celebrated as womens day in denmark in 1910 and is now commemorated annually as international womens day following a decision taken by the united nations general council in 1977 on november 25 1960 three sisters patria mercedes minerva argentina and maria terasa were taken out of their car raped and murdered as they went to visit their husbands in prison with the resolution adopted by the un general assembly in 1999 november 25th of each year is celebrated as the international day for the elimination of violence against women and international solidarity causes of violence against women sexist approach that does not believe in equality family conflicts and disharmony low income level personality disorders exposure to violence in childhood substance abuse traditional assumptions low level of education honor and ritual excuses are the most common causes of violence against women the most fundamental cause of violence against women is gender discrimination and asymmetrical power relations stemming from the patriarchal social structure in the un action plan on combating violence against women the concept of gender is defined as the socially constructed roles behaviors masculinities and attitudes that a given society deems appropriate for women and men we are one of the countries with the highest gender inequality and the deepest gender gap in this study conducted by the world economic forum in 2021 we ranked 133rd out of 156 countries in the same study we are the 1st country in the world in the rate of dismissal of women during the covid19 pandemic 28 the most common types of violence against women physical violence psychological violence sexual violence economic violence stalking forced or child marriage trafficking in women and forced prostitution genital mutilation of women are the most common forms of violence against women according to the world health organization one in every three women is subjected to physical or sexual violence by an intimate partner two out of every five women are known to have experienced psychological violence by their current or former partnerlife partner worldwide 38 of femicides are committed by the victims partner or intimate partner twice as many women die in domestic violence as in wars and global conflicts women aged 1544 are more likely to die from rape and domestic violence than from cancer traffic accidents or infectious diseases 27 femicides in general terms it is the killing of women or girls regardless of who commits it because they are women it is evaluated separately from male homicides due to its purpose ie gender discrimination in 2019 in the global homicide report published by the united nations office on drugs and crime which investigates the rates of women being killed because they are women it was reported that approximately 87000 women were victims of homicide in 2017 all over the world approximately 35 of these women were murdered by their lover spouse or family member asian countries lead the list of countries where femicides are most common followed by african and american countries the effects of violence against women on human health violence deprives women of their right to health which is their most fundamental right women victims of violence face physical and psychological consequences violence can lead to negative health behaviors such as smoking alcohol and substance abuse decreased physical activity overeating and obesity negative effects on mental health such as low selfperception posttraumatic stress disorder depression anxiety phobias panic attacks and social exclusion can be observed unwanted pregnancies sexually transmitted diseases gynecological diseases such as pelvic inflammatory disease pregnancy complications unsafe abortion may occur which may negatively affect womens reproductive health it has been reported that women who experience violence during pregnancy are negatively affected in terms of reproductive health and newborns and fetuses are also affected by this situation 31 violence can result in homicide or suicide and have fatal consequences where can women victims of violence apply 89 of women who are subjected to violence do not apply to any institution 8 apply to law enforcement agencies 5 to family courts 4 to health institutions 3 to prosecutors offices 1 to bar associations in our country women who have been subjected to violence can apply to administrative law enforcement bodies judicial law enforcement bodies public prosecutors offices family court judgeships health institutions the ministry of family and social services and its affiliated units local governments bar associations and nongovernmental organizations 32 preventing violence against women the universal declaration of human rights drafted by the un after world war ii although the universal declaration of human rights prepared by the un after world war ii is a comprehensive international convention it is not legally binding published in 1979 to combat all forms of discrimination against women the cedaw convention is legally important it has been accepted by 165 countries including turkey 33 cedaw was prepared based on the basic principles and principles in the universal declaration of human rights and it has put the fundamental rights and freedoms for all human beings on a legal basis for women one of the internationally recognized and binding conventions on violence against women is the istanbul convention it was adopted on april 7 2011 with this convention physical violence against women domestic violence sexual violence including rape psychological violence stalking forced marriages forced abortion forced sterilization and sexual harassment are defined as violence against women the istanbul convention aims to prevent violence against women protect victims punish perpetrators of violence and develop holistic state policies on the issue 34 it was repealed in our country with the presidential decree published in the official gazette no 31429 on march 20 2021 35 the most important piece of legislation on violence against women in turkey is the law no 6284 on the protection of the family and prevention of violence against women which was drafted in light of the provisions of the istanbul convention and entered into force in 2012 another important piece of legislation the regulation on the opening and operation of womens guesthouses entered into force in january 2013 the regulation on violence prevention and monitoring centers on violence prevention and monitoring centers to which women victims of violence can apply entered into force in 2016 there are şöni̇m in 73 provinces and 144 guest houses in 81 provinces 36 conclusion and recommendations enacting laws to eliminate gender discrimination making arrangements to ensure equal opportunities in education increasing womens employment in business life providing women with the same economic freedom as men strengthening and supporting womens social and economic status ensuring womens equal representation in politics and decisionmaking mechanisms and their effective participation in these areas ensuring that the media conveys the negativity of violence in an appropriate language and raising awareness in society it is important for us to prevent violence against women and gender discrimination to make programs based on gender equality on state radio and television to include courses on womens human rights and gender equality in the curriculum to make preventive and deterrent regulations on early and forced marriages to change the sociocultural structure dominated by patriarchal structure to develop decisive state policies to prevent gender inequality and to improve womens rights compliance with ethical standards we confirm that no funding was received for the conduct of this study and the preparation of this manuscript the costs of the study were paid by us

in history the greatest aspiration of people is that all humanity has equal rights regardless of race language religion or gender gender inequality seen in communities where patriarchal structure prevails has caused women to be deprived of their rights the exclusion of women who have been deprived of their rights due to their gender and even exposure to violence is a global problem that continues from past to present violence against women which is as old as the history of humanity is a phenomenon that affects all societies deeply and negatively as a fundamental human rights and freedom problem it continues to exist all over the world as a universal public health problem regardless of ethnic origin class religion social status culture economic and geographical boundaries domestic violence is the most common form of violence against women in this study the historical process of women and their rights the place of women in society today the historical process of violence against women the causes and types of violence against women femicides the end point of violence against women the effects of violence on public health violence in our country will be discussed furthermore institutions and organizations that women victims of violence can apply to and suggestions against violence towards women are mentioned

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as a chronic psychiatric disorder schizophrenia is accompanied by disruptions in perception cognition emotions behaviours and life functioning 12 the onset of schizophrenia typically starts in late adolescence or early adulthood and the symptoms appear gradually 34 frequent relapse and readmission to hospitals often afflict persons with schizophrenia and their families 1 schizophrenia poses longterm challenges not only to the patient but also to his or her family particularly the primary caregiver previous research showed that caregiving burden remained significantly high among primary caregivers of pwss with a deterioration in social functioning 56 worse selfcare abilities 7 and more care demands 8 the theory of transactional stress and coping can be applied to conceptualise the relationships between different patterns of stressors and caregiving burden 910 according to this theory caregiving burden is defined as a transaction between a caregiver and the surroundings that is perceived by a caregiver as surpassing his or her available resources and being a threat to personal wellbeing 1112 family caregivers perceived burden is affected by factors from their internal world and external surroundings such as the care recipients more severe symptoms and impaired social functioning 213 prospective studies examining the associations between clinical characteristics and caregiving burden have documented inconsistent results specifically some studies have found that increased severity of psychopathology and reduced social functioning predicted a heavier burden 1415 nevertheless a recent longitudinal study reported that clinical changes in schizophrenic symptoms were not significantly related to longterm experiences of the caregiving burden 13 although previous studies suggested the psychological consequences of impaired social functioning on caregivers 216 most of them were crosssectional little is known about the effects of changes in patients social functioning over time on the caregiving burden throughout the illness trajectory the caregiving burden for pwss is a complicated aspect of mental healthcare 14 in many societies the original family is deemed the most significant social contact for a person 17 a high level of caregiving burden is prevalent among family caregivers of pwss for instance a substantial number of studies have reported a high risk of psychological distress experienced by parent caregivers 18 19 20 marriage or partnership was also greatly influenced by the illness especially among cases in which the spouse caregivers resided with and cared for the pwss for many years 17 recent studies found that the psychological wellbeing of sibling caregivers was affected by a significant caregiving burden 2122 family structure and caregivingrelated arrangements may change over time parents are usually expected to take a caregiver role throughout their childs longterm illness trajectory particularly when the ill child does not have a partner 23 24 25 as parents get older siblings might take over the caregiving responsibilities for their ill sister or brother from their parents 2226 when transitioning to being the primary caregiver of a pws the new caregiver may be confronted with great challenges and need to adapt to the caregiving role 27 however there has been limited research exploring the determinants of caregiving burden when caregiver transition occurs in a family of pwss in this study caregiver transition was defined as a change of a pwss primary caregiver from one type of family caregiver at baseline to another type at followup caregiving burden may vary across different caregiving roles for example a recent empirical study reported that parent caregivers experience a significantly higher subjective burden than their spouse counterparts 28 parent and spouse caregivers of pwss may perceive the psychological burden differently 2930 nevertheless few studies have been conducted to evaluate the longitudinal predictors of caregiving burden in families with and without caregiver transition the objective of this study was to evaluate the effects of changes in social functioning on the caregiving burden for pws with and without caregiver transition over a period of 21 years we hypothesised that among families of pwss in rural chinese communities the caregiving burden might be predicted by sociodemographic characteristics of pwss differently in families with and without caregiver transition the caregiving burden might be predicted by the severity of symptoms of pwss differently in families with and without caregiver transition and the caregiving burden might be predicted by changes in social functioning of pwss differently in families with and without caregiver transition over 21 years method data and procedure this study employed panel data from the chengdu mental health project which has been conducted in xinjin county chengdu china since 1994 43132 six townships were randomly sampled from all 12 townships of xinjin county 33 this study analysed data from two epidemiological surveys conducted in 1994 and 2015 34 the same research methods were used for the two epidemiological surveys including the sampling method screening procedures and diagnostic criteria for psychosis 32 details of the procedures used for the longitudinal surveys including sampling methods have been described in our previous studies 3234 initially to identify potential cases of pwss trained investigators used the psychoses screening schedule to interview the heads of all households in the six townships 2 if the head of household could not attend the interview another household resident was invited 2 afterwards the trained psychiatrists carried out a comprehensive general psychiatric interview for the potential patients via facetoface interviews in hospitals with the purpose of maintaining diagnostic reliability a diagnosis of schizophrenia was determined by psychiatrists with over 5 years of clinical experience and they used the same diagnostic criteria from the icd10 33 in 1994 and 2015 after identifying pwss the family caregivers were invited to attend investigations to report caregivingrelated information the care recipients in this study met the following inclusion criteria diagnosed with schizophrenia in both waves and completed both waves of the surveys the exclusion criteria were as follows pwss died before 2015 and family caregivers had a diagnosis of mental disorders the eligible caregivers had kinship with pwss which could include being the pwss spouse parent child sibling childinlaw or other collateral relatives were aged 15 years or above and had been caring for the patient for more than 6 months in the past year 35 family caregivers who were also mentally disabled or unable to communicate well were excluded 3235 among the 510 pwss identified in 1994 250 were investigated 21 years later in 2015 excluding those who did not have family caregivers the analytic sample in this study included 225 dyads of pwss and primary caregivers who had completed the questionnaires in both 1994 and 2015 ethical approval for conducting the investigations was provided by the university human research ethics committee of the west china university of medical sciences in 1994 and by the university of hong kong in 2015 informed consent with signatures was collected from all respondents at each stage of the surveys measurements clinical characteristics severity of symptoms the positive and negative syndrome scale 36 was used to measure the severity of symptoms in pwss the 30item panss is a sevenpoint likert scale in which all items are divided into three dimensions positive negative and general psychopathology a higher score on the panss represents a more severe degree of symptoms of schizophrenia 36 the panss has been validated in the chinese population 3738 in our study the cronbachs alpha coefficient of the panss was 090 social functioning the social functioning of pwss was measured using the chinese version of the social disability screening schedule 39 in both 1994 and 2015 the sdss is a tenitem scale used to assess the overall severity of dysfunction of pwss with a higher score indicating a poorer level of social functioning 3940 the scale has been validated in chinese populations 41 the cronbachs alpha coefficient of the sdss was 095 and the total score ranged from 0 to 20 caregiving burden caregiving burden the burden scale for family caregiversshort 42 was used as a selfreport instrument to evaluate the subjective burden of the family caregivers this scale examined the following ten aspects of the caregiving burden reduced life satisfaction physical exhaustion wish to run away depersonalisation decreased standard of living health affected by caregiving caregiving reducing strength conflicting demands worry about the future and relationships with others affected 42 the responses to each question were rated on a fourpoint likert scale coded as 0 strongly disagree 1 disagree 2 agree and 3 strongly agree 4243 a higher total bsfcs score represents a greater degree of subjective burden in informal caregivers 42 the threelevel classification system was used to interpret the bsfcs score with 0 to 4 points ranked as none to a mild degree of subjective burden 5 to 14 points as a moderate level and 15 to 20 points as a severe to very severe level 44 in this study the internal consistency reliability of the chinese bsfcs was verified with a cronbachs alpha coefficient of 094 sociodemographic characteristics sociodemographic characteristics in this study included patients age gender marital status and education and caregivers relationship to the patient age gender family size and selfreported annual income statistical analysis prior to replacing missing values with imputation techniques littles missing completely at random test was performed the results of the mcar test were not statistically significant indicating that the data were probably missing at random therefore missing values were replaced by an expectation maximisation technique as appropriate for mcar data descriptive and frequency analyses were carried out to compare the differences between groups with and without caregiver transition the pairedsamples ttest was used to compare clinical characteristics between 1994 and 2015 analysis of variance was used to estimate the mean differences in caregiving burden within the groups with different clinical characteristics the generalised linear model approach was used with timevarying clinical characteristics as independent variables and the followup caregiving burden as a dependent variable in the regression analysis models the hypothetical predictors included baseline demographic variables total duration of illness followup severity of symptoms and timevarying clinical characteristics together with the duration of schizophrenia and the panss the sociodemographic variables were included as covariates in the regression analysis to estimate the associations of changes in clinical characteristics with caregiving burden after adjusting for the aforementioned variables illnessrelated predictors were entered into the regression models where the stable status subtypes served as the reference groups the outcome variable was the followup caregiving burden spss version 240 was used for statistical analysis results demographic characteristics and caregivingrelated information table 1 presents a comparison of demographic characteristics between baseline and followup in the analytic sample the pwss consisted of 82 males and 124 females with average ages of 397 years at baseline and 608 years at followup more than half of the pwss were married at baseline 21 years later over half of them were married and 155 were widowed the mean durations of schizophrenia were 105 years in 1994 and 299 years in 2015 at baseline there were 133 male caregivers and 73 female caregivers with an average age of 457 years at followup there were 162 male caregivers and 44 female caregivers with an average age of 572 years in 1994 597 of the pwss were cared for primarily by their spouses and 194 by their parents in 2015 631 were cared for primarily by their spouses 228 by their adult children and 121 by their parents based on the threelevel classification system suggested by pendergrass et al 44 in 2015 most of the families experienced the caregiving burden at a severe to very severe level and 252 of the families perceived the caregiving burden to be at a moderate level the median scores for family income per year were rmb 1000 yuan in 1994 and rmb 236667 yuan in 2015 the median numbers of family members were 35 and 30 in 1994 and 2015 respectively severity of symptoms and caregiving burden across the groups by caregiver transition table 2 shows the characteristics of the two groups by caregiver transition and gender in the whole sample most of the pwss were cared for by their husband in both waves and 97 were cared for by their wife in both waves 141 transitioned to adultchild caregiving from other types whereas 141 transitioned to spousal caregiving mean bsfcs scores ranged from 153 to 204 among different types of families indicating that the families experienced the caregiving burden at a severe to very severe level on average 44 significant differences across the groups were observed in terms of the caregiving burden specifically the results of the least significance difference test showed that mean bsfcs scores were significantly higher in the parental caregiving in both waves group compared with the spousal caregiving in both waves group predictors of family caregiving burden over 21 years table 3 presents the potential predictors of caregiving burden between families with versus without caregiver transition among families without caregiver transition a heavier caregiving burden was significantly related to a larger family size and more severe symptoms in pwss the results also indicated that a lower level of caregiving burden was significantly associated with deteriorated functioning in social activities outside the household and improved functioning in activity in the household among families with caregiver transition a higher degree of caregiving burden was found to be significantly associated with younger age of pwss improved marital functioning deteriorated selfcare functioning of pwss and improved functioning in social interest or concern of pwss discussion to the best of our knowledge this is the first study to measure the predictive effects of changes in sociodemographic and clinical factors on the caregiving burden in family caregivers with versus without caregiver transition this study contributes to the literature by emphasising the importance of caregiver transition and changes in the social functioning of pwss over time when exploring the longitudinal determinants of caregiving burden in rural chinese communities predictors of caregiving burden in families without caregiver transition in this study compared with the families with pwss having spouses as primary caregivers in both waves the caregiving burden was significantly higher in families with pwss having parents as primary caregivers in both waves this result is consistent with a recent crosssectional study reporting that parent caregivers experience a significantly higher degree of subjective burden than spouse caregivers in rural china 30 this result shows that additional social support is particularly warranted to assist parent caregivers in accessing appropriate services and available resources in communities 2045 a larger family size predicted a heavier caregiving burden among the families of pwss without caregiver transition consistent with previous studies 4647 the results of this study indicate that larger families or those with parents as primary caregivers providing care to pwss for a long period of time in rural chinese communities are potentially more vulnerable and need more support in accordance with previous findings 2 48 49 50 the results of this study add evidence to the linkage between the severity of symptoms and caregiving burden among families without caregiver transition during longterm home care evidence shows that caring for a pws with greater severity of illness may exacerbate the strain in families over time in rural chinese communities for instance based on previous studies families might experience a decline in economic status because of the higher expenditure on medication and lower labour capacity of both patients and their family caregivers due to the illness 344751 the results of this study showed that deteriorated functioning of social activities outside the household predicted a lower degree of caregiving burden among families without caregiver transition this result is in contrast to previous research indicating that a lower level of social interest or social interaction was linked to a greater degree of caregiving burden 5253 given the cultural influence and social stigma in rural areas of china this finding may be related to the possibilities that pwss with decreased social interest may lessen caregivers longterm distress in terms of worrying about the trouble that a pws may cause outside the household or the fear of being stigmatised by nonfamily members 54 55 56 57 these possibilities warrant further investigation in our study the improvement of pwss with respect to activity in the household was found to be a protective factor against a heavy caregiving burden this could be pws person with schizophrenia a to compare the variables between 1994 and 2015 pairedsample ttests were used for betweengroup differences of continuous variables χ 2 tests were used for betweengroup differences of categorical variables b others other relatives no caregiver or unknown c data regarding caregiving burden were not collected in 1994 explained by the possibility that these patients might be able to interact with other family members or even assist them with housework and farm work which could to some extent release caregivers from a heavy workload and improve family relationships thereby alleviating caregivers psychological burden 5558 predictors of caregiving burden in families with caregiver transition building on previous crosssectional studies 47555759 the present study further examined the association between patient age and caregiving burden demonstrating that taking care of a younger pws might predict a higher degree of caregiving burden in families with caregiver transition this may be related to the psychological distress of caregivers resulting from a higher prevalence of disruptive behaviours 6061 and poor medication adherence 62 among younger adults with schizophrenia among families with caregiver transition from 1994 to 2015 improved marital functioning of the pwss was found to predict a higher degree of caregiving burden in rural chinese communities it is plausible that after the pwss married in families where the primary caregiver of pwss changed from other family members to their spouse the new spouse caregivers were confronted with a high degree of psychological distress in terms of adopting the caregiving role 27 in addition in contrast to the aforementioned result in families without caregiver transition improved social interest or concern functioning in the pwss was found to be a risk factor for a heavier burden among families with caregiver transition consistent with prior studies 5253 this finding may be related to family caregivers concerns about pwss safety 20 or caregivers fear of being discriminated against by neighbours owing to stigma about schizophrenia 5455 when pwss frequently interact with nonfamily members in the rural chinese context the results of this study also indicated that deterioration in the selfcare functioning of pwss predicted a heavier caregiving burden this finding is congruent with previous studies showing that family caregivers of pwss are more likely to perceive psychosocial burden when taking care of pwss with more care needs or a lower level of independence 5253 this finding might be related to the possibilities that when primary caregivers change over time the new caregivers might be more stressed if they are not familiar with the longterm illness status of a pws without basic selfcare abilities as pwss and their caregivers get older issues regarding who will continue to take care of these patients and where the patients will stay after the caregivers pass away may become important concerns among the majority of family caregivers 63 thus the current findings suggest the importance of having family intervention programmes to help patients learn how to take care of themselves and to support new caregivers in learning how to familiarise themselves with patient selfcare needs limitations several limitations of the present study are worth noting first given the main focus on the change in social functioning and predictors of the later caregiving burden we did not repeatedly examine the caregiving burden at baseline and followup baseline symptom information was not collected thus the current findings were limited to interpreting the covariation of associations between changes in the caregiving burden and changes in clinical correlates 64 future studies are warranted to further assess the differences in family caregiving burden and its clinical correlates at different stages throughout the trajectory of the illness second when measuring caregiver transition this study only compared the differences between caregiving statuses in 1994 and 2015 we acknowledged that fluctuations regrading detailed arrangements of primary family caregivers were not observed in the present study third the small sample sizes of several subgroups including the adultchild caregiving in both waves transition into parental caregiving and transition into sibling caregiving subgroups limited the transferability of the findings of this study in addition the risk of sample bias should be noted given the high percentage of female patients in this study which was somewhat inconsistent with a nationwide populationbased study reporting that schizophrenia is more prevalent among males than females 65 in addition the unusual number of married patients probably reflects the high proportion of female patients fourth the mental status of pwss was measured using a single item by professionals comprehensive measures should be considered in future longitudinal studies to provide more items to uncover patients everchanging illness status fifth the generalisability of these findings was limited by the rural sample and the dropout patient sample during the long time interval in the study therefore the findings might not be applicable to those residing in urban areas or during a long hospital stay a sample combining both rural and urban residents is suggested for future investigations policy and practical implications despite the limitations this study provides empirical evidence that the effects of changes in sociodemographic and clinical correlates on the caregiving burden were significantly different from those of transition in primary caregivers over 21 years in rural chinese communities these findings could inform future culturespecific interventions to work with different types of households with persons suffering from schizophrenia for long periods of time identifying determinants associated with the caregiving burden is essential in developing more appropriate strategies for family interventions and homebased services in families of pwss 66 based on the social context of rural china primary health professionals social workers or family therapists should provide culturespecific suggestions to the primary caregivers of pwss based on kinship types and the actual situation of caregiver transition along with detailed guidance for improving the quality of family caregiving for instance based on our findings effective interventions are particularly needed to improve patients interest skills and functioning in daily household tasks and to help family caregivers arrange these tasks to facilitate patient participation moreover for social policymaking and public service provision in mental health more targeted policies and mental health services could be designed to serve families who are experiencing a great burden of care in underdeveloped areas in china 326667 for instance medical expense waivers antistigma interventions ongoing expert consultation or stress management training could be provided by the local government to serve the families of pwss the findings of this study highlighted the needs of more vulnerable groups such as largersized families patients with more severe symptoms younger patients and patients with poor selfcare functioning regular selfmanagement training and rehabilitation programmes could be tailored to pwss cared for at home for long periods of time to assist them in reintegrating into their communities data availability the data are not publicly available because they contain information that could compromise the privacy of research participants declaration of interest none

little is known about how sociodemographic and clinical factors affect the caregiving burden of persons with schizophrenia pwss with transition in primary caregiversthis study aimed to examine the predictive effects of sociodemographic and clinical factors on the caregiving burden of pwss with and without caregiver transition from 1994 to 2015 in rural chinausing panel data 206 dyads of pwss and their primary caregivers were investigated in both 1994 and 2015 the generalised linear model approach was used to examine the predictive effects of sociodemographic factors severity of symptoms and changes in social functioning on the caregiving burden with and without caregiver transitionthe percentages of families with and without caregiver transition were 388 and 612 respectively among families without caregiver transition a heavier burden was significantly related to a larger family size and more severe symptoms in pwss deteriorated functioning of social activities outside the household and improved functioning of activity in the household were protective factors against a heavy caregiving burden among families with caregiver transition younger age improved marital functioning deteriorated selfcare functioning and better functioning of social interest or concern were significant risk factors for caregiving burdenthe effects of sociodemographic and clinical correlates on the caregiving burden were different among families with and without caregiver transition it is crucial to explore the caregiver arrangement of pwss and the risk factors for burden over time which will facilitate culturespecific family interventions communitybased mental health services and recovery

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introduction depression is a common mental disease which can cause serious harm to physical and mental health if longterm relief from symptoms is not achieved the widespread impact of depression is not only reflected in the extremely high health lost and numerous complications such as type 2 diabetes and cardiovascular diseases but also in its promotion of suicide depression has evolved into a serious social problem and has accordingly attracted wide research and clinical attention according to the latest estimates more than 300 million people currently experience depression and the prevalence increased by 184 between 2005 and 2015 among different age groups prevalence peaks in middle and old age with the development of an aging population depression among middleaged and older people would become relatively more prevalent china as the largest developing country is also experiencing a trend of rapid population aging it is estimated that between 2012 and 2050 chinas elderly population will increase from 194 million to 483 million and the aging level will increase from 143 to 341 at that time china would be one of the countries with the fastest population aging rate a study indicated that there were 5636 million people living with depression in china in 2017 accounting for 213 of cases worldwide the prevalence rate of depression increases with age and becomes more serious in persons over 60 years thus for china it is important to adopt measures to promote mental health among highrisk groups such as middleaged and older people to avoid the adverse outcomes of depression this would also provide the benefit of globally improving mental health currently conventional interventions against depression such as cognitive behavioral therapy and medication are considered effective approaches however it is difficult to meet the needs of lowand middleincome countries for current depression treatments given resource limitations the cost for depression treatment is notably high it has been estimated that an annual global cost of us 115 trillion is attributable to depression in china a study calculated that total economic expenditure per capita for depression was 21650 cny with direct economic expenditure of 6806 cny and indirect economic expenditure of 14844 cny this heavy economic burden on developing countries is not affordable thus it is important to seek other effective and feasible lowcost approaches and pay particular attention to preventive interventions since the concept of sp was introduced to the field of aging research at the beginning of the 20th century increasing attention has been paid to the relationship between sp and depression activity theory posits that sp by older persons helps them to maintain selfesteem obtain psychological satisfaction and live a long and healthy life maintaining intellectual physical and certain social activities are necessary in later life not only to promote physical health but also to foster mental health prior studies also indicated the relationship between sp and depression among the elderly group a study found that sp plays a protective role against depressive symptoms and continuous sp may have strong association with fewer depressive symptoms moreover a few studies further explored the effect of different types of sp on depression formal voluntary activities reduce the risk of depression in older persons but informal help has no such effect social activities group activities fitness exercise and intellectual participation can all reduce the risk of depression in older persons but helping and dedication activities have no significant effect voluntary participation has positive effects but obligatory participation has harmful influences in addition some studies suggested that sp could relieve depression among certain older adults however most studies were conducted using ordinary least squares regression and a few of them use propensity score matching which could reduce bias and improve internal validity of the statistical analysis in addition few studies have explored the correlation between depression and sp in china while considering frequency type and quantity of sp this study made the following assumptions first sp was associated with a lower depression score the higher the frequency of sp the larger the quantity of sp and the more diverse the types of sp the lower the depression score our study explored the impact of sp on depression among middleaged and older chinese persons using a psm method and explored the relationships with respect to the frequency type and quantity of sp effects were further compared among different age groups genders and places of residence the findings could provide evidence for the targeted social participation measures for specific groups of middleaged and older people methods sample and data collection the datasets were obtained from 2018 wave of the china health and retirement longitudinal study a national representative survey adopting a fourstage stratified cluster sampling method to collect chinese residents aged 45 years and above covering 450 villages and 150 counties in 28 provinces in china and the detailed sampling methods can be retrieved from the study of zhao et al the baseline survey started in 2011 and conducted followup surveys every 23 years and the 2018 wave is the latest wave data in the 2018 charls database 19816 observations were admitted from the 2018 charls database after screening and excluding invalid samples a total of 9312 respondents were included in the study supplementary figure s1 shows the process of sample screening variables outcome variable depression is the outcome variable in this study which is estimated by the cesd10 scale the respondents were asked the frequency of their feeling or behavior during the last week and each answer of positively oriented questions was coded from 0 to 3 according to the frequent value the answers of the negatively oriented questions were reversecoded the total score of the scale ranges from 0 to 30 with higher scores indicating more serious depression our study used the score of 12 as the cutoff point to describe the prevalence of depression in the previous related studies cesd 10 showed a good internal reliability explanatory variable the explanatory variable in this study is sp which was estimated by their participation in 11 social activities in the past month if respondents participated in any of the social activities they were considered to have sp otherwise they were considered not to have sp confounding variables the following variables were selected as possible confounding variables according to previous studies confounding variables include three aspects demographic characteristics including gender age marital status education retirement residency individual income medical insurance number of family member and living near childchildren lifestyle characteristics including smoking physical activity and alcohol consumption and health status including types of ncds selfrated health changes detail codes and definitions are shown in table 1 statistical analysis a chisquare test was used on categorical variables to test the differences in social participation and its diversity and frequency in addition an independent sample ttest was used for continuous variables to assess social participation differences an analysis of variance was performed to evaluate the differences in social participations diversity and frequency psm was used to estimate the effect of sp on depression as the data we used were observational there existed the risk of bias caused by study design unbalanced distribution or grouping nonrandom sampling subjective tendency of the measurer and so on as well as confounding variables all of which can lead to biased estimation psm can address covariate imbalances between treatment and control groups in observational studies by matching respondents with similar characteristics in the two groups this can reduce the influence of data bias and confounding variables and facilitate a more reasonable comparison between the exposure and control groups observational data are thereby rendered more akin to random trial data and robust estimation results may be obtained thus this study used the psm method to estimate the average treatment effect of sp on depression of the middleaged and older people the psm method was first proposed by rosenbaum and rubin and it has become one of the important empirical methods to deal with nonrandom data the process of the psm method is as follows first calculating propensity scores by logit regression model to predict the probability of sp which was matched by confounding variables we then calculated the average treatment effect for the treated and the formula is as follows att e e where e represents the depression scores of respondents participating in social activities and e is the reference outcome next the matching effect was assessed by testing the absolute standard bias between the treatment and control groups after matching previous studies showed that the smaller the asb of confounding variables after matching the better is the matching effect according to rosenbaum and rubins definition if asb is 20 the matching effect can be considered reliable we used three matching methods including knearest neighbor matching radius matching and kernel matching to ensured the robustness of our results in the radius matching a 02 sd caliper was employed and in the kernel matching a bandwidth of 006 was set with an epan kernel in addition we also applied ordinary least squares regression models to estimate the impact of sp on depression and we used robust standard errors to alleviate the potential effect of heteroscedasticity all statistical analyses were conducted by stata version mp170 software a pvalue 005 was considered as statistically significant results characteristics of respondents the characteristics of respondents are shown in table 2 these include the characteristics of social participation and its diversity and frequency among the respondents most respondents were women partnered rural residents and with a median age of 64 years old of the respondents the education level was illiterate primary school middle school and ≥high school which accounted for 1772 4450 2338 and 1440 respectively the median of the depression score was 8 the value for the sp and no sp groups were 7 and 9 respectively and the prevalence of depression symptoms among middleaged and older chinese people was 4292 whether middleaged and older people engaged in social participation differed with respect to most characteristics social participation was associated with younger respondents those who were not of single marital status with better economic status living in an urban area having at least a high school education and living far from childchildren the frequency and variety of social participation differed with respect to most of the characteristics social participation rate of respondents with different characteristics figure 1 shows the social participation rate of respondents with different types numbers and frequencies and social participation rate by different ages genders and residencies the proportion of social participation among middleaged and older people account for 5649 3028 of the respondents participated in one activity and 2620 participated in at least two activities 4204 of the respondents participated in activities more than one time a week we also obtained that among all types of social participation the top two types with the highest participation rate are interpersonal activities with 3608 and entertainment with 2933 significant differences were shown among different types numbers and frequencies of social participation the social participants rate had no significant difference between men and women while respondents aged 60 years or those in urban regions had a higher participation rate than the reference group the probability of social participation among middleaged and older people the estimation results of the probability having sp among middleaged and older people by logit model are depicted in supplementary table s1 through the logit model the psm score was estimated and the matching of treatment group and control group was completed the finding showed that pseudor2 is 00540 indicating that the model fits well and the association between possible confounding variables and social participation was revealed for example those younger and those with better selfrated health changes were more likely to have social participation effect test on depression using unmatched and matched data after data matching we conducted a series of tests to check the matching effect first we compared the density function of propensity scores of the treated group and control group figure 2 shows that the distribution of the two groups is closer than before matching next the covariates balancing test was conducted the results are depicted in figure 3 all the standard bias of the covariates are reduced substantially after matching the covariates showed no significant difference among the two groups in supplementary tables s2s4 and all the asb are 20 which indicates that the matching has a good quality we constructed a histogram of the propensity score in the treated and control group as figure 3b shows no essential difference in the distribution of propensity score of the treatment group and the control group after matching it was clear that no matter which matching method we used the propensity score distribution became symmetrical most of the observations are in the expected range thus satisfying the common support hypothesis median 0 0 0 0 0 0 0 0 0 that sp had a positive effect on decreasing depression scores by 08750898 points namely sp was associated with lower depression scores taking the result of the radius matching method as an example the depression scores of the respondents with sp were 0881 points lower on average than those of persons without sp propensity score matching estimation of the effect of social participation on depression scores physical all types of sp had a significantly positive effect on decreasing depression scores of the different types of sp participating in community activities had the largest effect psm estimation also showed that compared with no sp taking part in one or two types of social activity had significant negative effects on depression scores while the more activities participants engaged in the lower their depression scores psm estimation suggested that a higher frequency of participation promoted lower depression scores estimation results for the effect of social participation on depression scores using ordinary least squares the results estimated using ols are shown in supplementary table s5 in model 1 sp had a significant negative effect on depression scores control variables related to demographic characteristic variables were added in model 2 further lifestyle characteristics were added in model 3 and health status characteristics were added in model 4 the coefficient of sp increased to 0892 0868 and 0774 respectively while the regression significance level remained at the 1 level the regression results imply that compared with middleaged and older adults who did not engage in sp those who participated in social activities exhibited a depression score that was reduced by 063 on average after adjusting for the control variables heterogeneity analysis of the effect of social participation on depression we further conducted a heterogeneity analysis by age gender and residency the results showed that sp had a significant negative effect on depression scores among different ages genders and residencies being female woman aged ≥75 and living in an urban area were all associated with more negative effects on depression scores discussion this study applied a psm method to explore the effect of sp on depression scores including examining the effect with respect to the type number and frequency of sp and further conducted a heterogeneity analysis in addition we also applied ols regression models to estimate the impact of sp on depression our main findings indicated that sp was associated with significantly reduced depression scores participating in community activities higher frequency of sp and engaging in more types of sp promoted a lower depression score in the subgroup analysis sp had a greater effect among older persons women and urban residents the results using ols also revealed a negative impact of sp on depression scores prevalence of depression symptoms in middleaged and older chinese people through this largescale investigation we found that the prevalence of depression among middleaged and older chinese people was 4292 although the cesd10 scale was widely used in depression investigation it was just the estimation of depression symptom not obsoletely equal to the real diagnosis and thus highly far from the monitoring data in domestic studies using the cesd10 scale to measure depression a study showed that the prevalence of depression of the middleaged and older in 2015 was 3262 zhou found that depression prevalence was 3519 in 2018 which can be seen that the trend of prevalence is rising and the recent finding was close to us an explanation was that physical pain caused by chronic diseases often leads to mental disorder which may lead to depressive symptoms domestic studies showed that middleaged and older people are not only the main patients with chronic diseases but also the highrisk groups of depression nevertheless the result in our research was also higher than other previous studies that used an estimated scale the incidence of depression is not only higher than in earlier reports but also exceeds that of other developed countries and even some developing countries the high prevalence is a reminder that depression in chinese middleaged and older persons is an urgent concern china will face greater challenges in terms of the increasing burden of depression accordingly attention must be paid to this issue and feasible preventive measures are urgently needed social participation could benefit older middleaged and older adults mental health our study verified that sp promotes mental health we found that respondents who engaged in sp had lower depression scores consistent with previous studies this could be explained by social participation incentivizing mutual support providing a sense of belonging and largely reducing social isolation which therefore result in better mental health due to aging retirement and declining health quality among other factors middleaged and older people may experience a considerable psychological burden social isolation changed social roles and the need to adapt to aging these factors may promote depression against a background of population aging trends worldwide mental health has attracted substantial research attention the who noted out that sp is a key factor in healthy aging therefore effective measures should be developed to promote sp policy makers should provide support for middleaged and older people first by constructing service facilities suitable for this population and second forming related organizations with a community or village committee as a unit and encouraging middleaged and older people to actively participate in social activities participating in community activities higher frequency of social participation and more types of social participation promoted lower depression scores we proceed to explore the associations between depression and different types of social engagement we observed that taking part in community activities was the best way to promote mental health among all types of activities considered community activities are carried out by a mutually beneficial organization formed by people with certain common characteristics we speculate that such organizations are associated with promoting a sense of belonging however the participation rate of community activities was only 277 in china development of leagues for older persons is incomplete and informal most leagues are selforganized and lack legal status consequently there is no legal basis for the construction and operation of associations for older persons and hence a lack of guarantee in terms of policies organizations and funds this results in many contradictions difficulties and problems in the construction of associations for older persons in addition we observed that engaging in more diverse social activities and engaging in sp more than once a week were relatively conducive to mental health consistent with prior studies therefore governments should make effective use of the community as a platform to promote the development of diverse activities such as by providing financial support furthermore incentive mechanisms could be used to promote the participation of middleaged and older people in various activities social participation had a greater effect on older persons women and urban residents through further comparing the effect of subgroups of age gender and residency we determined that sp had a greater effect on women and urban residents we also found that the older the age the greater the impact people over 75 years of age had the largest effect among the age groups the percentage of social participants had no significant difference between men and women while respondents aged 75 years or those in urban regions had a higher value than the reference group the above results emphasize that sp appears to be a more effective measure to prevent depression for women older persons and urban residents older women are more likely to lack social interaction than older men furthermore influenced by the traditional chinese concept of men dominate the outside women dominate the interior older men often enter the labor market to earn income and have frequent contact with the outside world while older women generally engage in housework or take care of children or older relatives at home compared with men this part of communication with the outside world is insufficient for women activities in which women participated were the primary source of relief for their depressive symptoms and thus had a more considerable effect on them as age grows the mental health status and social adaptability of the elderly generally decreased and the possibility of social isolation become higher our study also showed that as age increased social participation decreased thus social participation plays a greater role among the venerable age group residents of urban regions received more benefit than did rural residents as the former had a more convenient environment for participation due to greater availability of diverse social activities in a city targeted measures should consider women elderly and rural residents such as middleaged and older women and elderly persons with limited mobility for example accessibility of participation should be improved by installing elevators in buildings or introducing social workers to conduct activities in the homes of elderly people with disabilities for rural elderly persons the social activities currently available have limited effects on improving health activities such as guangchangwu and other community activities that are widespread in cities have beneficial effects on health are rarely available in rural areas therefore it is necessary to improve the provision of various organized activities for elderly persons in rural areas and to guide such persons to participate in these activities on a consistent basis comparison of effects between propensity score matching and ordinary least squares analysis strategies a significant negative association between sp and depression scores was found in both psm and ols analysis although the estimated effect was larger in the ols method than the psm method that is not balancing covariates led to overestimation of the treatment effect the primary strength of our study is that the psm method enabled a reasonable comparison to be made between groups with and without sp reducing estimation bias there are also some limitations to our study first as a crosssectional study causal relationships between sp and depression could not be determined future studies should use longitudinal designs to address this limitation second psm cannot solve endogenous problems such as selfselection and omission of variables which may affect the accuracy of the results third we obtained the result from scale responses thus it reflects a degree of mental status namely depressive symptoms however it does not equate to depression clinically diagnosed by a physician fourth the sample size of persons who took part in several types of sp such as voluntary activities community organizations or using the internet was small using a larger sample of such persons would provide more reliable results future studies are needed for such further exploration conclusion this study highlighted the crucial role of sp in preventing depression and promoting the mental health of middleaged and older chinese people community activities were the most effective of all activities participation in more diverse activities and participation with the frequencies of once a week or more is beneficial to mental health sp had a greater effect on older persons women and urban residents the results suggest that as the population of china ages the government should provide support for middleaged and older persons social participation such as by providing venues funds and channels for social participation organized and diverse activities should be provided and measures should be taken to encourage middle aged and older persons participated in such social engagement in particular attention should be paid to women rural residents and older persons who would benefit from targeted measures provided according to their needs data availability statement the dataset are available from the charls repository charlspkueducn ethics statement this study was approved by the ethical committees of peking university during the investigation all participants provided written informed consent charls is publicly available and deidentified the patientsparticipants provided their written informed consent to participate in this study supplementary material the supplementary material for this article can be found online at 2022825460full supplementarymaterial conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher copyright © 2022 wang xu nie pan zhang li liu liang gao wu hao and shah this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author and the copyright owner are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

background depression is one of the greatest public health problems worldwide the potential benefit of social participation sp on mental health has been widely acknowledged nevertheless a few studies have used propensity score matching psm to reduce the influence of data bias and confounding variables this study explored the effect of social participation on depression among middleaged and older chinese persons through a psm method considering the frequency type and quantity of sp effects were compared among different age groups genders and places of residencethe datasets were obtained from the 2018 wave of the china health and retirement longitudinal study a total of 9404 respondents aged 45 and above were included in the study psm and ordinary least squares methods were used to estimate the effect of social participation on depression results psm estimation results showed that sp had a significantly positive effect on decreasing depression scores p 0001 by 08750898 compared with persons without sp all types of sp had a significantly positive effect p 0001 and participating in community activities had the largest effect β 1549 to 1788 p 0001 higher frequency of participation and more types of sp promoted lower depression scores subgroup analyses revealed that the promotion effect was significantly greater among women those aged ≥75 years and those living in urban areas conclusion psm indicated that sp could alleviate the depression of middleaged and older chinese persons targeted measures should be adopted to promote sp and thereby improve mental health and promote healthy and active aging

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their relationship in daily life among older adults even less is known about what social factors may help attenuate the affectpain connection we examined whether social interactions and reported enjoyment in daily life were associated with an attenuated link between negative affect and two important pain outcomes this was examined among a socioeconomically and racially diverse sample of 317 older adults aged 70 who were recruited from the bronx ny as part of the einstein aging study and who completed ecological momentary assessments five times daily for 14 days threelevel multilevel models were estimated controlling for mild cognitive impairment status gender age education body mass index and average level positive affect for models that did not include enjoyment in given moments higher negative affect and lower enjoyment were associated with higher pain intensity and pain interference momentlevel negative affect and enjoyment significantly interacted to predict both higher pain intensity and pain interference with patterns suggesting a buffering effect of enjoyment in addition a threeway interaction emerged such that during moments when no interactions occurred and negative affect was lower than a persons average there was a buffering effect of momentary enjoyment on pain intensity findings extend understanding of the affectpain connection and the potential mitigating impact of social interactions and moments of enjoyment abstract citation id igad1043286 do older adults believe they are aging successfully in the circumpolar north britteny howell 1 amber worthington 1 dale golden 1 and leslie redmond 2 1 university of alaska anchorage anchorage alaska united states 2 university of manitoba winnipeg manitoba canada peoples perspectives on successful aging may impact their own aging outcomes to gain more insight we surveyed a convenience sample of 58 adults aged 55 years in urban alaska about their perceptions of their own aging using fowlers successful aging scale overall older adults rated their aging in the middle of the 17 scale across all three questions how well they are aging how successfully they have aged up to now and how they rate their lives these days correlational analyses indicated that as perceptions of successful aging increase selfreported good general health increases r499 p 001 and selfreported disability decreases r27 p 05 despite a small sample size these findings that perceptions of successful aging increased as general heath increased and selfreported disability decreased suggest that participants may perceive successful aging and good general health to be positively correlated perceptions of successful aging were not related to age in this sample r125 p349 this is promising as it may indicate that older adults recognize good health and absence of disability as integral components for successful aging regardless of chronological age providing opportunities for targeted messaging in future interventions future work will

strong hesitancylack of trustconspiracy 119 white rrr1659 p 01 higher income rrr1005 p 05 and higher education rrr1078 p 001 were positively associated with no hesitancy respondents with higher education rrr0573 p 05 were less likely to be in the group of mild hesitancy with uncertainty hispanics rrr0583 p 05 and higher education rrr0332 p 001 were negatively associated with strong hesitancy with personal concerns african americans rrr2426 p 001 and those with lower education rrr1324 p 001 were more likely to be in the group of strong hesitancy with lack of trustconspiracy our findings show that vaccine hesitancy is not random which is closely related to social stratification impacting health disparities in this society

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introduction calls for solidarity have been an ubiquitous feature of policymaking since the onset of the covid19 pandemic in many countries and even at a transnational level solidarity has been used in appeals to the public to adhere to measures to contain the spread of the virus as well as a rhetorical device to underline the message that we are all in this together who has embraced the notion of solidarity to underline the need for international cooperation and for knowledge sharing solidarity has also been employed as an anchor point to underline the importance of specific policy measures such as steps to increase vaccine uptake to combat vaccine hesitancy however we know little about how people have thought of and practised solidarity in their everyday lives since the beginning of the pandemic what role does solidarity play in pandemic times and how does it relate to public health and other measures introduced since the onset of the pandemic we build on a practicebased approach to solidarity to answer these questions we present insights from a largescale international qualitative study that signals a societal longing for institutional transformationin the form of what we call institutionalised or tier 3 solidarityto address the many social injustices brought to light and exacerbated by the pandemic and to show how these insights are relevant for policymaking in pandemic times our analysis leads us to reflect on the role of medical humanities in pandemic times what lessons can we draw for policymaking healthcare practice and the potential for medical humanities to guide insights into future health crises these are important questions to address especially for a large and multidisciplinary field such as the medical humanities 2012 the analysis of solidarityrelated practices can help in exploring some salient social justice issues that the pandemic has brought to the forefront of scholarly public health political and societal attention and thereby contribute to one of the longstanding aims of the medical humanities to uncover contexts and meanings of social justice in medical practice and healthcare systems while the disciplinary conceptual or methodological focus of the medical humanities can vary depending on how inclusive an approach is taken towards the humanities and social sciences the patients experience is at the centre of most of the work in the field the medical humanities have thus been crucial in influencing and shaping the idea that patients and their experiences should be the core concern of the medical practice and research community more widely the humanities and social sciences have long original research highlighted the fact that societies are built on social relationships at different levels and that we need to understand these relationships in order to inform policy and healthcare practice in our research we build on the idea that one cannot aim to resolve complex problems or improve healthcare practice without understanding what patients and individual members of society experience sadly a pandemic means that most people will either become a patient have been a patient or know someone who is or has been a patient everyone is affected by a pandemic in one way or another drawing on 643 indepth qualitative interviews conducted during two phases in nine european countries this article explores solidaristic practices and how these changed between the two periods of the longitudinal study in line with prainsack and buyx we understand solidarity as practices by which people support others with whom they see themselves as connected in some relevant waymay it be a common goal a shared identity or the joint fight for a common cause or a social good in the interviews we found that appeals to solidarity resonated with people at the beginning of the pandemic who largely followed public health advice and stayed home during the first lockdowns we distinguish solidaristic practices from more rhetorical expressions of solidarity and show how an approach that focuses on concrete actions inaction or motivations of people to engage in ways that foster or hinder solidarity draws a nuanced picture it demonstrates where how different forms of solidarity take place and where solidarity is seen as lacking the approach also allows us to make sense of a crucial change that we identified between the two interview phases of the study whereas acts and expressions of persontoperson solidarity were strong in the first interview phase in april and may 2020 in october 2020 they were marked by a longing for more institutionalised forms of solidarity this may be a common trajectory in times of crisis where a strong sense of solidarity and the need for mutual support decrease over time as the circumstances of the crisis are more normalised and a certain crisis fatigue sets in beyond this however we see it also a result of injustices and inequalities exacerbated or brought on by pandemic policies a practicebased understanding of solidarity allows us to go beyond interpretations of the waning of solidarity as pandemic fatigue and instead to underline the need for solidaristic practices to be fostered by public institutions in order to sustain them throughout and beyond crises background solidarity in european healthcare public health and the medical humanities solidarity plays a role in healthcare and public health in at least three important ways first solidarity is often labelled a core value on which publicly funded healthcare systems in europe are built this applies to both taxfunded health systems as well as systems funded through social health insurance contributions in the case of the former saltman argues that the notion of equity as a guiding principle for how resources are distributed fairly between patients is the conceptual nearequivalent of solidarity in social health insurance systems the underlying idea is that healthcare should be provided and accessible to all as needed when needed without negative financial repercussions and in a reciprocal fashion over time through the institutionalisation of public healthcare this has led to people accepting the costs of paying into collective pots of healthcare even if they are healthy knowing that one day when they might need healthcare they can access it without this having negative consequences for their personal financial situation this institutionalised form of solidarity hinges on the assumption that all members of society share a vulnerability to ill health which can be mitigated by a system of mutual support against this background it is easy to see how a health crisis such as the covid19 pandemic has the potential to threaten the very foundation on which public healthcare systems rest as practitioners are faced with morally intractable decisions of having to prioritise some patients over others even though the value of mutual support and equal treatment enshrined in the system would suggest otherwise second solidarity is one of several principles that health practitioners and policymakers might draw on when developing public health guidance in pandemic and nonpandemic times in the literature on public health ethics and bioethics solidarity is often juxtaposed or compared with other more individualised principles that justify public health action such as autonomy or personal responsibility the latter notions tend to take centre stage in public health discussions leading dawson and jennings to argue that solidarity has been an overlooked concept in public health ethics and pandemic ethics frameworks they conclude that solidarity can and should be applied in a much more explicit way when justifying public health interventions at the heart of their argument lies an understanding of solidarity as a collective concept one that transcends many of the other elements of public health ethics such as beneficence nonmaleficence justice and autonomy for public health interventions to be successful an understanding is needed that safeguarding values and rights at the individual level for example the value of autonomy is not possible without first securing values at the collective level for example through increasing vaccination uptake from this point of view the encouragement of populations to get vaccinated is more than a rhetorical frame it is a policy instrument deeply rooted in notions of solidarity and humanism third despite its fundamental importance in healthcare and public health solidarity remains an opaque concept that is often used but rarely defined this article highlights the value of understanding solidarity through a prism of a practicebased approach that allows us to identify multiple and varied forms of solidarity at different stages of the pandemic hence circumventing some of the operational problems that might otherwise arise from discussing an often poorly defined concept we do this by adopting the definition of solidarity by prainsack and buyx that encompasses practicebased understandings which has proved to be a fruitful lens for researching enactments of solidarity in healthcare prainsack and buyx argue that the recognition of similarity with another person that in turn gives rise to a solidaristic action is a key element in explaining solidaristic practices solidarity is an enacted commitment to carry costs to assist others with whom a person or persons recognise similarity in a relevant respect one of the key elements of this definition of solidarity is that it has to be enacted that is to say a concrete action has to emerge from which we can extrapolate that solidarity is being practised this working definition of solidarity allows us to analyse interview data from several angles when investigating which actions and practices might be identified as solidaristic practices in addition to the motivations that people describe as factors for following public health advice or in supporting others during the pandemic we can reflect on the types of costs people are original research willing to incur to support others or the way in which they describe groups with whom they feel connected in some relevant way importantly for the findings presented in this paper solidarity can manifest itself at various levels the interpersonal level group level and at the level of institutions and norms solidarity at the interpersonal tier refers to practices by which people support others based on shared experiences at the persontoperson level at this tier we observe and identify many different forms of solidarity and acts of support between individuals especially in the first phase of the pandemic the second tier refers to manifestations of a shared commitment at a group level for example within a selfhelp group in our interviews this emerged in terms of supporting initiatives implemented by new and preexisting groups the third tier refers to institutions policies and other formalised processes that are organised according to the principle of solidarity or that help to realise it the understanding of mutuality and equity in access that underlines many european healthcare systems is probably the most prominent example of such institutionalised forms of solidarity in healthcare as our findings show however that such institutionalisations cannot be taken for granted many respondents expressed their frustrations with governments not doing more to institutionalise and support the solidaristic practices that were seen in great abundance at the interpersonal level of solidarity the concept of solidarity is particularly useful in thinking about some of the normative and applied ambitions within the medical humanities as a broad field that draws on methods concepts and content from different humanities and social sciences disciplines first it supports the fields ambition of uncovering providing and understanding contexts and experiences in medicine and healthcare in investigating the experiences of respondents during the pandemic we found that the practicebased understanding of solidarity provides a useful lens for interpreting what respondents told us about their motivations hopes expectations and fears regarding public health measures second the concept can offer insights for the medical community generally and medical students specifically by investigating concrete practices of solidarity we gained insight into instances related to public health or the management of the pandemic in which respondents felt that solidarity was lacking thereby creating opportunities for formulating recommendations for practitioners and policymakers alike incidentally this ties in with a third ambition found in some of the medical humanities literature the call for more empirical and policyoriented work last but not least the concept of solidarity plays an increasingly important role in scholarly thinking in the humanities the social sciences and increasingly in public health ethics and bioethics methods this publication has been made possible by the joint work of the solidarity in times of a pandemic research commons a large multidisciplinary research consortium set up at the beginning of the pandemic to explore peoples experiences solpan is a largescale qualitative comparative research study comprising interviews with residents from nine european countries participants were recruited through online advertisement via university websites social media networks convenience sampling snowballing and purposive sampling aiming to cover a range of demographics age gender income employment status education household situation and rural or urban living area were assessed all participants received a study information leaflet prior to the interview formal consent to participate was obtained orally directly before the interview both the consent and the subsequent interview were recorded on a digital recorder or using a video chat recorder compliant with the countries data protection regulations even though interviews were held in the participating countries official languages all country teams used the same qualitative interview guide developed by the solpan research commons interviews were conducted with the same participants in april and may 2020 and october 2020 participants were asked about their practices and lived experiences during the covid19 pandemic with the aim to assess the reasons behind those practices even though solidarity served as the theoretical framework for the study we did not use this term in the interview guide to avoid socially expected answers instead we asked about how participants protected themselves and others against covid19 how they supported others how they accessed information they trusted their perceptions on covid19related policies and regulations and future expectations participants were encouraged to talk freely about their lived experiences even if answers diverged from the interview topics only audio and no video material was stored for transcription and transcripts were pseudonymised interviews lasted between 25 and 90 min for data analysis the solpan research commons inductively developed a coding scheme that was applied to all interviews using atlas ti or nvivo interview data coded with the codes supporting practices solidarity and protecting others was analysed indepth by each country team in the interviews original language using the concept of solidarity proposed by prainsack and buyx countryspecific analytic reports in english language were written including descriptions of solidaristic practices as described in the interviews the motivations behind those practices perceived costs what tier of solidarity practices accounted for as well as references to similarities and differences with individuals or groups people were solidaristic with moreover attention was paid to whether and how these practices changed from april to october 2020 those reports were then used as a basis to structure and compare findings between countries which was done first through exploratory meetings among all coauthors and then in small analytic groups including two to three researchers from each country findings were then reassessed by each country team for consistency with their data interview excerpts were chosen in collaboration between the country teams the consortium devised an interview key that ensures pseudonymity but allows readers to identify the country and interview phase from which the excerpt stems which is used throughout this article the interview identifier is provided in brackets at the end of every quotation and includes the interview phase the country code the initials of the researcher who conducted the interview and the interview number original research patient and public involvement patients and the public were not involved in the design phase of this study because the research project was set up at the onset of the pandemic in which coproduction of research projects was difficult due to lockdowns as well as the speed in which the project needed to be set up from scratch the interview guide for the first phase of the interviews was conceptualised by members of the solpan consortium based on the available literature on solidarity and based on the public discourse on solidarity in different countries the interview guide for the second phase of interviews was informed in part by the findings of the first phase and by priorities raised by respondents the study findings continue to be disseminated to the participants and to the public in the form of blog posts media communications and academic publications the precondition for this dissemination was that interviewees gave their consent to being informed about the outcome of the study findings at the end of the interview findings persontoperson and groupbased solidarity interviews carried out across europe at the start of the pandemic suggest the emergence of novel forms of interpersonal and groupbased solidarity we found that the practices composing this kind of solidarity were similar in different european countries most prominently they included provision of material and emotional support which takes the form typically of financial aid provision of food and basic items to those most in need home delivery of food and other basic items and social support in the form of organising telephone rotas to ensure that people who live alone are not abandoned setting up neighbourhood whatsapp groups to organise socially distanced onstreet gettogether or creating solidaristic hampers where people leave what they want and people in need can take without asking moreover many interview participants described doing the groceries for elderly neighbours or contacting friends and family who live alone more frequently this type of solidarity is often expressed through a heightened level of attention to the needs of others and the desire to do something for the community across the spectrum of solidaristic practices several interesting commonalities can be traced we noticed in data across all countries that many participants talked about their motivations for complying with public health measures to contain the pandemic as rooted in understandings of solidarity even if the term solidarity was not always used solidaristic reasonings were displayed in terms of making sacrifices and helping each other as a way out of the crisis in the words of our interviewees following guidelines is at a cost to your own it could be at a cost to your own business it could be at a cost of your ability to interact with your family with your friends your social interactions you know upholding the guidelines comes at a cost but we all seem to be quite happy to do it given that we know that the value it has to each other everyone dutifully does what is required of them i notice that there is a lot of discipline much more than you might have thought of beforehand of course there is also a kind of underlying solidarity a bit of looking out for each other we see here not just an abstract sense of solidarity or sense of duty but a concrete desire to protect others especially those who are perceived to be at greater risk than our respondents considered themselves to be this translates into a willingness to accept the costs and sacrifices to personal freedoms that go handinhand with complying with containment policies in singling out vulnerable people when sharing thoughts about why measures are adhered to our data give empirical support to theories about the need to identify people or groups with whom one feels solidaristic in order to give substance to solidarity groups that were mentioned in the interviews included frontline healthcare workers people who are not able to work from home small business owners and those in precarious working and living conditions such as the unemployed or people with refugee status hopefully this crisis requires a lot of solidarity with older people with the healthcare workers with other workers who are most affected by that it is like this yes upon being asked if the interviewee adheres to the measures but less out of a concern that i could become sick myself but merely if one does not follow it the measures yes it would especially affect the generation above me that would perhaps become infected through me and yes it the older generation is clearly more in danger than i am at the moment so i am not scared that they clients of the interviewee carry something contagious for me that could harm me … it is really important to me that i dont give it to anyone who is a risk patient and thats why one has to be careful one never knows with whom one would have contact if one were infected before even knowing that one is infected on the other hand many respondents saw instances of other peoples noncompliance to public health measures as unsolidaristic so we have neighbours they party with friends every day which i dont find great because i then think yes then firstly we will perhaps still be stuck in these lockdowns for longer when everything the virus breaks out again and it could also be … that people die this i find so…it gets on my nerves if people do not at least try to get through this together as much as possible … and one day my sister who no longer works as a nurse … but she has now been called up to work as a nurse again through a compulsory measure and she had to sign a document to say she will be available up to 60 hours a week and as she told me this some friends arrived at my neighbours house with bottles of wine and started making noise and in that moment i was so angry … because i thought why does my sister maybe then have to care for such idiots i dont accept this but yes i dont know such unsolidaristic behaviour really annoys me at the same time some of our interviewees justified certain infringements of pandemic measures on the basis of solidarity some participants broke the rules to support others in need of help socially or psychologically especially during lockdowns i went to visit him an elderly friend living alone one morning i defied the law because we were in full lockdown but i was worried because i had not heard from him he was not replying to the texts on our chat anymore i knew where he lived so like a thief in the night slipping from corner to corner in the street i reached the neighbourhood where he lived and i saw him in his house 1 the neighbours son had gone missing they were completely panicked and then we took care of their younger child it is actually not allowed but you do it anyway because that panic is more important than … a guideline … what you also do more often because of that covid is that you take walks in your own village its actually very strange you never do that otherwise and we do that now and on such a walk we came across a man who had fallen with his walker but we helped him up and brought him home i sometimes make exceptions in that sense i see that more as a kind of priority rule you have to do things like that … so for me these are not measures that are taboo but they are measures to limit risks as much as pos original research sible every now and then you have to do something and make an exception i think but not in the sense that we secretly have parties or anything we dont these quotations illustrate the types of reasoning that were employed in instances in which helping others in an emergency situation or during tough times were viewed as more important than the strict adherence to the lockdown rules people were aware that strictly speaking they were not allowed to engage in such practices but they were willing to accept the possible consequences in order to assist others we are staying in a student residency and a close friend of ours feels lonely … hes seeing a psychologist as well and i dont know normally were not allowed to see him or visit him but we do invite him to dinner every day just to give him some structure in his day and yes to carry his mental pressure or burden a little bit … yes to me that matters more than leaving him alone in his room knowing that he has a hard time mentally in other words in several situations the willingness to act in a supportive manner manifested itself in actions with potentially significant costs for the individual in the form of fines or other reprimands if one were caught breaking the rules such instances illustrate the nuances of solidaristic actions brought to light through a practicebased definition of solidarity these forms of support occurred primarily during the first lockdown phases of the pandemic in which rules and guidelines provided little room for exception or justified infringements by the time of our second round of interviews in october 2020 many participants expressed fatigue with the pandemic situation which corresponded with the public debate in many countries about lower social cohesion and less persontoperson solidarity participants also explicitly mentioned that they had not maintained some solidaristic practices that they had engaged in or observed in april 2020 because it was too difficultfor financial social or psychological reasons some related the disappearance of organised solidarity initiatives to the mere fact that they were not as greatly needed as before many were confident that supporting initiatives and groups would swing back into action if needed yes well thats decreased now but for the reason that the older people are now going out again themselves not in the old peoples home someone still does the shopping for my father but for example for my former bosses for whom they also did the shopping they now go out themselves so they no longer have so much to worry about when the situation gets tragic again these practices will appear again to sum up solidarity was seen as one of several motivating factors to comply with measures and to engage in practices to support others interestingly regarding instances where rules and measures were seen as inefficient or unfair not sticking to the rules was sometimes also seen as solidaristic nonadherence to rules that were seen as useful howeversuch as wearing face masks or keeping a physical distance to others in crowded placeswas explicitly labelled unsolidaristic especially in the second phase of the interviews we saw that fatigue and frustration with government action can affect peoples willingness ability and endurance to act in solidarity this suggests that acts of solidarity also depend on opportunities and circumstances in which solidarity can flourish the longer a difficult situation lasts and the more people lose confidence in collective forms of solidarity the more likely it is that solidarity at the interpersonal level will also be difficult to sustain and the more likely it will be that people long for a transition to more collective forms of solidarity the longing for collective and institutionalised solidarity many participants engaged in reflections about how their personal practices can contribute to safeguarding the healthcare system van hoyweghen and lievevrouw show that such reflections were a key motivating factor for compliance with public health measures in belgium interviewees in france also expressed gratitude for what they perceived as the continuation of institutionalised solidarity in healthcare for example when medical care continued even in the absence of a prescription for a particular intervention theres a lot of mutual aid stuff and also shopping for people who cant thats good i need injections the nurse came i dont even have a prescription but she comes anyway as theyve closed the practice its small stuff but its good in many countries reflections of ones role in the collective realm of solidarity and of the importance of this realm led to concrete actions or rather to the refraining from risky actions that might lead to injuries as an example of practicebased forms of solidarity … more than usual i pay attention to a healthy lifestyle … so that i do not get ill i would also not do any risky things right now because i think to myself i do not want to have to get treatment in a hospital unnecessarily something somebody else perhaps needs so the space in the hospital these reflections may be interpreted as signalling an understanding of the healthcare system as deeply solidaristic in nature something that needs to be supported by individuals and government action alike we will return to this argument in our discussion in both rounds of interviews participants also expressed concern and disappointment that there was not more solidarity at regional national and international level many participants in all nine countries were unhappy about the support provided by their governments for those who had lost work as a result of the pandemic support was often seen as inadequate during the first phase participants were unclear how the supporting process would work would they hear from someone about their case when would the payments arrive how would they make ends meet or pay bills in the meantime also participants complained that support measures were implemented unequally as some categories like irregular or even independent workers were left out from governmental support initiatives in switzerland there were political debates concerning supporting the selfemployed but id find it also important to talk about rents for example because those running costs remain they could have been pushed out or eliminated i am not earning anything at the moment it is true that from a state perspective i was not earning anything before either but they should also care for those who were not working prior to original research we often say in ireland it is because of the lack of services we grew out of the lack of services you see that werent being provided for people unfortunately sometimes the government depends on us but at the same time i think it is very nice that all these people who try you know what i mean to do something for their neighbour or their town or their you know some little things where you are living to make your environment good participants criticised some expressions of solidarity that were encouraged at the institutional level as merely symbolic tokenistic and even hypocritical while they longed for more concrete forms of support for example many interviewees across the nine countries reflected on acts of clapping for carers such as frontline healthcare workers in the first weeks of the pandemicsomething which was put forward by different media sources as a prime example of the upsurge of solidarity in times of a crisis our respondents however were rather critical of such expressions of support as acts of solidarity it was something that was cited by respondents as creating a sort of community feeling or togetherness in a difficult time but even respondents who participated in these national clapping initiatives did not always perceive them as being a form of solidarity because of the low to no costs involved in showing this support and because in most countries it did not translate into concrete support at the institutionalpolitical level such as an increase in funding for hospitals and other healthcare facilities … to stand at the window at 7 or 8 pm and to clap … well you can do that but i think this is not an expression of solidarity necessarily for the people working in the hospitals or in care homes it is a way an attempt that people stay optimistic so showing optimism i think this is okay it makes sense but i would not say that it is a very strong solidaristic measure no of course i think thats a nice sense of solidarity at 8pm but when i hear it i think wow they still keep it up even my mother shes a nurse but she doesnt really think that this attention is necessary either and there was also talk of a pay rise and thats not really happening in the healthcare sector she doesnt think thats necessary either its mainly the young freelancers someone who has just started a business and has invested heavily and then suddenly cant open his store they have more need for it shes more like were just doing our job so i hope that this clapping is something that is going to be longlasting and i hope that it is something that has a positive consequence for those people eg care professionals as well if only in a pay rise or extra leave this year all of that will cost some money too but … im just very scared of how quickly were going to be forgetting about this after the pandemic how quickly people forget how quickly are we going to want to go back to wanting to travel … the worry about forgetting what emerged as important or relevant for society in the pandemic is a concern that respondents reflected on more deeply especially in the second round of interviews we conducted in the beginning there were these efforts we go shopping for you etc there were many incentives from the civilian population where one felt that this is an act of moving closer togetherthere was focus on the atrisk groups … and then when the first restrictions were eased it the sense of togetherness was at least in my perception … gone quite quickly the comfort was back in focus this idea of everyone for themselves … i think that nothing will change in a sustainable way because one is spoilt with consumerism and with luxuries and simply every person…one doesnt want to give up the things that are comfortable these concerns about the sustainability of the lessons learnt from the lockdowns exposed a set of nuanced understandings of institutional solidarity sometimes expressed explicitly and sometimes implicitly explicit perceptions of and expectations for institutional solidarity included respondents discussing that individual acts of solidarity typically have relatively small impact compared with more institutionalised forms such as an universal basic income or other forms of state social protection maybe the neighbours will get a little closer at least in my small environment but in spain this unconditional basic income has already been introduced which would be good of course if several countries could get involved in trying it out which i would find very good in the current situation but i think that this applause for the doctors and nurses that is im afraid it wont last long some interviewees expressed gratitude for state measures that provided safety nets to individuals and businesses at the beginning of the pandemic and expected that this would lead to less societal disruption in the longterm i know people especially in the restaurant industry who have benefited from them the government measures either they are partially unemployed so they can continue to pay their rent on the other hand i know other businesses that are not considered to be of primary importance like this student who had an eventorganising business that didnt get anything but on the whole i think people are being helped theres a net theres a safety net if only by the fact that we have social security we have health care solidarity all this will mean that compared to other more liberal countries there will be less breakage the above excerpt underlines the perceived importance of institutionalised solidarity in the form of safety nets provided by the state in times of crisis and beyond this was often accompanied by a strong sense of worry that an easing of restrictive measures and the gradual return to prepandemic life would open up a vacuum where solidaristic practices had been prominent during the pandemic people want to generate even more sales and accumulate even more they want to have even more luxury goods for themselves so that they really have something in bad times i dont think that solidarity will survive what every individual can do yes okay like me now in our house we have a lot of elderly people here but i was in touch with them before and im the kind of person who likes to approach people ive baked weve cooked for the people here weve offered to shop for people but the thing with the corporates or the rich that is going to get worse much much worse theyre going to have more turnover theyre going to have more euros theyre going to have more bitcoins theyre going to have more money in the banks theyre going to do more sleazy deals so they can get more money this concern about the unsustainability of the kinds of solidarity seen during the pandemic was visible in both rounds of interviews and in all countries in some countries such as austria and germany respondents were explicit about what they thought was needed to hold on to some of the positive examples of societal cohesion during the pandemic that is more institutionalised policies of solidarity such as universal basic incomes respondents in other countries were less explicit about such policies but reflected on the fact that collective solidarity would not last if big corporations for example are not held to higher standards and made to contribute to a more equal distribution of economic benefits and burdens in society institutionalised solidarity was seen as a crucial factor in mitigating against the multiple negative effects of the pandemic beyond the crisis it was seen on may 9 2024 by guest protected by copyright original research as an instrument to learn from and to develop policies that contribute to a stronger sense of solidarity in society while preventing a return to the prepandemic states of affairs discussion a practicefocused understanding of solidarity allowed us to explore how solidarity was enactedor notat the individual and interpersonal level overall there was a striking resonance across countries of a great deal of varied solidaristic practices in t1 with a demonstrable onset of solidaristic fatigue in t2 our findings show that adhering to measures was seen as a matter of solidarity as long as measures were viewed as effective and fair when people felt that solidarity was needed but did not yet exist they enacted it in different ways at a persontoperson level the abundance and variety of interpersonal and groupbased examples of solidarity that emerged in the early weeks of the pandemic was striking our data show that the beginning of the pandemic provided space for extraordinary acts of solidarity which in turn became moments in which people experienced solidarity and support in deep and sometimes challenging ways in some cases these experiences translated into a longing for solidaristic practices to last beyond the pandemic with some respondents believing that this is only possible if governments step in to institutionalise policies that aid solidarity the solidaristic practices at the persontoperson and groupbased level filled an important institutional void in a situation where formal support systems such as pandemic social security payments or support for local shops to set up an online shopping and delivery presence were yet to be devised our respondents seemed to have a shared understanding that individual solidaristic acts matter in fact when asked about their reasons for engaging in solidaristic practices many offered deep reflections about what it means to be a member of society who is aware of the consequences of her actions or inactions and who cares about the people around her such a tacit shared understanding may at least partly be due to the fact that the countries included in this study all have solidaristic healthcare and social security systems which may have fostered an implicit sense of solidarity as mentioned in the beginning frequent appeals on the part of politicians and other public figures to citizens solidarity were more overt reminders of the indispensability of solidaristic action in a crisis forms of assistance such as emotional and mental health support to people suffering from isolation financial aid donation andor delivery of primary goods to those in need are practices that emerged on individual or smaller organisations initiative rather than as response to institutional calls these practices often emerged to respond to a lack of institutional support practices which were sometimes explicitly criticised as insufficient or inadequate in this sense the findings contribute to the medical humanities longstanding concern with … influencing … practitioners to refine and complexify their judgements … in clinical situations based on a deep and complex understanding … of illness suffering personhood and related issues by providing insights into human experiences of the pandemic and how people view themselves in relationship to others the healthcare system and the state our research illustrates that individual notions of solidarity can contextually and contingently lead to action inaction or feelings of discontent especially when other peoples actions are perceived as unsolidaristic this nuanced picture of solidarity can provide a useful starting point for future research transitions and teachings in the medical humanities and beyond if we acknowledge that solidarity is needed for resilience in a public health crisis then we can say that for it to endure it requires institutional support as westoram argues e ffective public health programmes cannot rely solely on private individuals always engaging in interpersonal solidarity in an optimal fashion they also need institutionalised solidarityin the sense of strong healthcare systems and other institutions and policies that satisfy peoples basic needs and support the wellbeing of people and communities placing emphasisand focusing financial and other resourceson institutions and practices of support for people who are disadvantaged would help to reduce inequalities and thus support social cohesion it would also we argue bolster peoples ability and willingness to enact solidarity with others importantly it would help to reverse some of the loss of trust that governments in many countries have caused by demanding solidarity of citizens while engaging in unsolidaristic actions themselves such as vaccine nationalism or protecting industry interests over the needs of workers according to westoram a government which fails to engage in solidarity with its constituents makes an implicit statement about the nature of the relationship between itself and the rest of society in light of this we strongly encourage public health and government officials to institutionalise practices of solidarity more systematically such manifestations and policies of solidarity might include but are not limited to policies introducing a universal basic income strategies to award and recognise the hard work of healthcare workers in the pandemic either in monetary or structural terms or sharing resources such as vaccines with countries with less access the opportunities for solidifying new forms of solidarity at the institutional level are numerous but as the definition of solidarity by prainsack and buyx suggests solidarity comes at a cost whether or not new inroads in the pursuit of institutionalised solidarity will be made therefore depends on policymakers willingness to accept the costs for example the costs associated with sharing healthcare resources with other countries and to explain the need for such costs to society at large certainly the data presented in this article suggest that many of the people we interviewed are willing to act in solidarity and that they are ready and even eager to see more political and social transformation as a result of the covid19 crisis based on the interview data we contend that there are several risks of not taking seriously the longing for more institutionalised forms of solidarity for one there is a risk that solidarity becomes tokenistic if encouraged by officials individuals may consider tokenistic practices such as clapping as an easy or a less tiresome and costly substitute to other and arguably more impactful acts of solidarity collectively these may also be seen as a tokenistic substitute for more decisive government action for instance paying healthcare workers more a second risk is that peoples sense of community may erode over time we saw this in our data to a certain extent in the second phase of our interviews where the former sense of being in this together was partly replaced by a recognition of societal divisions for instance between masked and unmasked individuals such divisions may especially affect those individuals who were particularly solidaristic in their practices andor who carried greater costs of the pandemic it is also vital at those stages of pandemic original research management where public health measures are being relaxed institutionalised communitylevel solidarity scaffolds may in those cases be a bridge between statelevel measures and an individualistic rhetoric of personal responsibility for instance communitylevel outdoor sports programmes or subsidised online grocery shopping may just be two such measures that would allow people to continue to adhere to safety measures once public health ones are relaxed we offer a number of observations from our research on why the medical humanities play a crucial role in addressing complex problems in health crises and how their methodological approaches may be adapted in light of specific challenges of pandemics such as lockdowns one of the core ambitions of the medical humanities is to shed light on the often overlooked lived experience of health and illness the very nature of a pandemic means that the number of people affected by the experience of disease and crisis increases exponentially as anyone and anywhere can or will be affected methodological approaches need to be adjusted accordingly we accounted for this specific feature of a pandemic health crisis by pursuing a largescale comparative qualitative approach that embedded the study in transnational contexts additionally our study provides ground for calls to offer a more integrated disciplinary approach that links the humanities and social sciences the study illustrates what such an integrated disciplinary approach can look like and underlines the fruits that transdisciplinary and transboundary research collaboration can carry last but not least we argue that the medical humanities have much to gain from directing their attention to individual health issues and to health or illness situations that are experienced at a collective level thus harnessing the previously mentioned emphasis on societal relationships in the humanities and social sciences the analysis of patient experiences through a collective lens such as the solidarity approach offers unique insights to understandings of the individual self and the collective community in a way that sheds light on health and social inequalities by focusing on solidarity and solidarity practice we have shown how the medical humanities might adapt to address poignant social justice issues without losing the ambition of uncovering the individual experience of disease crisis and vulnerability we propose three advances which in our view are essential for research endeavours in the medical humanities that aim to map out existing social justice issues and help uncover collective experiences of diseases and health crises a strong position for empirical and practicebased research alongside more normative approaches the confidence to make recommendations for practice and policymaking alike and the pursuit of crossnational and multidisciplinary research collaborations in order to provide context to empirical findings and conceptual understandings of the situated nuances of social justice issues given the size of the solpan research consortium we cannot emphasise this last point enough the challenge of analysing data from nine countries was fruitfully addressed by a continuous open and trustworthy exchange between team members leaders and the whole consortium with 40 participating academics at different stages of their careers we were able to draw on a vast array of skills knowledge and training in different disciplines of the humanities and social sciences thus making it possible to probe our data from different angles limitations while our crossnational indepth and longitudinal research bears crucial academic and policy insights it also exhibits limitations although considerable at close to 700 interviews spread across a range of sociodemographics and 9 different countries our research cannot be considered representative of the citizens of any particular nation or group of nations likewise because of its nonrandom sample design it cannot be generalised the qualitative design afforded us the opportunity to probe into peoples less obvious views and less overt practices more so than broader survey designs were able to a second limitation is that while authors had ontheground exposure to public health messages and media discourses as they lived in the countries in which they did the research for the purposes of this paper and due to the lens adopted we did not conduct a full public discourse analysis which may have given further insights into tier 3 solidarity a final limitation of the current article is that while we were sensitive to variations in our findings across countries we did not engage in a systematic crosscountry comparison conclusion this article demonstrates that a practicebased understanding of solidarity can help shed light on a frequently used but often poorly defined concept practices of solidarity during the covid19 pandemic were abundant in our sample from nine european countries many respondents across all investigated countries told us that they felt the pandemic had exacerbated previously existing health and social inequalities and that governments were not doing enough to mitigate these developments specific societal groups were highlighted as being particularly vulnerable to the negative knockon effects of isolation and stayathome measures namely people who live alone children who cannot go to childcare or schools healthcare workers who have to put themselves and their families at risk without adequate remuneration or recognition the unemployed or selfemployed and people who cannot work from home due to the nature of their work to name but a few the interview guide and the conceptual lens of solidarity provided a useful means for us to map out these social justice issues and they brought to light a longing for more institutionalised forms of solidarity the study suggests that the medical humanities continue to play an important role and that they can take on a more prominent role in uncovering collective experiences of disease or health crises the pandemic reminded people policymakers and scientists alike that crises of large societal relevance can only be addressed when everybody contributes their partat least in democratic countries investigating peoples lived experiences through the concept of solidarity sheds a light on the motivations and limits of this endeavour we offer three takeaway messages for public health practitioners and policymakers solidarity can be an important motivating factor for compliance as well as noncompliance to public health measures that is to say that a nuanced picture about compliance emerges in which people sometimes disregard public health measures in order to act solidaristically towards particularly vulnerable groups compliance and solidarity are thus not equivalent different forms of solidarity at different tiers emerge during a public health crisis it is important that public health officials and policymakers recognise and where possible support these forms of solidarity rather than leave them unrecognised or even worse act against them by for example pursuing policies that are overly focused on personal rather original research than collective responsibility the longing for institutionalised solidarity needs to be taken seriously and transformed into concrete institutional manifestations of solidarity our respondents expressed a strong wish not to return to life as it was precovid19 but rather think more sensibly and sustainably about the activities actions and futures of societies contributors all authors were involved in the planning conception and design of the manuscript the first author led the writing and the review process all coauthors were involved in data acquisition and contributed to data analysis all authors contributed to the original draft of the manuscript all coauthors read and approved the final version of the manuscript kk accepts full responsibility for the finished work had access to the data and controlled the decision to publish competing interests none declared patient and public involvement patients and the public were not involved in the design phase of this study because the research project was set up at the onset of the pandemic in which coproduction of research projects was difficult due to lockdowns the interview guide for the first phase of the interviews was conceptualised by members of the solpan consortium based on the available literature on solidarity and based on the public discourse on solidarity in different countries the interview guide for the second phase of interviews was informed in part by the findings of the first phase and by priorities raised by respondents the study findings continue to be disseminated to the participants and to the public in the form of blog posts media communications and academic publications the precondition for this dissemination was that interviewees gave their consent to being informed about the outcome of the study findings at the end of the interview patient consent for publication not applicable ethics approval several institutional ethics committees approved this study including the university of vienna the technical university of munich ku leuven and ucd 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 on reasonable request data are stored in a secure location all members of the consortium have access to the data access to the data is restricted to the members of the consortium to ensure the confidentiality and anonymity of the research participants 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 this article is made freely available for personal use in accordance with bmjs website terms and conditions for the duration of the covid19 pandemic or until otherwise determined by bmj you may download and print the article for any lawful noncommercial purpose provided that all copyright notices and trade marks are retained

calls for solidarity have been an ubiquitous feature in the response to the covid19 pandemic however we know little about how people have thought of and practised solidarity in their everyday lives since the beginning of the pandemic what role does solidarity play in peoples lives how does it relate to covid19 public health measures and how has it changed in different phases of the pandemic situated within the medical humanities at the intersection of philosophy bioethics social sciences and policy studies this article explores how the practicebased understanding of solidarity formulated by prainsack and buyx helps shed light on these questions drawing on 643 qualitative interviews carried out in two phases aprilmay 2020 and october 2020 in nine european countries austria

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introduction everybody will diedeath matters to everyone hong kong is experiencing rapid population aging 1 in 2016 30 of the total population was aged 55 or above and this figure is expected to reach over 40 by 2050 23 there has been active discussion in recent years about the concept of advance care planning advance care planning is a process that enables patients to express their preferences regarding endoflife care and it enables family members and healthcare workers to understand patients preferences and to make decisions on the behalf of patients when they are unable to do so 4 advance care planning preferences can be indicated in advance in the form of an advance directive 5 an advance directive is a written statement that allows a person to indicate the form of health care he or she would like to receive in the future when he or she is no longer competent 6 many western countries have already passed laws for ad for example the united kingdom passed the mental capacity act in 2005 which provides a legal framework for introducing advance decisions to refuse treatment 7 in 1991 the united states passed the patient selfdetermination act which requires all statefunded hospitals to have a policy on living wills and advise patients of their right to execute an advance directive 8 death is still a taboo subject that is difficult to openly discuss in asian cultures in traditional chinese culture mentioning death is sensitive and should be avoided 910 advance directives have not been legislated in hong kong presently advance care plans and advance directives were seldom discussed among healthcare professionals or the public in hong kong until 2006 when the law reform commission recommended promoting the concept of advance directive through nonlegislative means 11 while there is no specific legislation for advance care plans or advance directives in hong kong it does not mean that people cannot make an advance directive under the common law framework people can establish their endoflife care wishes in advance a valid and applicable advance directive has legal status and family members cannot override it 12 although there is a growing interest in advance care planning in hong kong the studies of advance care planning in hong kong are limited many studies were conducted among elders in a nursing home or hospital setting by medical practitioners in hong kong 13 14 15 for example chu et al conducted a survey in 140 nursing homes in hong kong and found that despite the fact that many of them did not understand the idea of an advance care plan or advance directive 88 of them would prefer to have an advance care plan or advance directive after they had been explained to them 13 however one of the major problems of conducting studies in a nursing home or hospital setting is that the respondents or the target samples will be ill or older people 1415 chung et al and pang et al have tried to conduct telephone surveys in hong kong 1116 both studies found that respondents were mostly unaware of advance care planning and advance directives two studies also reported differences in the preference for using advance care planning the study by pang et al found that 78 of people would use advance care planning after researchers explained the terms to them and younger people and those with secondary education or above had a greater chance of adopting advance care planning 16 the study by chung et al found that only 60 of people would use advance care planning after having it explained to them during the interviews and they found that age and education level were not related to the preference for using advance care planning 11 telephone surveys although less expensive than facetoface surveys have limitations especially in hong kong time constraints are one of the disadvantages of telephone interview surveys some potential interviewees might be reluctant to participate in the survey because they fear it would take a long time therefore the questions used in telephone surveys are generally short and simple furthermore the quality of the collected answers is questionable because when researchers reach out to people at home they are often engaging in other activities such as eating dinner or watching television there are also some unique issues to the telephone surveys in hong kong for example the sampling lists of telephone surveys are often fixedline telephone numbers however in the 21st century when mobile phones are popular many households do not have a fixedline telephone number it is also not feasible to use mobile phone numbers as a sampling listas mobile phone numbers in hong kong are not registered with real names many people in hong kong have more than one mobile phone number and the number of mobile phone numbers in use will not be proportionate to hong kongs population while telephone surveys are convenient and inexpensive the limitations of telephone surveys have become increasingly apparent as landline telephones have fallen out of fashion although the cost will be higher communitybased sample surveys are preferable to telephone surveys for many social researchers because the questions in communitybased sample surveys can be more detailed and the investigators can be onsite to ensure that respondents answer the questions seriously however because discussing death is taboo in chinese society studying death in a community setting in hong kong is difficult such research is unlikely to be popular with communities such as conservative town councilors or homeowners the concept of a good death has emerged in hong kong over the past decade luk et al have defined that a good death means people have choice and control over where death occurs and who is present with them at the end 17 therefore having the option of dying in place or in a familiar environment and of having the company of family members is important in japan the government has promoted dying in place and terminal home care over the past decade especially in rural areas 18 19 20 21 22 23 however in hong kong death at home or dying in place is basically impossible due to high residential and population density the majority of hong kongs population die in hospital according to luk et al this is because people may fear depreciation of property value if the elderly die at home 17 furthermore inappropriate admissions to hospital are common in hong kong almost all older patients with terminal diseases or irreversible chronic illnesses die in hospitals as they are rarely referred to palliative care services 17 as for the willingness to die at home chung et al found that 68 of people would still be unwilling to die at home if they could get medical assistance at home more than 90 are unwilling to die at home without medical assistance at home 11 as most of hong kongs residents will eventually die in hospital people need to have a plan for a good deathdeciding how to die where to die and who to share the final journey with having an awareness of advance care planning is a good start to having a good death given that advance care planning is a new concept that was only recently introduced in hong kong and that most of the previous studies in hong kong were conducted in hospital or elderly home settings it is necessary to conduct a study asking for communitydwelling older adults views on advance care planning while not all the older people in the community are patients results from community settings can provide a different angle to results collected from a nursing home or hospital setting by asking older adults views on advance care planning in the community we can better understand what medical concerns affect advance care planning how to promote advance care planning and what the older adults are concerned about when they decide whether to use advance care planning the purpose of this study was to investigate the factors that influence the advance care planning opinions of communitydwelling older adults three research questions were formed 1 what are the demographic factors that influence the preference of using advance care planning 2 what are the important medical treatment factors that influence the preference of using advance care planning 3 what are the important decisionmaking factors that influence the preference of using advance care planning materials and methods selection of area kwun tong town center was purposely selected to carry out this study as kwun tong has the most extensive aging population in hong kong furthermore kwun tong is one of the postwar new towns developed in the 1970s under the governorship of murray maclehose 24 according to the latest census in 2016 210145 older people were aged 55 or above in kwun tong in the residential area selected for this study 8501 people were aged 55 or above 3 sampling the targeted respondents were chinese people living in the kwun tong town center aged 55 or above with the assistance of town councilors 2446 households were randomly selected within the sampling frame all of the households with someone aged 55 or above were counted as targeted households and the inhabitant was asked if they would like to be interviewed if there were no responses at the first visit two more visits at different times and dates would be arranged if there was still no answer the household would be listed as a noncontact if there was more than one eligible older adult in one household the next birthday method was used to sample one respondent of the 2446 households 1089 households were able to be contacted after three attempts of the 1089 households who were able to be contacted 683 were identified as having eligible residents and 282 of the 683 were willing to participate yielding a response rate 413 for the eligible households in this research measurements basic demographic information was obtained from each respondent including age religious belief and place of birth they were also asked about their basic health status this study did not ask for either personal or household income due to privacy concerns then respondents were asked whether they would use advance care planning whether they would prepare for death and whether they had received any death education an explanation of advance care planning was provided in case the respondents were unaware of it four statements related to medical treatments and four statements on decisionmaking were also given 1 i will insist on receiving treatment even it is painful 2 i will terminate treatment to maintain life quality 3 i want to use drugs and other means to alleviate physical pain 4 i want to receive mental support 5 i want to discuss my situation with the medical staff 6 i want to discuss my death decision with my family beforehand 7 if the decision made by my family contradicts my wishes i will insist on my wishes 8 if i cannot decide i will trust family rather than the doctor all questions were dichotomous questions in order to make the questions more manageable for older adults and to avoid triggering any negative feelings about death from the respondents since death is a taboo subject in hong kongs society this study avoided asking too many specific questions so as not to trigger any bad feelings from the respondents these questions were carefully selected according to different literature a pilot test was also conducted on 20 older people to ensure the questions were easy to understand analysis this was a crosssectional descriptive study the data was then analyzed using statistical software spss 25 demographic data were combined for ease of analysis for example health status was recoded into yes and no hong kong has freedom of religion different religions exist in hong kong if we break them down the data will not be enough for analysis therefore it was decided to recode them as has religious beliefs and no religious beliefs the education level was also recoded as received secondary or above and did not receive secondary or above using secondary school as the boundary was based on work from pang et al who found that people who did not receive secondary education were less likely to use advance care planning 16 pang et al also found that because of the previous education system implemented in china and hong kong there was only a small number of tertiary education recipients the compulsory education in hong kong in the 1960s was only six years and many people could not attend secondary school 24 not all of the respondents answered all the questions missing data would not be replaced or edited as all variables were nominal data after recording basic descriptive statistics including the mean and standard deviation were then obtained by using spss to examine the different factors influencing advance care planning use the chisquare test was used for independent samples after that a multivariable logistic regression was used to find out which characteristics remain significant after controlling for covariates all characteristics with significant p value in the chisquare test were included as a full model the enter method would be used then nonsignificant variables would be removed from the model one by one starting from the highest p value until all variables remained significant the final model would be reported the hosmerlemeshow goodness of fit test was used to check the model fit if the p value of the hosmerlemeshow goodness of fit test is smaller than 005 the model should be rejected while stepwise regression is a popular datamining tool that uses statistical significance to select the explanatory variables to be used in a multipleregression model the stepwise method would not be used in this study because the fundamental problem with stepwise regression is that some real explanatory variables that have causal effects on the dependent variable may happen to not be statistically significant whereas nuisance variables may be coincidentally significant 25 instead of using software to eliminate data using substantive knowledge to guide variable selection is more important and reliable 25 ethics all participants gave their informed consent for inclusion before they participated in the study the research was approved by the research ethics committee of the authors institution and was conducted according to the guidelines of the declaration of helsinki results basic information about the respondents a total of 138 males and 144 females were enrolled the ethnicity of all respondents was chinese their mean age was 727 years old and their ages ranged from 55 to 93 years old a total of 156 respondents had a longterm illness and 26 were disabled in this study 553 of the respondents had a religious belief only 212 of respondents were born in hong kong only 135 of respondents had heard of advance care planning before the survey for those that had heard of advance care planning before the survey 632 of them had discovered it through the internet among all respondents only 48 respondents would consider setting up an advance care planning after it had been explained to them this study found that while respondents had prepared for death only 20 respondents had attended a life and death course or talk demographic characteristics and advance care planning the study showed no association between advance care planning and gender the study showed no association between advance care planning and religious belief for education level the study showed no association with advance care planning with an aging population in hong kong people generally have a longer life expectancy this study divided respondents into two groups according to age 5569 and 70 or above the reason for using 70 as a cutoff was because the mean age in this study was 727 there was a significant correlation between the age and advance care planning suggesting that people in the younger group had a higher chance of using advance care planning than those in the older group using an independent sample ttest also obtained a similar result as the mean age of advance care planning favorers was 698 and 734 for advance care planning nonfavorers in terms of place of birth the study showed a significant correlation between the place of birth and advance care planning suggesting people born in hong kong were more likely to use an advance care planning health status and advance care planning while the study showed no association between advance care planning and disability there was a significant correlation between longterm illness and advance care planning suggesting that almost 865 of respondents with longterm illness had no plan to use advance care planning life and death education and advance care planning death education is not popular in hong kong as death is sensitive subject to talk about in this study only 20 respondents had attended a life and death course however this study reported that there was a significant correlation between life and death courses and advance care planning suggesting that people who had received life and death education were more likely to report a preference for using an advance care planning than those who had not attended life and death course or talk the study also reported a significant correlation between death preparation and advance care planning medical treatment decision making and advance care planning in order to understand how to promote advance care planning in hong kong this study also looked at what medical considerations are associated with advance care planning in terms of treatment the study found that those who wanted to use advance care planning in the future would have less desire to receive treatment if it would be painful the reason needs to be studied in the future as the study found that terminating treatment to maintain life quality was not associated with the use of advance care planning there was also no significant correlation between use of drugs and other means to alleviate physical pain and advance care planning the study reported a significant correlation between mental support and advance care planning for decision making the study reported that there was no significant correlation between discussing the situation with medical staff and advance care planning however the study found that respondents who would like to use advance care planning would be more likely to discuss their death decision with their family beforehand respondents who prefer advance care planning would also be more likely to insist on having wills the role of doctors was also important as the study reported a significant correlation between trusting a family rather than the doctor and advance care planning multivariable logistic regression multivariable logistic regression was used to understand which characteristics remain significant after controlling for covariates all characteristics with a significant p value in the chisquare test were included as a full model the enter method was used then nonsignificant variables would be removed from the model one by one starting from the highest p value until all variables remained significant one of the reasons behind the unfit full model was the small sample size of advance care planning favorers the sample is not large enough to include 10 variables in the model simultaneously furthermore gradually eliminating variables from the regression model would make it possible to find a reduced model that best explains the data the final model reported that five out of 10 variables that were significant in the chi square test remained significant in the regression test they were illness prepared for death want to receive mental support if the decision contradicts mine i will insist on your own and if i cannot decide i will trust family rather than the doctor this model was fit as the hosmerlemeshow test was not significant the model therefore should be accepted discussion this study was one of the first to ask questions about the advance care planning preferences of communitydwelling older adults in hong kong using a residential sampling method while only dichotomous questions were asked to avoid triggering any negative feelings about death from the respondentsa taboo and ominous topic in the chinese cultural context the results provided valuable insights to help promote advance care planning in hong kong this study showed that only 17 of the respondents would like to use advance care planning even after being given an explanation of the meaning of advance care planning previous studies conducted by luk et al and pang et al reported that 88 and 76 of the respondents were in favor of having an advance care planning respectively 1516 the result of this study was far lower communitydwelling older people may not have considered endoflife arrangements yet due to their age and health a telephone survey study by chung et al also suggested this point as their study found that only 143 of the sample had heard of advance care planning before the interviews and just 609 of the sample expressed that they would be willing to make an advance care plan after being given an explanation of what advance care planning was during the interviews 11 the study by chung et al was slightly different from this study because the sample of their study was made up of people that were over 30 years old however the results of their study were still lower than the data obtained in hospitals or nursing homes in terms of age this study found that a greater percentage of the younger people in the sample would like to use advance care planning older adults without chronic illnesses were also more likely to use advance care planning the result from the multivariable logistic regression also reported the same as it found that the likelihood of using advance care planning in the without illness group was 28 lower than in the illness group the results of this study echoed the study by pang et al 16 given that the mean age of advance care planning favorers was significantly younger than advance care planning nonfavorers it is natural to think that the younger generation without illness or disability is likely to choose advance care planning in order to have their own will realized in the sample of this study 667 of respondents aged 70 or older had longterm illnesses which was significantly higher than the group of 5569yearolds if we exclude the group of 5569 yearolds and only analyze the group of people that are 70 years old or older the data indicate that only 63 of advance care planning favorers had longterm illnesses for advance care planning nonfavorers up to 938 had longterm illnesses the results of this study are very different from previous studies previous studies have shown that older adults strongly favor advance care planning but these studies were conducted in hospitals or nursing homes and many of the interviewees were dying patients for instance the studies of luk et al and pang et al were conducted in the hospital and nursing home settings this might be the reason for the completely different results 1516 older adults receiving treatment in hospitals or nursing homes may be advised on or informed about advance care planning by medical professionals older adults facing terminal illnesses must also consider endoflife arrangements and they might take advance care planning as an option based on the advice of medical professionals therefore the results obtained in hospitals and nursing homes will differ from the research done in a residential setting while the results of this study are distinct from previous studies conducted in noncommunitydwelling settings the results reflect two factors that affect the understanding and awareness of advance care planning the first is the promotion of death education and the second is the openness and information acceptance of the respondents the results of this study implied that death education should be promoted in hong kong as the results suggested that most older adults living in nonhospital or nursing home settings were not ready for death or had never attended any life and death education a chinese saying goes death and life have their determined appointments riches and honors depend upon heaven older adults with chronic illnesses may feel that life and death are determined by destiny so they might not pay much attention to death preparation since it is taboo to talk about death publicly in chinese society if there is a lack of promotion or public education by medical professionals the communitydwelling older adults may naturally not understand advance care planning or even consider using it this is one of the reasons why olderaged respondents with chronic illnesses surprisingly tended to be advance care planning nonfavorers in this research compared to previous studies that were conducted in hospitals or nursing homes where patients would have chances to receive information about advance care planning therefore this study recommends that more death education should be promoted so that people will have the appropriate knowledge and emotional preparedness to face their illnesses as well as illnesses of family members and friends that may be expected or unexpected the results also indicated that death education could promote advance care planning as the results showed that the percentage of willingness to use advance care planning in those who had attended a life and death course or talk was higher than the willingness of those that had not those who had prepared for death were also more willing to use advance care planning the result from the multivariable logistic regression also reported that the odds of using advance care planning in the prepared for death group was 494 times higher than those were not for the openness and information acceptance of the respondents young and healthy older adults may have more time to and channels through which they can receive information such as newspapers and the internet given that public discussion of death is taboo in hong kong and advance care planning and advance directives as the introduction of this article points out are not separately enacted as a law in hong kong patients need to use advance care planning and advance directives through other common law frameworks 11 therefore the government rarely promotes advance care planning in public broadcasts such as television and radio at present most discussions on advance care planning rely on the public promotion carried out by patient organizations and social welfare agencies or presentations given to dying patients in medical institutions by medical staff such as hospitals for communitydwelling older people this study asked the advance care planning favorers where they first had heard of advance care planning 632 had discovered it through the internet 158 from traditional press another 158 from medical professionals and 53 from family members and friends as a result the internet plays a vital role in spreading this new endoflife planning concept the role of the internet may explain why the group of those aged 70 years old or above was less willing to use advance care planning unlike other countries the internet penetration rate of the elderly in hong kong is relatively low according to the census and statistics department the internet penetration rate for persons aged between 10 and 54 was close to 100 in 2016 but for persons aged between 55 and 64 years it was 877 for persons aged 65 or above the penetration rate was only 44 26 as the internet is not popular among the elderly this will reduce their exposure to information if we compare the study of chung et al this conjecture may be true because the study of chung et al which included young people over 30 years old reported that more people were willing to use advance care planning furthermore since the government has not publicly promoted advance care planning using traditional media older people seem to have less accessibility to advance care planning information this might make them advance care planning nonfavorers due to a lack of understanding or misunderstanding this study also found that the difference in birthplace also has a great effect on the results for the group who would use advance care planning the proportion of hong kongborn was higher than the group that would not use advance care planning this is probably related to hong kongs social and political history after the second world war a civil war broke out in china many mainland chinese inhabitants fled to hong kong many of them gave birth to the next generation in hong kong this study found that the place of birth and age were associated at the significant level with only 267 of the group of those aged 70 years old or older having been born in hong kong for the group aged 55 to 69 733 were born in hong kong as hong kong was a british colony at that time the education system was the british system and most of the schools were run by either anglican or catholic churches these baby boomers were born in hong kong and received education locally they were therefore relatively openminded and many of them even accepted the christian faith in other words with the influence of western education and civilization the baby boomers in hong kong not only have more channels through which to learn about health information but also have less chinese cultural identity than the prewar generation 26 27 28 previous studies have shown that people born in hong kong generally have a more western and open way of thinking than people from china 28 29 30 it may be possible that they are less likely to treat death as taboo and more likely to accept advance care planning moreover the previous studies found that socialeconomic backgrounds such as sex religion or education level are not related to the use of advance care planning in hong kong 1115 therefore it is suggested that future research should focus on the relationship between advance care planning and social status or cultural backgrounds apart from age birthplace and life and death education the results also found that medical care and social support were related to the use of advance care planning the results suggested that the medical care and social support for endoflife patients should be improved as when the respondents were asked the medical questions which related to advance care planning 275 of the respondents who were willing to make advance care planning expressed that they would not want to receive treatment if the treatment would be painful however the exact reason for this needs to be studied in the future as this study reported that neither terminate treatment to maintain life quality or use drugs and other means to alleviate physical pain results were statistically significant the logistic regression also reported that the results for insist on receiving treatment even it is painful were not significant after controlling for covariates the study also reported that 202 of the respondents willing to make advance care planning expressed that they would like to receive mental support which was higher than those who said no to advance care planning the result from the multivariable logistic regression also reported that mental support was important in explaining the use of advance care planning as it remained significant after controlling for covariates those who would like to receive mental support were 81 times more likely to use advance care planning than those who would not want to receive mental support based on the results we can see that medical care and social support for endoflife patients are important therefore the government should consider improving the medical care and support services for patients without them there could be difficulties in achieving some of the patients expressed preferences and wishes 31 the current study also reported that respondents willing to make an advance care plan were more likely to want to discuss their death decision with family in advance however the results also showed that 25 of the advance care planning favorers would insist on their own death decision if the decision contradicted with the wish of their family members furthermore 288 of the advance care planning favorers said they would trust their doctor rather than family members if the respondents could not make a decision regardless of whether this was due to mental or physical health reasons or just disagreements with family members the percentage was higher than the percentage of people that would trust their family members the multivariable logistic regression also found that these two were the most important for the respondents as the results reported that the group of people that would insist on their decision being carried out rather than the decision of the family members was 533 times more likely to use advance care planning than the group that would trust their family members decision the results also reported that the group that would trust the doctors decision was 75 less likely to use advance care planning than the group that would trust their family members decision the regression results imply two important issues firstly older adults empowerment is a critical part of the decision to use advance care planning the government and medical professionals should think about how to promote patients rights in the future secondly this study showed the importance of healthcare professionals providing advice to patients and their family members especially when the patients are more likely to insist on their own will being carried out when using advance care planning while the government and the hospital authority should continue to promote advance care planning to patients and in the public community there should be more education among healthcare professionals regarding advance care planning so as to improve their knowledge and the communication skills required to handle such issues this is very important as healthcare professionals are on the frontline in terms of informing the public of their medical options 32 they also play a crucial role in promoting advance care planning so more education among healthcare professionals is needed limitations and future research this study has several limitations while the sample of this research was collected in a residential area in hong kong with a random sampling method this study was a crosssectional design and was exploratory in nature thus limiting the ability to identify substantial implications causality can only be inferred cautiously furthermore the possibility of type 1 error could not be excluded in this study due to the low frequency of advance care planning favorers this study has tried to recruit the elderly as much as possible however because the interviewees were recruited through sampling it was impossible to know how many people had heard of advance care before the interview this was different from snowball sampling although very few of the interviewees had heard of an advance care plan yet said they would make one this does not mean that this research is worthless this research not only reflects the attitude of the interviewees towards advance care planning but also proves as chung et al found that the public awareness of advance care planning is low 11 it should also be noted that due to the legal issue related to the privacy ordinance of hong kong it is difficult to obtain all the names and personal details of all residential addresses to generate the sampling frame of all residents in hong kong in other words it was not possible to do a random sample study of all of hong kong 15 as a result the location of this research is selected purposely because kwun tong is a district with the largest elderly population in hong kong 23 and there were openminded local councilors willing to help and provide the list of all residential addresses in their wards to generate a sampling frame although this research was only conducted in one district in hong kong this study was an attempt to survey the unknown waters of the use of advance care planning of the communitydwelling older adults in hong kong when reading this article readers should also refer to previous studies carried out in other settings in hong kong for future research researchers should consider increasing the number of samples when studying advance care planning in a community setting this can reduce the probability of type 1 error in addition hong kongs residents awareness of and intention to use advance care planning are low comparing with previous studies in western countries it is generally believed that education level and religious belief will affect the results of this type of research because previous studies found that the favorer rate of advance care planning in the united kingdom and the united states is higher than that of hong kong 3334 whereas poland and italy have very low rates and are both have catholicism as the main religion 34 35 36 however in hong kong this study and some previous quantitative studies found that education level and religious beliefs had no significant relationship with preparations for death or advance care planning 1115 this may be related to the higher education level of hong kongs residents and hong kongs freedom of religion as there is no religion playing a dominant role in hong kong in addition to education and religious beliefs future research can also focus on the cultural aspect to study whether culture influences the preparation for death and the use of advance care planning as previous and current research in hong kong reported that education and religious beliefs were not associated with advance care planning furthermore as most previous studies were conducted by medical professionals they rarely involved cultural issues yet culture is often an important indicator of understanding the publics acceptance of the policy from a policymaking perspective data availability statement the data are not publicly available due to privacy and ethics approval approved by the institutional review board declaration of helsinki and was approved by the ethics committee of the university of edinburgh informed consent statement informed consent was obtained from all subjects involved in the study

1 background hong kong is experiencing population aging but there is little research on advance care planning this research asks for communitydwelling older adults views on advance care planning in order to provide a different angle to the results collected from nursing homes and hospitals 2 methods the targeted respondents were people aged 55 or above a total of 282 questionnaires were collected using the random sampling method respondents were asked whether they would make an advance care plan whether they would prepare for their death and whether they had received any death education they were also given eight statements related to treatments and decision making 3 results the study found that only 17 of the respondents would like to use advance care planning even after it was explained to them advance care planning favorers would be more likely to insist on having wills and would be more likely to trust doctors rather than family members 4 conclusions the results also suggested that the medical care and social support for endoflife patients should be improved the results also showed the importance of medical professionals as they showed that respondents wanted advice on endoflife decisionmaking from medical professionals

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background the growth and development of children is directly related to their current and future health status the height of children is an important indicator of growth and development 1 height is a multifactorial characteristic which is affected by genetic and environmental factors 2 early childhood low heightforage is associated with a series of irreversible adverse outcomes including athletic development retardation cognitive impairment and poor academic performance 3 therefore it is important to identify the environmental factors associated with height so as to improve the overall health status of children the average height of chinese children has increased in the past two decades 4 possibly related to the improvement of individual factors such as protein intake 5 family income 67 and maternal education level 89 these improvements of individual factors resulted from chinas economic and social development through increased food supply better housing conditions and improved health care services 10 chinese government has made great efforts to fill the gap of maternal and child health inequalities between urban and rural areas by explicit policy of ensuring safe birth in health facilities huge investment in human resources to improve the number of licensed doctors reducing financial barriers and providing childbirth subsidies and many other public health programs 11 however the ruralurban disparities that concerning health services still exist 1213 a study 14 evaluated the effects of chinas economic reforms on the growth of children and showed an increase in the average height of children in both rural and urban areas while this increase in urban areas was five times that in rural areas in developing counties like china urbanization has been found to improve child health outcomes such as lower underfive mortality and lower undernutrition rate 1516 through increasing access to health care services education resources and safe water supply 17 smith et al 18 also indicated that in developing counties urban children were more likely to have wellnourished mothers which meant better prenatal and birthing care better feeding practices and greater use of health services for preventive and curative care result in improved growth and lower morbidity however whether and how urbanization is associated with childrens physical development in china remain unclear understanding the relationship between communitylevel contextual factors can help explaining the disparity in childrens physical development between regions and inform the approaches for improving childs health in this study we investigated the effects of urbanization index on child height among chinese children aged 518 years old from the china health and nutrition survey in 2011 methods study population this study used secondary data from the 2011 dataset of the chns which was a large survey conducted in nine provinces and three megacities in china a multistage stratified sampling design was conducted to ensure that chns provided a fair representation of urban and rural areas using sampling strategy two cities and four counties per province were selected based on income within cities two urban and two suburban communities were randomly selected based on urbanicity within counties one community in the capital city and three rural villages were randomly chosen also based on urbanicity twenty households per community were then randomly selected for participation survey protocols instruments and the process of obtaining informed consent for this study were approved by the institutional review committees of the university of north carolina at chapel hill as well as the national institute for nutrition and health which is affiliated with the china center for disease control and prevention participants provided written informed consent data documentation and details on sampling representativeness and validity of data can be accessed through the carolina population center website a total of 1712 children between 5 and 18 years old from 290 communities was enrolled in the 2011 dataset we excluded participants with major medical conditions and had missing information on main variables finally our study included 1606 observations in 272 communities outcome variable physical height of child height was measured without shoes using a portable stadiometer and recorded to the nearest tenth of a centimeter the height for age z score which is an indicator standardized for age and sex was calculated to evaluate the height levels of children and adolescents higher haz indicates better height growth who growth reference 2007 was used this reference is a reconstruction of the 1977 national center for health statistics who reference and it is recommended by who as a growth reference for children and adolescents aged 519 years 19 sas macro was used for calculation as who recommended community level variable urbanization index urbanization level of each communityvillage was measured using urbanization index the urbanization index was developed by jonessmith and popkin 20 using in the chns it was defined as a 12component index capturing communitylevel physical social cultural and economic environments designed and validated for the chns urbanicity scale is used for measurement of the 12 component each component was given a score from 0 to 10 and then weighted equally in the overall index and added together for an overall maximum possible score of 120 higher scores indicate greater urbanization this scale has been validated for content validity reliability and stability 20 we represented urbanization by quintiles of an urbanization index reflecting population size and density and community infrastructure individual level variables maternal education chns classified maternal education level as follows no school primary school junior middle school senior middle school middle technical or vocational school college and graduate school maternal education level was then categorized into 3 groups low education middle education high education family income in chns household income was evaluated by household income per capita inflated to 2011 with the equalized household income values we created four break points to define income quintiles with the 1st quintile set as the baseline percentage of energy intake from protein dietary intake was assessed using three consecutive inperson 24h recalls randomly allocated to begin between monday and sunday in combination with a household food inventory conducted over the same 3day period dietary data in children was based on a parentassisted selfreport or selfreport questionnaire food models and picture aids were used by trained interviewers to assist with estimating portion sizes for dishes prepared at home recipe components were taken from the household food inventory and portion sizes were based on the proportion of the dish reportedly consumed by the participant energy and nutrient intake levels for dietary data were calculated using the china food composition table details of the process can be accessed through the carolina population center website statistical analysis descriptive statistics on individual demographic variables were calculated continuous variables were presented as means and standard deviations categorical variables were expressed as percentages the present study focused on crosssectional analysis of chns data in 2011 we applied multilevel models and statistical software spss 210 to conduct a twolevel regression analysis we examined the relationship between urbanization index and child height after controlling for individual variables the modelling was done in four steps model 1 examined only withingroup homogeneity model 2 included the communitylevel contextual variable in model 3 the individuallevel explanatory variables were added to model 2 these individual variables consisted of child gender age maternal education level maternal height family income per capita and percentage of energy intake from protein then in model 4 the urbanization index was modified to 12 components of the urbanization index the individual variables were the same as in model 3 finally subgroup analysis was conducted to explore the heterogeneous effects by different age groups in each model the interclass correlation was calculated as the ratio of betweencommunity variance to total variance in childrens heights results demographic and anthropometric measurements are shown in table 2 in total 1606 children were included among them 9147 were han ethnicity the average percentage of energy intake from protein was the average heightforage z score was 019 ± 124 the proportion of heightforage z score below 1 was 8524 for the maternal education level the percentage of no school primary school and middle school was 8045 both family income per capita and urbanization index were categorized by quintiles table 3 shows the results of multilevel models model 1 constructed an empty model because the intercept of random effect was statistically significant the interclass correlation coefficient in model 1 was 026 suggesting betweencommunity heterogeneity in childrens height model 2 shows the fixed effects results for communitylevel factors urbanization was significantly associated with an increase of heightforage z score compared with 1st quintile children living in a community with higher urbanization levels reported higher heightforage z scores model 3 added individual and community variables boys higher maternal height higher maternal education levels higher family income and higher discussion in the current study we found that urbanization index was associated with child height among the 12 components of urbanization index education was associated with child height in multilevel models controlling for clustering by community additionally population density and housing were associated with height of adolescents aged 1318 years generally our results were consistent with previous studies smith et al 18 reported that urban children generally have better nutritional status than rural children in developing countries eckert et al 21 summarized that urbanization was associated with a lower risk of undernutrition of children in china with the rapid economic growth the inequalities between urban and rural areas was obvious the effect of urbanization on child health reflected the inequality between urban and rural areas 22 we observed a significant association between child height and the education segment of the urbanization component some studies have documented a positive impact of parental education on child height 89 however less is known about the effect of community mean education relating to child height as better education levels often correlate with better family income people with better education level may choose to live in better communities with improved healthrelated infrastructure as well as better educational institutions for their child those parents with better education level may respond better to community health educational and health promotion efforts and may pay more attention to their childrens growth and development therefore these children may have healthier lifestyle habits diet habits and health care therefore improving a populations education level as well as strengthening community health services may have important practical and theoretical significance the influence of urbanization on height seemed different in younger and elder age groups in the present study we divided all the participants into two age groups 512 years and 1318 years because most of the chinese children go to middleschool at the age of 13 their education environment and life styles might be quite different from children under 12 who were commonly in primary school according to the result children aged 1318 years were more likely affected by urbanization with three statistically significant factors this result was similar to previous studies 23 generally elder children acquire more physical emotional cognitive social and economic resources that have effect on health 24 but the pathways of population density and housing influencing child height need further study higher population density and better housing reflect higher urbanization level that may help elder children to experience less poverty better social environment and health services and lead to a better physical development regarding influence factors at the individual level gender 25 family income 67 protein intake 5 maternal education 89 and maternal height 26 were previously demonstrated to be associated with child height these findings were consistent with our findings because the present study is a crosssectional design these factors may provide important reference points for making health policy at the individual level there are some major strengths of this study first the urbanization index is a more comprehensive composite index based on the specific study region it is typically applied to assess the socioeconomic environment of a community in china using the urbanization index may produce better findings regarding the relationship between community socioeconomic conditions and child height second in most previous studies a singlelevel model was commonly used which ignored the intercorrelation of children within same community we overcame these limitations by using a multilevel model a multilevel design can help researchers to examine relevant communitylevel characteristics that may be associated with child height and may provide evidence to identify disadvantaged communities and help children living there this study also has some limitations first as we all know the chns is a longitudinal structure data with several waves but we only used the data of 2011 the main consideration was that chinese society has experienced rapid urbanization during the recent decade by the time we did the data analysis the newest data was the data in 2011 which reflect the latest condition of chinese society second though multilevel model was meaningful for the current data the sample size of each community was small largescaled study is needed in further research third the study was a crosssectional design which cannot explain the causal relationships between child height and urbanization further prospective study design was needed forth individual factors which may be associated with child height were limited in the current study and more individual factors are needed to be involved in further studies for example genetic factors excises etc conclusion communitylevel contextual factors were significantly associated with child height especially for elder children in a representative national population in china our findings points to the role of contextual factors that generate differences between regions in shaping the distribution of child physical health outcomes our study suggests that public health programs and policies for childs physical development may need to combine individualcentered strategies and also approaches aimed at changing residential environments availability of data and materials data documentation and details on sampling representativeness and validity of data can be accessed through the carolina population center website abbreviations chns china health and nutrition survey icc the interclass correlation sd standard deviations authors contributions yz analysed and interpreted the data drafted and revised the manuscript hw analysed the data and revised the manuscript xw ml and yw1 review and revised the manuscript yw2 conceptualised the study and review the manuscript hz conceptualised and designed the study edited revised and critically reviewed the manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background recent economic development in china has been accompanied by welldocumented health inequalities between regions the impact of individual factors on child height has been widely studied but the influence of communitylevel factors has not yet been fully studied methods the crosssectional data of 1606 chinese children aged 518 years from the china health and nutrition survey 2011 were used multilevel analysis was used to examine the association of community factors using urbanization index with child height child height was measured following standardized procedures and heightforage z scores were calculated as outcome variables datasets were presented at two levels community variable level2 was an urbanization index which is a composite score summarizing 12 communitylevel contextual factors individual variables level1 were child gender ethnicity percentage of energy intake from protein maternal height maternal education level and family income results urbanization index was associated with child height among the 12 communitylevel factors education were positively associated with child height additionally stratified analyses by age showed that population density and housing were positively significantly associated with the height of elder children 1318 years at the individual level male sex higher maternal height higher maternal education levels higher family income and higher percentage of energy intake from protein were significantly positively associated with child height conclusions our findings point to the role of contextual factors that generate differences between regions in shaping the distribution of child physical health outcomes our study suggests that public health programs and policies for childs physical development may need to combine individualcentered strategies and also approaches aimed at changing residential environments

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alcohol alcohol use is a major contributor to morbidity and mortality worldwide causing 33 million deaths each year initiation of alcohol use during early adolescence is an important predictor of alcoholrelated motor vehicle crashes suicide neurocognitive impairment and alcohol dependenceabuse at later ages furthermore early use of alcohol and binge drinking are common among latin american adolescents in 2014 approximately 70 of argentine adolescents aged 13 to 17 years had ever consumed alcohol with a lower prevalence in mexico prevalence in these countries is similar to other latin american countries 2010 showing that underage drinking is an important public health problem in this region previous studies have identified numerous factors that influence the risk of alcohol use among adolescents including parents and peers school and work socioeconomic status other drug use risk taking and sensation seeking and drinking attitudes among others media and marketing represent another set of risk factors alcohol advertising such as direct advertising on television movie theaters and magazines has been associated with increased adolescent drinking and distribution of alcohol branded merchandise is associated with future alcohol use experimental studies have shown that alcohol portrayals in films directly influence actual alcohol intake presumably by imitation and cuereactivity processes finally crosssectional and longitudinal associations have been reported for the relationship between exposure to alcohol use in films and alcohol use and binge drinking among adolescents in the united states england and germany that alcohol companies pay for alcohol brand placement in films is important because it means that film alcohol depictions could be reduced if payments were restricted as was the case with smoking in films the studies mentioned above have been conducted in high income european countries and in the united states we were unable to find studies assessing the relationship between film exposure to alcohol and alcohol use among latinamerican adolescents in latin american countries like in most western nations film exposure to alcohol for adolescents comes primarily from hollywood films however latinamerican adolescents may not have the same level of viewership or exposure furthermore they may not react to the exposure the same way adolescents do in other western countries for example studies of us adolescents show stronger associations between exposure to film smoking portrayals and adolescent smoking behavior among white compared to black adolescents black adolescents appear responsive to film smoking but only to smoking by black actors or films oriented towards black cultural demographics similarly the lack of cultural congruence between film characters and latin american adolescents may dampen film social influence effects therefore we conducted this study to examine exposure of latin american adolescents to auf and its association with alcohol use methods study sample and procedure the study was conducted among students in argentina and mexico middle schools in argentina during may and june 2014 a convenience sample of 33 schools from three large cities participated in the study with public schools identified by the ministry of health and ministry of education and private schools identified through personal contacts in mexico in february and march 2015 60 public middle schools were selected using a stratified random sampling design in mexicos three largest cities sampling strata were based on a high and low levels of socioeconomic marginalization using 2010 census data for the census tracts where schools were located b cityspecific tertiles of retail establishment density in school census tracts within each of these six strata three or four schools were randomly selected with selection probability proportional to the number of students in each school and a quota of 20 schools per city when a school did not agree to participate a replacement school was selected randomly from the same stratum passive consent was requested from parents or caretakers and students signed an active consent form study protocols were approved by nihcertified human subjects research boards in argentina and mexico development of questionnaire measures the aim of the survey was to assess mediamarketing exposures and their association with adolescent risk behaviors the questionnaire included items used in surveys for adolescents previously implemented in argentina mexico and in the us items in english were translated and reviewed by spanishspeaking research staff and the final survey instrument was pilot tested with students both countries to ensure adequate understanding of questions instructions and confidentiality statements the selfadministered questionnaires were completed in the classroom under the supervision of trained research staff surveys included questions about attitudes that predict the onset of alcohol use alcohol use exposure to auf and pertinent covariates assessment of alcohol attitudes and behavior alcohol susceptibility was measured among those who never drank using items that captured future intent to drink during the next year and resistance to peer offers with four response options ranging from definitively yes to definitively no the susceptibility construct has been validated as a predictor of smoking onset in longitudinal studies of adolescents and also predicts the onset of drinking in longitudinal studies of adolescents to be consistent with how the measure is coded for smoking participants who stated definitely not to both questions were coded as nonsusceptible neverdrinkers the rest being coded as susceptible neverdrinkers a respondent was considered to be a current drinker if he or she reported any number greater than zero to the question during the past 30 days on how many days did you drink alcohol we assessed binge drinking by asking if he or she had ever drunk more than 4 or 5 drinks in a row with the quantity used depending on gender of the student exposure to alcohol measurement films chosen for this study included films released in argentina between 2009 and 2013 and listed by the argentinean national institute of cinema and visual arts amongst the top 100 revenuegrossing films for the year released the top 100 films for mexico were listed by the mexican institute of cinematography for the years from 2010 to 2014 because data collection took place one year after argentina to estimate exposure to auf we used methods validated for measuring exposure to film smoking by the dartmouth media research laboratory adolescents exposure to films was assessed by randomly selecting 50 film titles for each participant from the total film sample with participants indicating which films they had seen thus each adolescent questionnaire contained a unique subsample of film titles for each film depictions of alcohol were timed when there was real or implied use of an alcoholic beverage by one or more characters including purchases and occasions when alcoholic beverages were clearly in the possession of a character all alcohol use and implied use was timed in seconds from the moment the alcohol appeared on screen empty alcoholic beverage containers and those displayed but not implied as being consumed were not timed as alcohol use to evaluate interrater reliability for the us films a random sample of 10 of films was coded by two coders yielding kappa of 076 for alcohol time depictions these statistics represent the overall reliability for all films coded by the dmrl due to the smaller sample size of mexican and argentine films 20 were double coded yielding cohens kappas of 074 in mexico and 076 in argentina film alcohol exposure was determined by 1 summing the seconds of alcohol exposure across all films the adolescent reported having seen 2dividing seconds of alcohol use seen by the total seconds of film alcohol exposure across all 50 films in the participantś unique list 3 multiplying the proportion in step 2 by the total seconds of alcohol use across the full list of films for that country exposure to film alcohol use consisted of a continuous variable scaled in hours of exposure for figure 1 then scaled as a standardized score for figure 2 then classified into quartiles based on the distribution in each country for use in logistic regression covariates covariates included age sex parents years of formal education parenting style access to media peer friend drinking and sensation seeking parent drinking was not assessed because it was considered a sensitive question by school personnel and furthermore has not been found to be particularly influential in our prior studies of media use and drinking behaviors statistical analysis all data analyses were conducted with stata version v13 local scatterplot smoothing was used to graphically represent the crude relationship between exposure to auf and alcohol use binge drinking and alcohol susceptibility among never drinkers for each country to compare the doseresponse curves we standardized exposure to auf for each country so that the lowest value was 0 and the highest was 1 after recoding outliers in the 95 th percentile that otherwise substantially skewed the exposure distribution univariate linear regression models were used to compare continuous variables and logistic regression models to compare categorical variables between countries in both models random intercepts for schools were used multilevel logistic regression models were used to assess the relationship between exposure to auf and current drinking binge drinking and alcohol susceptibility among never drinkers all models included the covariates listed above age and indexed variables were entered as continuous variables adjusted ors were estimated across countryspecific quartiles of auf exposure with quartile 1 as the referent category we also tested for an aufcountry interaction multilevel logistic regression models using exposure to auf as a continuous variable instead of quartiles were also estimated separately in a sensitivity analysis for this we entered exposure to auf measured in hours of exposure the findings were similar in direction and statistical significance for both types of variables results description of the film samples the argentina analytic film sample had 427 films of which 47 were produced in argentina and 380 in the us the whole sample depicted 2474 hours of alcohol use the mexican analytic sample of films contained 446 films 46 of which were produced in mexico and 400 in the us that sample depicted 2485 hours of alcohol use description of the population samples of all eligible students in argentina 13 had parents who refused participation 45 declined participation and 11 were absent the day of the survey for a final sample of 3172 students in mexico the school participation rate was 92 of eligible students in mexico 5 of parents declined permission 002 of students refused to participate and 11 students were absent the day of the survey for a final sample of 10123 students the overall mean age of participants was 125 years 519 were male other characteristics are described in table 1 the prevalence of current drinking in the total sample was 198 among never drinkers 285 were susceptible to drinking and the prevalence of binge drinking was 109 there were many statistically significant differences between the argentinean and mexican samples in argentina more boys participated than in mexico and students from argentina were approximately four months older and their parents had more education and tended to have a more authoritative parenting style compared to mexican students means for sensation were significantly higher among argentinean adolescents alcohol consumption was also higher among argentine than mexican students exposure to auf and its crude association with drinking the median estimated exposure to auf was 60 hours in adolescents from argentina and 59 hours in those from mexico figure 1 shows the distributions for the estimated exposure to alcohol use in films both histograms were positively skewed with some adolescents having exposures that ranged upwards of 15 hours figure 2 shows the unadjusted association between a standardized measure of exposure to auf and current drinking binge drinking and alcohol susceptibility for adolescents of both countries for the most part the curves show a doseresponse association between exposure to film alcohol depictions and prevalence of the three outcomes studied any deviation from a linear doseresponse is restricted to adolescents with very high exposure as has been described in past studies of film smoking multivariate analysis table 2 shows that in both countries and after controlling by age sex parental education friends who drink sensation seeking parenting style and media access adolescents with higher exposure to auf were significantly more likely to be current drinkers to have engaged in binge drinking and to have a drink during the next year the ors comparing quartiles 2 and 3 with quartile 1 were also statistically significant with increasing odds ratios across quartiles that mirrored the linear doseresponse relation illustrated in figure 2 to determine whether the relationship between exposure to auf and alcohol use varied by country interactions between quartiles of exposure to auf and country were also examined no significant interaction was detected for any outcome adolescents from argentina tended to be more likely engage in binge drinking and to be more susceptible to drink in the next year in comparison with mexican youth independent of the exposure to auf discussion our study is the first to confirm the association between auf and drinking behavior in adolescents from latin america our results are consistent with studies conducted in other countries although our study suggested different mean levels of exposure to auf in argentina and mexico than for adolescents from the united states or germany we found a similar doseresponse association between exposure to auf and alcohol use engagement in binge drinking and alcohol susceptibility some authors suggest that it is difficult to attribute substance use to film depictions of the substance because youth at risk for alcohol consumption may selfselect to watch films that contain more alcohol portrayals than youth who are not at risk these associations were independent of many potential confounders that included peer drinking sensation seeking and other risk factors that could promote both higher alcohol use and higher likelihood to seek out films with drinking the fact that the association between exposure to auf and drinking persists after adjusting for covariates that are plausible confounders of media exposure effects including sensation seeking access to media and parenting styles supports the idea that exposure to auf is an independent social risk factor this study has several limitations which should be acknowledged first data on exposure to auf and alcohol use were all crosssectional therefore we cannot provide information on the temporal sequence of events second while alcohol susceptibility is a significant unique predictor of change in alcohol consumption among adolescents in the us longitudinal research is needed to confirm if exposure to auf has a similar effect on latinamerican teenagers third the samples may not be representative of the entire argentinean or mexican populations as schools were not randomly selected therefore the observation that the argentinian sample had higher risk for drinking and higher drinking rates could be a function of our sampling and not necessarily a reflection of how these countries compare visàvis adolescent drinking finally we examined exposure to only one type of entertainment media we are not able to estimate how much overlap there is between exposure to auf and exposure to alcohol use in television through programming or advertisements additional research is needed to clarify the contributions of these sources despite its limitations this study confirms that the association between exposure to auf and uptake drinking found in other countries exists in latin america taken together with multiple crosssectional and longitudinal studies published to date the results strongly suggest that steps to decrease exposure of adolescents to auf could prevent some young people from transitioning to problem drinking the combined evidence implicates movies as a disease vector that begins in one country and may affect alcohol use not only among us adolescents but also in most other western nations where hollywood movies are a staple in the media diets of children and adolescents as mentioned above alcohol companies pay to have alcohol placed in these movies so they represent a form of marketing moreover alcohol use is common in movies rated as appropriate for teens what should be done to affect this vector firstly we know that the most effective way to address the film alcohol depictions would be to prohibit product placement we know this because of our experience with cigarettes prohibition of cigarette brand placements that were imposed by the 1998 master settlement agreement between major cigarette manufacturers and the us state attorneys general heralded an exponential decline in cigarette brand placements along with a substantial immediate decline in tobacco screen time this suggests that similar restrictions on alcohol brand placement would also lower screen time and therefore youth exposure to this risk factor more progress could be made in this area if the us centers for disease control and prevention began to emphasize movie alcohol as part of their program to address youth exposure to alcohol advertising the cdc could post annual reports on movie alcohol that included titles and companies just as they do for smoking in movies secondly the motion picture association of america could take movie alcohol more seriously by conferring an adult rating for any depictions of youth or young adult drinking partying or drunkenness this would move the most objectionable alcohol depictions out of youthtargeted movies which have much higher youth viewership compared to adultrated movies in summary youth exposure to alcohol depictions in movies is widespread and consistently linked with problematic alcohol use it is time to do something about it crude association between exposure to alcohol in popular films and alcohol use susceptibility current alcohol use and binge drinking

objectivesto assess whether exposure to alcohol use in films auf is associated with alcohol use susceptibility current alcohol use and binge drinking in adolescents from two latin american countries methodscrosssectional study with 13295 middle school students from public and private schools in mexico and argentina exposure to alcohol use in over 400 contemporary top box office films in each country was estimated using previously validated methods outcome measures included current drinking ie any drink in the last 30 days ever bingedrinking ie more than 4 or 5 drinks in a row for females and males respectively and among never drinkers alcohol susceptibility ie might drink in the next year or accept a drink from a friend multivariate models were adjusted for age sex parental education peer drinking sensation seeking parenting style and media access resultsmean age was 125 years sd 07 and the prevalence of alcohol consumption and binge drinking was 198 and 109 respectively mean exposure to alcohol from the film sample was about 7 hours in both countries adjusted models indicated independent doseresponse associations between higher levels of exposure to auf and all outcomes the adjusted odds ratios or comparing quartiles 4 and 1 199 95 ci 173 230 for current drinking 168 139 202 for binge drinking and 180 152 212 for alcohol susceptibility compared to mexican

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methods participants covid19 this sample was recruited via an online questionnaire that was set up as part of a larger ongoing international multisite project during the most stringent lockdown restrictions the inclusion criterion was pregnant women when completing the survey two participants were excluded due to a pattern of random responses hence the final sample consisted of 1419 women no other exclusion criteria was used from the final 1419 participants 747 had some missing data these were generally pairwisedeleted 21 yet for the mediation analyses listwise deletion was performed 38 recruitment was performed through midwifery centers word of mouth social media and others the ethics review board of tilburg university rp2019143 approved the study which was conducted according to the declaration of helsinki participants provided informed consent before completing the survey and were compensated with 10€ precovid19 a sample of 1439 dutch pregnant women recruited from march 2017september 2018 constituted our comparison group the inclusion criterion was pregnant women when completing the survey this sample was recruited as part of an online questionnaire study investigating prenatal mental health treatment uptake 8 and screening for participants for an intervention study 39 an additional number of women were recruited but excluded from the study for not signing the informed consent not completing the questionnaire and for complicated pregnancies needing specialized treatment ninetyfive percent of women were recruited via 2 ultrasound scan centers while the rest via midwifery centers a lactation practice and social media women received an invitation email and upon providing informed consent completed an online questionnaire ethical approval was obtained from the faculty of social sciences of the radboud university ecsw20161710 42 covid19 lockdown in the netherlands the dutch lockdown in aprilmay 2020 entailed the closing of schools daycare centers restaurants bars gyms and other contact professions such as hairdressers while shops were allowed to stay open provided clients kept at a safe interpersonal distance no curfew was implemented moreover people were encouraged to work from home as much as possible and limit outings and social visits healthcare checkup visits for example to a midwife were unaccompanied and shortened or delivered online or via telephone instruments psychological distress statetrait anxiety inventory 40 was used to assess anxiety symptoms here we focused only on the state dimension assessing anxiety feelings in the present with 20 items on a 4point likert scale 41 total scores vary between 2080 with scores ≥ 40 indicating clinically relevant symptoms of anxiety 42 internal consistency was excellent in the precovid and the covid samples as previously reported 43 edinburgh depression scale 44 was used to assess depressive symptoms this is a 10item selfreport questionnaire on a 4point likert scale 45 total scores range between 030 with scores ≥ 13 indicating clinically relevant depressive symptoms during pregnancy 46 consistent with previous evidence 47 internal consistency was sound in the precovid and the covid sample 48 was used to assess covid19related experiences this questionnaire is a comprehensive assessment of the impact of covid19 on ones life covid19 exposure and symptoms healthcare finances social support community coping emotions mental and physical health addictions and demographics here we focused on perceived support during the covid19 crisis and related stress support systems three support systems were investigated partner social network and prenatal healthcare support partner and social network support were each assessed through two slideritems from 00100 with higher scores indicating more support how well were you supported by your partnersocial network prior to the covid19 outbreak for support prior to the pandemic and how well are you now supported by your partnersocial network for support during the pandemic to calculate the partnersocial support change the past reported support was subtracted from the present as an indication of womens social network composition we also asked from whom they receive social support prenatal healthcare support was assessed with a 3point likert scale item how well are you currently supported by your prenatal healthcare professionals with 1 very well supported 2 neutral and 3 not very well supported the item was reverse coded in the analyses such that higher scores consistently indicated better support changes in prenatal healthcare support was assessed on a 5point likert scale item has the support you receive from your primary antenatal healthcare provider changed due to the covid19 outbreak where 1 badly worsened 2 slightly worsened 3 no change 4 slightly improved 5 greatly improved healthcare support and changes were used as two separate items in the analysis differently from the composite scores of partnersocial support moreover we asked participants who the main prenatal healthcare providers were the complete instrument can be retrieved online osf io uqhcv covid19 experiences covid19 and perinatal experiences covid19related worries worries in relation to covid19 were assessed with 8 slideritems from 00100 with higher values indicating more worries we conducted a factor analysis and principal component analysis to identify the latent factors underlying the data three components were extracted general covid19 worries social support worries and work and financesrelated each component was computed by averaging the items loading on each component with higher scores indicating more worries statistical analysis descriptive statistics summarize the characteristics of the two samples summary statistics and the correlations amongst the variables are reported in table 2 for descriptive purposes we conducted paired sample ttests assessed perceived support changes during the covid19 crisis moreover we also performed repeated measures anova to test mean differences between covid19related worries components general social and work and financial to answer the first research question independent sample ttests assessed mean differences of anxiety and depression scores between the precovid19 and covid19 samples further to answer the second research question namely whether better support reduced covid19related worries and in turn psychological distress a parallel mediation analysis was performed separately for each support system the mediation analyses were conducted with 5000 sample bootstrapping 49 all analyses were also performed with education and gestational week as control variables due to statistically significant differences table 1 demographic characteristics of the samples m mean sd standard deviation t ttest x 2 chisquare p significance level set at 05 income information was not available in the precovid sample education low primary education or secondary prevocational education medium secondary education or vocational education high bachelor or masters degree or higher 11 of respondents in the covid sample indicated that they preferred not to answer the question on annual household income precovid sample covid sample test statistic m or n m or n age in years between the two samples on these characteristics but results remained unchanged the data analyses were conducted with ibm spss statistics 23 50 and process 38 results preliminary analyses given the variations in anxiety and depression across different trimesters of pregnancy 51 we assessed differences in symptoms of anxiety and depression between pregnant women in the second trimester of pregnancy given the prevalence discrepancy of this group in the precovid sample compared to the covid sample the results on this subgroup confirmed those presented for the whole group suggesting significantly higher t and anxiety in the covid19 compared to the precovid sample note that while women with complicated pregnancies were excluded from the precovid sample in the covid19 sample all pregnant women were included and here 14 reported highrisk pregnancies we reran the ttest and chisquare analyses excluding highrisk pregnancy women and obtained comparable results hence we retained all women in the covid19 sample to maximize the sample size furthermore due to the high correlation between anxiety and depression in the covid19 sample r 078 p 0001 we computed a composite score of psychological distress as the mean of centered anxiety and depression variables to use in further analyses worries confirming our hypothesis that better support leads to fewer worries which in turn have a smaller effect on psychological distress an illustration of our results is provided in fig 3 whereas the details of the statistical results of the mediation analyses are reported in table 3 support systems covid discussion pregnant women reported significantly more symptoms of anxiety and depression during the covid19 crisis compared to pregnant women prior to the pandemic more than 1 in 10 women experienced clinically relevant symptoms of depression and nearly 1 in 2 women experienced clinically relevant symptoms of anxiety three types of covid19related worries were identified general worries about covid19 worries about work and finances and worries about social support and all led to heightened psychological distress note that worries were moderately associated to anxiety symptoms with correlation coefficients ranging between 038 and 055 suggesting that although related the covid19 worries are also distinct from anxiety symptoms importantly having more support was related to fewer worries and consequently less psychological distress finally women reported an increase in partner support during the pandemic compared to prepandemic but a decrease in social support more than half of pregnant women also reported a decline in healthcare support the results on mental health worsening during pregnancy at the peak of the dutch covid19 pandemic first lockdown confirm those from other countries womens most reported worries were general worries about covid19 this finding is consistent with other reports 52 and may reflect the little knowledge and information regarding the virus profile in the early stage of the outbreak and its potential vertical transmission to the fetus next worries extended onto the financial domain probably due to the global recession that the world witnessed with businesses closing increased unemployment and governments being challenged to find economic solutions 53 the least reported worries were worries related to disruptions in social support this is intriguing given dutch covid19 containment strategies of social distancing and interpersonal isolation while all these three worries contribute to psychological distress general worries about covid19 contributed the most to psychological distress followed by social support worries despite women reporting considerable amounts of work and financial worries these worries had the smallest association with psychological distress this may be due to the strong covid19 financial support measures immediately taken by the dutch government to protect the economy which are already known and implemented at the time of our study the central finding of this study is that pregnant women reported less worries and consequently were at lower risk for developing psychological distress when they experienced more andor increased support from their partner social network and especially their healthcare providers this is consistent with the buffering hypothesis 23 table 3 worries as mediators between each source of support and psychological distress the column on the far left presents the predictors for which we ran three separate analyses the ensuing columns present the mediators in the order in which they were added to each of the three mediation analyses if the confidence interval includes 0 there is no effect if c c there is a mediation effect if c is no longer significant then it is a full mediation b unstandardized coefficient se standard error of the mean t ttest value p p value with significance set at 05 ci confidence interval n total sample for each analysis path a direct effect of each support system on each worry path b direct effect of each worry on psychological distress path c direct effect of each support system on psychological distress path c indirect effect of each support system on psychological distress via the suppressing effect of each worry path ctot indirect effect of each support system on psychological distress via the suppressing effect of all the worries together positing that support helps individuals to deal with hardship not surprisingly however the profound structural changes in response to the covid19 crisis might have translated into changes in perceived support for example partner support might have increased because of a shift to working at home which leaves more time for the partner to help in the household and support the pregnant woman despite this general increase in partner support the cases in which it decreased may be associated to relationship conflict which was shown to increase in nonpregnant populations during covid19 54 55 56 consequently cases that report low andor decreased partner support during crises such as covid19 deserve further attention as both indicators were associated with more psychological distress contrary to partner support social network support was lower to that prior to the pandemic this decline has already been reported in normal times during pregnancy and the transition to parenthood and may be the consequence of life changes associated with this period including changes in couples social dynamics 5758 a similar trend emerged for healthcare with 1 in 2 women reporting a decrease in support from their providers during the covid19 crisis amongst all sources of support healthcare provided most relief against covid19 worries and heightened psychological distress under the circumstances of the sudden and exponential increase in the number of covid19 contagions the healthcare system became saturated understaffed and often unable to deliver clear and timely information andor care given the primary importance of healthcare providers support for preventing psychological distress the fact that 53 of pregnant women reported worsening of their healthcare support is worrying additionally it may be worthwhile for future studies to examine support through objective measures such as number nature and duration of maternity care visits to gain insights into the structural aspects of the healthcare system that contribute to perceived support and in turn improved mental health an additional consideration could be the location from which healthcare was received it could be the case that specific regions andor hospitals that experienced a higher number of covd19 infections may coincide with those in which women reported less perceived support prenatal mental health deterioration during covid19 holds important implications for treatment in light of recent evidence indicating that even prior to the covid19 crisis only 15 of women with heightened psychological distress are actually treated possibly due to symptoms going undetected or low treatment uptake rates 859 this phenomenon could have been even exacerbated during the covid19 crisis with even more pregnant women experiencing psychological distress and even more symptoms going undetected because of worsening healthcare quality prenatal mental health worsening thus needs timely attention especially during times of crisis our findings highlight the necessity for universal screening for psychological symptoms during routine health checkups in the perinatal period and for interventions aimed at increasing healthcare support during the vulnerable period of pregnancy interpersonal psychotherapy for example may be a promising intervention as it has been found effective in improving mood and decreasing depressive symptoms in pregnancy and the perinatal period in general 60 61 62 two main aims of ipt are to enhance social support and decrease interpersonal stress during times of transition our findings that higher support leads to fewer worries and in turn psychological distress are in line with the ipt framework and as such provide further support for this therapeutic approach other therapies that involve social support such as personcentered approach based and cognitivebehavioral therapy based interventions may also be effective in reducing psychological distress in pregnancy 63 moreover online support groups for pregnant women led by healthcare professionals might help to address the feelings emotions and concerns that pregnant women experience as a result of the pregnancy and of living in a pandemic or other type of crisis also timely information should be given about the covid19 health risks for pregnant women and their unborn child taking action is crucial to avoid psychological distress becoming chronic and spilling over into the postnatal period continuing to affect mother and child as previously documented in prior natural disaster studies 6465 our findings hold implications for both prevention and intervention work to establish support systems for vulnerable populations and to facilitate timely access to mental health structures respectively indeed in future work it would also be important to carefully document pregnant womens access to mental health during a major crisis such as the covid19 pandemic this study documented the impact of the covid19 pandemic on prenatal mental health with a large sample of 2858 pregnant women half assessed prior to the pandemic and half during the pandemic moreover the pandemic data were collected real time through online questionnaires at the peak of the first dutch covid19 outbreak and lockdown at a national level nonetheless some limitations are noteworthy firstly the crosssectional nature of the study design limits the ability to identify the direction of associations moreover the sample did not have a balanced prevalence of women in each trimester of pregnancy which may have yielded differences in psychological distress this is however unlikely given that performing the analyses solely on the second trimester subgroup confirmed the results of the whole group furthermore our sample was prevalently well educated in a marital relationship and reported a mediumhigh annual household income indicating a selection bias of the participants in this research it could be argued however that these results may be even more pronounced in women with fewer resources that may contribute to higher stress and mental health issues an additional limitation was the length of the survey and the fact that demographic information was gathered at the end this resulted in a large amount of missing demographic data which informed our decision of not including covariates in the analyses nonetheless the sample was sufficiently large to obtain wellpowered reliable results finally the two samples were not perfectly matched the precovid sample was regional 8 while the covid sample was national and the two samples also differed in education and gestation however the two samples were very similar in size and were recruited relatively close in time providing a unique opportunity for comparison to conclude our study indicated a twofold increase in the prevalence rate of women experiencing depression and anxiety symptoms during the covid19 crisis importantly support systems especially from healthcare providers counteracted the negative effects on covid19 related worries and psychological distress our results scientific reports 1120261 indicate a major opportunity for healthcare providers including midwives and gynecologists to reduce covid19 worries and mental health problems in pregnant women by providing additional support data availability anonymous data can be made available upon request received 14 june 2021 accepted 21 september 2021 competing interests the authors declare no competing interests

while pregnant women are already atrisk for developing symptoms of anxiety and depression this is heightened during the covid19 pandemic we compared anxiety and depression symptoms as indicators of psychological distress before and during covid19 and investigated the role of partner social network and healthcare support on covid19related worries and consequently on psychological distress a national survey conducted during the first lockdown in the netherlands assessed covid19 experiences and psychological distress n 1421 whereas a comparison sample n 1439 was screened for psychological distress in 20172018 during covid19 the percentage of mothers scoring above the questionnaires clinical cutoffs doubled for depression 6 and 12 and anxiety 24 and 52 women reported increased partner support during covid19 compared to prepandemic but decreased social and healthcare support higher support resulted in lower covid19related worries which in turn contributed to less psychological distress results suggest that a global pandemic exerts a heavy toll on pregnant womens mental health psychological distress was substantially higher during the pandemic than the prepandemic years we identified a protective role of partner social and healthcare support with important implications for the current and future crisis management whether increased psychological distress is transient or persistent and whether and how it affects the future generation remains to be determined pregnancy involves profound physiological and psychological changes in women 13 due to the hormonal and biological changes in the body 45 and due to the surrounding context 67 these changes have been associated to elevated prenatal symptoms of anxiety and depression 8 9 10 which in turn are related to poor outcomes in the offspring 11 12 13 accordingly pregnant womens known vulnerability for anxiety and depression has become a concern during the covid19 pandemic and the severe lockdown measures including social distancing workrelated changes and limited access to healthcare services 14 whilst reports show a general rise in anxiety and depression rates associated with covid19related worries 15 16 17 18 pregnant women might experience even more worries these may include the uncertainty around the transmission of the virus in utero and its effects on the fetus and the implications for healthcare and birth arrangements 16 18 19 20 a recent metaanalysis found heightened mental health problems with 43 of pregnant women experiencing anxiety and 32 depression during the covid19 pandemic 21 yet how and which risk or protective factors contribute to anxiety and depressive symptoms henceforth psychological distress during the covid19 pandemic remains unexplored subjective experiences due to the covid19 pandemic may vary considerably across pregnant women availability of social support may play a significant role in managing covid19related worries contributing in turn to diminishing the risk of developing psychological distress 22 according to the buffering hypothesis 23 support from others defined as regular positive interactions and integration in a larger network that provides help during hardship financial legal health emotional etc is one of the most important protective factors from adverse events likewise social support is a central focus of mental health interventions such as in interpersonal psychotherapy that views psychiatric disorders as a precipitation of the interpersonal context and support systems 2425 in the context of physical distancing regulations support systems are fundamental for

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introduction the global losses due to luxury brand counterfeiting have reached us 600 billion annually the trade of illicit goods is expected to continue growing in the coming years particularly in indonesia based on the results of the indonesian anticounterfeiting society survey in 2016 counterfeit products had already caused an economic impact of us 612 million on the national economy during that year with the government losing approximately us 30 million in indirect tax revenue annually specifically the prevalence of fake luxury goods and counterfeit products is closely tied to consumer motives for purchasing luxury products to establish their own identity the acquisition of identity can be achieved through the use of luxury items the urge of an individual or social groups to showcase themselves to appear attractive is often done by displaying a glamorous lifestyle through the use of luxury brands such motives appear to be prevalent across various social strata motive is an individuals driving force for behavior these motives can be both negative and positive its the negative motives that drive consumers to knowingly engage in using counterfeit products in markets that intentionally sell counterfeit or nondeceptive products the consumer motives across all classesstrata in using luxury products are aimed at signaling social status as symbols of materialism without considering the authenticity of the original products wherein the true satisfaction comes from satisfaction in obtaining status through the consumption of luxury products stems from audience reaction status represents ones position in the social hierarchy determined by honor and social influence historically this position could be obtained through lineage or recognition but today its not solely applicable as an individuals status is viewed through achievements that generate wealth such as possession of money high income and prestigious positions the social status hierarchy in ancient rome included the patricians parvenus poseurs and plebs which were associated with brand prominence brand prominence is a branding concept involving soft and loud logo designs on a product more specifically strong brands are described as striking and prominent with visible and observable brand signs that send out a louder signal to others as opposed to subtle brands the phenomenon of signaling status within the patrician class when purchasing authentic luxury goods is not necessarily dependent on loud brand designs however newcomers or newly wealthy individuals opt for authentic luxury products with conspicuous brand designs in contrast the poseur class attempts to emulate parvenus by purchasing counterfeit products with prominent brand designs to showcase their status to the audience however this perspective has been contradicted by several recent studies introducing a new trend called fake chic where highclass consumers enjoy buying counterfeit products even though they can afford genuine luxury goods the rationale behind this is that buying counterfeit products offers similar quality to genuine items an easy and enjoyable process and significantly lower prices the objective of this research is to explore consumer motives across different classes using prominent or nonprominent logo products to signal status to others the motives of each class among consumers differ significantly from one another in psychological and behavioral aspects prior research has not been specific about which classes or strata and how consumer behavior affects logo choice to convey their status to others previous literature also suggests that signaling status is a human behavior motivated by the desire to display products worn to gain recognition from others as symbols of wealth and identity without explicitly specifying the target audience recent studies indicate that individual status signaling is not only motivated by utilitarian purposes but also by symbolic meanings underlying products or brands within the power strata to the best of the researchers knowledge the methods through which each class or strata employs its power to send status signals to others have not been deeply explored therefore this research aims to bridge this gap by developing a framework that explains motives regarding product legitimacy and brand prominence along with purchasing behavior across three consumer classesstrata simultaneously the researcher proposes a hypothesis that consumer perceptions in the patrician parvenus and poseur classes towards product legitimacy and brand prominence are factors influencing the intention to purchase a product and the brands strength for signaling status additionally we test this model across three consumer class groups the following section reviews prior research on motives counterfeit products and buying behavior the research methodology explains the measurements used to test the hypotheses followed by a discussion and concluding remarks literature review consumer motives towards counterfeit products based on the literature two prominent consumption motives stand out especially in the study of luxury goods consumption today the first is the wealth accumulation motivation which portrays the image of individuals as belonging to the highest social circle being successful and prosperous the second motive is the unpleasant comparison where individuals strive to differentiate or distance themselves from others they perceive as being below them ustuner and thompson and truong and mccoll also add that selfexpression and vanity are considered primary motivations reflecting success and pleasure the use of counterfeit luxury products aims to stay within the circle of peers and be perceived as part of a group trend fashion or social class that is equivalent or even more prominent than their community the motivation to use fake luxury brand items reflects a desire to be a change agent in fashion aspiring to be an innovator and influencer consumers perceive no difference in quality and appearance between counterfeit and genuine products which can reduce any shame for users moreover law enforcement agencies police and local governments show less seriousness and ethical standards are low negative consumer motives become important predictors of the intention to purchase counterfeit goods and they represent a consensus within the community of users motives for purchasing counterfeit products include social and cultural factors consumer ethnocentrism especially when the counterfeit is of foreign brands another motive is purchasing counterfeit products to obtain a sense of glamour admiration and hedonistic pleasure another category involves those who buy counterfeit products due to previous experience with such brands lastly some purchase counterfeit products to acquire unique experiences during their visits to certain places these motives drive consumers who continuously seek counterfeit luxury products to attain the desired social status therefore we propose the following research hypothesis h1 the higher the consumer classstratum the less positively consumer motives are related to counterfeit products consumer motives towards brand prominence of fake luxury products brand prominence explains a brand being marked prominently or vaguely like the g of gucci or the bold red and green striped signature on a bag to ensure that observers recognize it as a gucci brand brand designs on a product serve as symbols or signals previous literature states that the benefits of branding as signals for consumers can reduce product search costs making the brand highly familiar brands are also used to communicate a companys image erdem swait suggest that a brand can convey a variety of brand associations and brand equity making it easier for consumers to identify its product characteristics the choice of a luxury product brand can send social signals to consumers indicating the status of the user consumer motives for purchasing counterfeit luxury products also consider the form of the brand whether its prominent or subtle a prominent logo can be easily seen and recognized by others especially those who are less familiar with wellknown luxury brands therefore consumer motives for using genuine or counterfeit luxury purwanto rahayu s fitrianti r jurnal riset manajemen sains indonesia14 2023103104105106107108109110111112113114eissn 23018313 doi doiorg1021009jrmsi014209 goods can influence the choice of prominent or subtle brand designs with the aim of signaling status to equivalent or lower classes therefore we propose the following hypothesis h2 consumer motives for purchasing counterfeit luxury products are related to brand prominence in all classes patricians parvenus and poseurs perceptions of fake products regarding brand prominence consumers reasons for purchasing counterfeit luxury goods stem from aspiring to possess luxury items without being able or willing to pay the high prices counterfeit luxury goods become the target for fashion enthusiasts to signal their status to others as good counterfeit items serve as substitutes for genuine products carrying social and personal significance brand prominence largely noticeable becomes a significant consideration for consumers in the poseur class when buying counterfeit luxury goods the tendency towards significantly lower prices and more conspicuous brand logos is observed they desire status by purchasing counterfeit items with prominent brands and lower prices sending signals to others specifically parvenus have the need to prominently display the brand as they are often not accustomed to recognizing and evaluating genuine luxury items hoping others will quickly identify them on the other hand the patrician class seeks to distance themselves from motives to purchase counterfeit products and prominent brands consequently the consideration of brand prominence is significant when purchasing counterfeit luxury goods therefore the proposed hypothesis is h3 perceptions of counterfeit luxury products are related to brand prominence with a conspicuous brand design brand prominence and the purchase behavior of fake luxury goods according to the theory of planned behavior attitude is the most influential factor in predicting intentional behavior this relationship has been supported by numerous studies across various disciplines specifically referencing counterfeit luxury goods eisend schuchertguler and evidence from schlegelmilch stottinger suggest that attitudes towards counterfeiting arise when the price disparity between counterfeit and genuine products is too high which will positively correlate with purchasing behavior various previous studies have indicated that higher prices are positively associated with counterfeiting and buying behavior attitudes towards using counterfeit luxury goods are the most influential factor in intentional behavior thus the characteristics of counterfeit products have a positive influence on consumer buying behavior attribute considerations such as benefits brand design product appearance durability and perceived quality significantly affect purchasing behavior additionally previous research indicates that brand prominence also creates specific brand images for counterfeit products which influence buying behavior therefore the hypothesis that can be proposed is h4 consumers who prefer brand prominence have a stronger tendency for buying counterfeit products research methods procedure and sample this survey was conducted with consumers encountered at various locations such as wellknown boutiques selling genuine branded fashion products prominent malls in metropolitan cities and several retailers accustomed to selling counterfeit goods in jakarta and surabaya the sample used was purposive sampling the sampling procedure was carried out meticulously as the classification of classesstrata was intentionally not disclosed to respondents instead it was based solely on the signaling behaviors they exhibited as well as their expertise and status needs while we believe that wealth serves as an indicator for each class they occupy we did not explicitly test this questionnaires were distributed by involving 30 students adopting techniques from previous research on product or service marketing distributed 10 questionnaires to anyone shopping at predetermined locations in the questionnaire respondents were asked to mention one product they purchased during a specific period and circle their perceptions of that product sample characteristics a total of 300 questionnaires were distributed to respondents with 230 deemed eligible resulting in a response rate of 766 that could be accurately identified the majority of respondents were female totaling 190 individuals while the remaining 40 were male their ages ranged from 25 to 60 years respondents income distribution revealed that approximately 3913 fell into the lowincome category 38268 into the middleincome category and 26 were classified as highincome the sample sizes for each classstratum were determined subjectively by the researcher based on screening questionnaire responses regarding respondents income and knowledge of branded luxury goods criteria the researcher honestly acknowledges the inability to extensively validate this information however through indepth interviews with 10 individuals outside the closed questionnaire the researcher believes that the information provided can depict the actual situation the key points in the interviews were organized based on respondents perceptions of branded luxury goods understanding of such goods prevalence and impact of using counterfeit luxury items and their affiliation with social circles the response data were analyzed to formulate classifications based on classesstrata for this study the results of the classification are as follows 52 respondents were classified as patricians having experience purchasing genuine luxury items as well as counterfeit ones 87 respondents were categorized as parvenus with experience buying counterfeit luxury items but recently purchasing genuine ones and 91 respondents were labeled as poseurs having no experience buying genuine luxury items measurement based on previous studies we developed questionnaire items to measure consumers motives for purchasing counterfeit luxury goods and brand prominence examples of these items include using counterfeit luxury brands to appear successful the significant price difference between counterfeit and genuine luxury goods the desire to experience wearing counterfeit luxury items without spending much money and the satisfaction of accurately distinguishing between counterfeit and genuine luxury products to measure the choice of brand prominence and counterfeit products we developed questionnaire items based on three studies for instance buying luxury products with a prominent brand design is very satisfying prominent brand designs are widely available in the black market and inconspicuous brand designs aim to camouflage counterfeit luxury products to measure buying behavior we assessed consumer attitudes towards counterfeit luxury products consumers exhibit a positive attitude towards purchasing counterfeit products when the price is significantly lower the quality is comparable and they are willing to buy counterfeit products or vice versa loureiro et al also added that behavior to buy counterfeit products is measured by the willingness to continue using counterfeit items and recommending them to others for all items a sevenpoint likert scale was employed respondents were also asked to state which luxury fashion brands they have purchased and whether they prefer inconspicuous or prominent brand designs if a respondent indicated a preference for inconspicuous brand designs they were asked whether their classstrata peers would recognize the type of item they were using on the other hand respondents who preferred prominent brand designs were asked this question to assert that the item they were using was indeed luxurious additionally questions were posed regarding experiences with counterfeit luxury products and finally to understand the poseur classgroup our sampling was conducted in locations where counterfeit products were freely available the research results are presented in table 1 which displays the means standard deviations construct reliability average variance extracted and bivariate correlations between latent factors the measurement model exhibits a good fit with the data the items included in the measurement model have estimated construct reliabilities ranging from 076 to 081 demonstrating strong convergent validity and high reliability of the measurement instrument the latent constructs included in the confirmatory factor analysis show strong evidence as all items have strong significance levels this indicates that the items have strong explanatory power on error variance furthermore the ave values for each latent variable exceed 050 indicating that the variance explained by measurement error is smaller than the variance explained by the construct collectively convergent validity provides robust evidence supporting the scales for consumer motives counterfeit luxury products brand prominence and purchase intentions lastly the ave for all constructs surpasses the shared variance among constructs and all other variables thus demonstrating strong discriminant validity results and discussion hypothesis testing to analyze whether h1 h4 are supported in the patrician parvenus and poseur classes the data were categorized into three groups and parameter estimates were freely estimated for each group using lisrel 91 subsequently all parameter estimates in a specific class group were constrained to be equal to the other class groups to evaluate the difference in fit between the unconstrained model and the constrained model a χ2 difference test was conducted differences between the two χ2 values ranged from 22 to 136 across the three class groups indicating that the constrained and unconstrained groups significantly differed in the estimated parameters the unconstrained model for the poseur class demonstrated generally moderate fit while this model had a strong foundation potential model specifications should be considered to assess the extent to which the conceptualization encompassing the data can enhance validity in the poseur class model we identified an additional path from counterfeit products to brand prominence as poseurs lack experience with various genuine luxury brands and even actively seek counterfeit items their expectations for signaling status are lower compared to the parvenus class if poseurs encounter counterfeit luxury goods with prominent branding they are more likely to engage in purchasing behavior compared to the parvenus class consequently this class feels proud and confident in their ability to select the best counterfeit luxury items feeling accomplished compared to the two classes above them such feelings become stimuli for consumer motives and confidence in purchasing counterfeit luxury products thus the path between consumer motives and purchase behavior through brand prominence and counterfeit products can be substantiated for the poseur class as depicted in figure 1 the results of the study show that all parameter estimates are significant supporting h1 h4 the χ2 value is 4477 which is lower than the initial model and the cfi 094 gfi 089 tli 086 rmsea 007 srmr 005 the difference between the two χ2 values is 33 which is greater than the significance level of 251 additionally the coefficient γ22 is 004 which is also significant at p 005 these results indicate that the model fit is acceptable and improved significantly compared to the initial model which did not include the path from fake luxury product to brand prominence for the unconstrained patrician model the χ2 is 2365 cfi is 091 gfi is 085 tli 088 rmsea 006 srmr 007 indicating an overall acceptable model fit however one path is not significant in figure 2 the path from consumer motive to fake luxury product and brand prominence is not significant because the patrician class has a sense of prestige and negative emotions towards fake luxury brand products 2015 state that using fake luxury items with eyecatching brand designs is indeed embarrassing lowers prestige and elicits negative emotions lastly the relationship between fake luxury products and brand prominence towards purchasing behavior is also not significant indicating that the perception of fake products and prominent brand designs does not trigger this class to make purchases and even leads to a negative response however there is also a hidden consumer motive behind the purchase of fake luxury goods with subtle branding to camouflage the fact that this class has never bought counterfeit products some respondents admit to being intrigued to experience the sensation of seeking counterfeit goods in the black market this can also be explained through interviews with certain respondents considered part of the elite class therefore we can add a direct path from consumer motive to purchasing behavior which is significant this is what we refer to as the dark motive in the patrician class this is supported by the prevailing perception that whatever is worn by entrepreneurs highranking officials celebrities and famous lawyers is believed by society to be luxurious and expensive for the unconstrained model in the parvenus class the χ2 is 2825 cfi is 092 gfi is 083 tli 086 rmsea 008 srmr 007 indicating overall acceptable model fit in figure 3 the significant paths are from consumer motive to eyecatching brand prominence and from brand prominence to purchasing behavior the reason for this finding is that the parvenus class tends to purchase genuine luxury products but they desire a brand design that is eyecatching this is because apart from showcasing themselves to the class below they also signal to the class above that they have achieved success and can be aligned with that class consumer attitudes in this class towards fake products are negative this is because they want to build a positive image that portrays them as newly affluent individuals who aspire to gain status within their own group and the class above them as a result the path from consumer motive to counterfeit products is not significant for this class even though this class deeply understands the characteristics of fake luxury products they are extremely cautious when it comes to the legitimacy of luxury goods this caution stems from their desire to ensure the success of the social status they have built discussion in this study we applied the concept of consumer decisionmaking in aspiring for status with luxury branded products and brand prominence with either conspicuous or subtle designs in an empirical study the research results indicate that consumer motives are significantly positively related to counterfeit luxury products and conspicuous brand prominence as well as buying behavior within the poseur class conversely in the patrician class there is a negative relationship between consumer motives and the perception of counterfeit luxury products conspicuous brand prominence and buying behavior the parvenus class only exhibits a positive relationship between consumer motives and conspicuous brand prominence as well as buying behavior these research findings partially support the findings of han et al and wilcox et al wherein consumers in the poseur class when signaling their status are only capable of purchasing counterfeit luxury products with conspicuous brands this is because products with conspicuous brands effectively serve the social function of selfexpression and selfpresentation similarly for brands with conspicuous designs they can evoke consumer memories and strengthen their relationship with the company since poseurs feel incapable of aligning themselves with the two classes above them they resort to buying counterfeit goods to signal their status within their group without hesitation they purchase counterfeit luxury products in the black market to appear wealthy fashionable in line with trends and as something commonly done by many thus imitating parvenus is a way for poseurs to establish their status within their group in the parvenus class the motive is to use genuinely branded luxury products with conspicuous designs as signals to clarify that they are not part of the lower class for the parvenus class the patrician class is aspirational while the poseur class is dissociative the parvenus group is a newly elevated social class that hasnt acquired the skills associated with their new position so they strive to align themselves with the patrician class since they are new to luxury goods they arent familiar with intricate details like ultraluxury fashion brands they prefer popular luxury products with conspicuous brand designs to signal their success for them the distinctive lv monogram of louis vuitton or the chanel brand favored by red carpet celebrities serves as a way to showcase their status even though the prices reach millions of dollars lastly the patrician class possesses expertise and experience with luxury goods along with substantial wealth therefore their purchase of products is not intended for display to lower classes as they consider themselves exclusivesuperior this group carefully maintains its identity choosing products that can be recognized by their ingroup they view buying luxury goods as a pleasure or a way of life for instance they might purchase a 5 million hublot big bang watch that appears quite ordinary for the patrician class the use of luxury products signifies elegance and refined taste when signaling to their group the patrician class employs abstract methods that are difficult for outsiders to understand some individuals within the patrician class exploit their inherent selfimage for their own benefit they might buy counterfeit luxury items with subtle branding rare products that are almost perfect although such behavior is risky for their group as it could undermine their overall selfworth they view their actions as mere indulgence assuming that the lower classes are unaware this validates previous research by d amato thanos 2013perez et al 2010 indicating that consumers are indeed capable of purchasing genuine luxury items however for the thrill and experimentation they enjoy purchasing counterfeit luxury products and consider what they wear as expensive genuinely believing its authentic in conclusion patricians parvenus and poseurs vary in terms of expertise and status needs which motivate them in how they intend to use luxury goods as status signals expertise in signaling status means that consumers need a strong understanding of prices product knowledge and other cues of quality the most elite class do not rely on conspicuous branding as a signal while newcomers require conspicuous branding to convey their message poseurs trying to emulate parvenus opt for more conspicuous counterfeit products conclusions and suggestion the findings of this research prove that products with conspicuous and lowercost branding are targeted towards the poseur consumer class while those that are more expensive and subtly branded are directed towards the patrician class and conspicuous for the parvenus class the patrician parvenus and poseur classes exhibit distinct ways of showcasing their status which are demonstrated by consumers strong understanding of prices product knowledge and other cues of quality the most elite class do not rely on conspicuous branding as a signal and sometimes to the untrained eye their products might appear ordinary and less appealing yet they are exceptionally elegant on the other hand newcomers require conspicuous branding to convey their message poseurs attempting to emulate parvenus resort to purchasing more conspicuous counterfeit products

this research aims to explore the relationship between consumer motives mediated by brand prominence selection in the purchasing behavior of counterfeit products among three consumer groupsclasses patricians parvenus and poseurs in the luxury fashion brand context the data were obtained from a sample consisting of 230 respondents who were considered eligible there are three findings first for the poseur class consumer motives in purchasing products are positively related to counterfeit products and prominent brand prominence second for the parvenus class consumer motives are not related to counterfeit products but they are related to prominent brand prominence third for the patrician class consumer motives for purchasing products are not related to counterfeit products and subtle brand prominencepenelitian ini bertujuan untuk mengeksplorasi hubungan antara motif konsumen yang dimediasi oleh pemilihan brand prominence pada perilaku beli produk palsu pada tiga kelompokkelas konsumen patrician parvenus dan poseur dalam fesyen brand mewah data diperoleh dari sampel yang terdiri dari 230 responden yang sudah dianggap memenuhi syarat ada tiga temuan pertama untuk kelas poseur motif konsumen dalam membeli produk berhubungan positif terhadap produk palsu dan brand prominence yang mencolok kedua kelas parvenus motif konsumen tidak berhubungan terhadap produk palsu tetapi berhubungan terhadap brand prominence yang mencolok ketiga kelas patrician motif konsumen membeli produk tidak berhubungan terhadap produk palsu dan brand prominence yang lembut

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background peoples state of health and the manner in which it is cared for is indeed regarded as a very important component of economic development of any country 12 the health sector targets often relate to traditional hospital functions such as diagnosis outpatient treatment and inpatient care outpatient services are those hospital services that do not require an overnight stay and may include care such as diagnostic tests prescriptions or simple treatmentprocedures 3 these services are offered on ambulatory basis and they account for the majority of patientmedical professional encounters than any other hospital services few studies have examined patient experience for quality of care in resourcescarce environment like subsaharan african countries such as nigeria measurement of quality can be very useful to stakeholders who choose between different health care providers and to the policy makers who strive to enunciate better health policies 4 standardized surveys of patients and relatives can reliably measure hospital performance by assessing patients experience and outcomes of treatment patient experience evaluates what happens at the point of contact between the patient the practice and the provider 5 it captures health system responsiveness including the manner and environment in which people are treated when they seek healthcare 6 it also includes sufficient information and education of the patient coordination of care physical comfort emotional support respect for patient preferences involvement of family and friends 4 patient experience is not the same as perceived quality which is predominantly a cognitive assessment of what happened and how it happened 7 it is also different from patient satisfaction which is referred to as patients emotion feelings and their perception of delivered healthcare service 8 patient satisfaction is regarded as the degree of congruency between patient expectations of ideal care and their perception of the real care received 9 and it tends to seek subjective responses from patients in contrast pe asks patients to give factual responses to questions about what did or did not happen during episode of care a major challenge to measuring healthcare quality in lowand middleincome countries was highlighted by a study carried out by dunsch et al on more than 2200 patients in nigeria using positive and negative framed satisfaction statements 10 the result showed that patient satisfaction measurements are deeply sensitive to the framing of the questions and hence the need to adapt patient experience that avoids a shortlaced response of agreedisagree and yesno questions it is believed that pe survey questionnaires that are well designed and appropriately administered can provide a robust measure of quality of care and reliably measure hospital performance against explicit standardization 1112 several studies have been carried out on quality of healthcare services especially in developed countries quite a handful in african region and very few in subsaharan african countries like nigeria many reviewed literatures on quality of healthcare show that waiting time is one of the most important indicators or variables of healthcare quality one of such is a cross sectional observational study by the patels on waiting time and outpatient satisfaction at gujarat medical education research society hospital india using 135patients from the outpatient department 13 a cross sectional survey of nurses and patients in 12 countries in europe and the united states on patient safety satisfaction and quality of hospital care using hierarchical modelling and robust logistic regression showed that deficits in hospital care quality were common in all countries 14 mejabi et al in their work on dimensions of hospital service quality in nigeria as published in european journal of social sciences used probability and quota sampling methods on 6 service points and applied correlation matricesfactor analysis to evaluate quality of healthcare in two nigeria teaching hospitals their findings show that eight dimensions of resource availability quality of care condition of the clinicward condition of the facility quality of food attitude of doctors and nurses attitude of nonmedical staff and waiting time adequately describe service quality phenomenon in nigerian hospital setting 15 the aim of the present study is to evaluate patients experience on quality of care among clients accessing ambulatory healthcare services in teaching hospitals southeast nigeria there is paucity of knowledge on the effects of socioeconomic variables on pe for ambulatory healthcare services in hospitals the present study focused on how socioeconomic factors represented in the context of this study by level of education and employment status of outpatients affect pe on quality of care level of education and employment status were used because the two are the commonest socioeconomic parameters that are used by the teaching hospitals in nigeria when disaggregating socioeconomic status of their patients methods the study design was a crosssectional exit survey three tertiary hospitals were randomly selected from seven teaching hospitals in southeast nigeria the study population was 7847 patients which was the projected outpatients flow for the 3 hospitals over a period of 3 months the data collection lasted the hospitals are enugu state university teaching hospital university of nigeria teaching hospital and federal teaching hospital abakaliki the sample size was determined using a formula for calculating required sample size for a patient population of less than 10000 persons n f n1 n is average number of target population value of n was calculated using n z 2 pqd 2 as the formula 16 where n is minimum sample size required z is normal standard deviation at 95 confidence level and is 196 p is prevalence of the factor under study and from previous studies it is 84 for outpatients 17 a pretested structured patient experience questionnaire with scores assigned to the questions was developed and used for this study the peq is designed to elicit actual experiences ranging from the duration of hospitals waiting time to the environmental condition of the outpatient department the quality of care rendered by the doctors and other health workers the responsiveness of care and indeed the patients overall rating of his experience 18 the study generated and attached relative weights to each question as an indirect measure of the quality of ambulatory healthcare services this was based on plausible measurements from previous studies that were adopted for the context of the study area 18 19 20 the weights in the present study were represented by scores ranging from zero to ten the questionnaire was pretested in a secondary level hospital that is located within the same geographical region using about 10 of the sample size the instrument was then revised for language and better understanding hence there was no obvious problem with the respondents comprehending the questions and providing plausible answers to the questions a reliability test for the questionnaire was carried out for internal and external consistency using cronbachs alpha test and this gave cronbachs alpha coefficient of 0632 showing that the questionnaire was consistent and therefore reliable a total of 422 questionnaires were administered to respondents in the teaching hospitals by welltrained interviewers the responses were elicited without patients identifier after a written consent were obtained from respondents 1820 the data were analyzed using statistical methods such as ztest and anova to examine mean differences and chisquarelog linear association tools to compare the relationship between pe variables with level of education and employment status results out of the 422 questionnaires that were administered a total of 408 were fully responded to this represents a response rate of 967 the study results show that 507 of the respondents were male whilst 493 were female majority of the patients were within active age range of 1865 years about 24 were above 65 years and 29 were below 18 years of age it was found that 407 of the respondents had university education and 252 had high school education whilst the remaining 341 had either primary school education or no formal education less than half were employed while 282 were unemployed and 181 retirees that were no longer economically active table 1 also shows that slight majority of the patients received healthcare services at the surgical outpatient department while 49 were cared for in medical outpatient department table 2 shows that there were significant statistical differences among hospitals for mean patient experience scores on waiting time quality of doctors care and that of overall rating fetha had the highest mean pe score for quality of doctors care and for overall pe rating unth had the best score for waiting time pe score table 3 disaggregates the healthcare services into medical and surgical and compared the differences in their mean pe scores within and between the hospitals fethas mopd had mean pe score of 2722 ± 043 points for its environment better than that of its sopd which had mean pe score of 2536 ± 052 points fethas mopd overall pe rating was 7837 ± 114 and significantly higher than that of sopd similarly in esuth the mopd services were significantly better than those of sopd for quality of doctors care quality of care by nursesother health professionals as well as for overall rating only unths sopd overall pe rating of 7696 ± 151 was significantly better than that of its mopd table 4 shows that higher proportion of outpatients without a formal education had mean pe score of more than 10 points for waiting time compared to 343 of outpatients with university education and 417 of those with high school education the result shows significant association between pe scores on waiting time and level of education this was not so for pe score on opd environment quality of doctors care and responsiveness of care for outpatients with quality of care by nursesother care givers the result show significant association with educational status again larger proportion of outpatient without formal education scored this domain high compared to 686 of outpatients with university education in addition the result shows that employment status only had significant association with the overall pe rating about 757 of retirees and 647 of employed outpatients recorded higher overall pe rating in the hospitals studied students and the unemployed had least overall pe rating discussion the present study evaluated how outpatients of two different socioeconomic groups rate their experience in respect to various domains of care at teaching hospitals in southeast nigeria the study is an attempt to know how patient experience can serve as metric for health industry competition and differentiation since it reflects quality of care from the patients perspective 21 the study confirms that measurement of patient experience is an important aspect of evaluation of healthcare services and it provides an opportunity to improve care meet patients expectations enhance strategic decision making as well as effectively manage and monitor health care performance 21 these are vital because there is no doubt that in the public eye hospitals will continue to be the face of the health system and upon it the public assesses the quality of services provided 22 moreover there is this emerging consensus that patient experience is a fundamental aspect of provider quality 23 an inference from the findings is that unth had the shortest waiting time because patients spent less time waiting for services from doctors or other care givers the other hospitals could learn from what unth is doing right and apply the same procedures in their the figures in the bracket are along the column facilities in order to decrease their waiting times and enhance pe for quality of ambulatory care it has been shown that increased waiting time also affect the overall treatment provided by physicians and other care givers 24 in uk the national standard or accepted waiting time is 30 min 25 in nigeria previous studies show that the majority of outpatients wait as long as 80180 min or more in the opds and the commonest reason for this long waiting time is the large number of patients as against few health workers 1726 a study in india obtained average waiting time outside the various opds of only 12 min and 9852 of patients were very satisfied with it 13 the finding that very educated patients unlike the illiterate ones are less satisfied with waiting time could be a reflection of their increased awareness of their rights and privileges because of their level of education and therefore more discerning of the expected quality of healthcare services the educational status of the respondents was also related to their expectations of the quality of care by the nursesother health workers the poorly educated outpatients rated waiting time and quality of care by nursesother health workers higher than the more educated people probably because they were not aware of their right to quality services and care on the other hand educational status was not significantly associated with patients rating for opd environment doctors care and responsiveness of care however this differs from the findings of zalmanovitch and vashdi who reported that a lower level of education predicates greater responsiveness of care for primary and preventive healthcare than higher level of educational status 27 the mean overall patient experience rating in this study though higher than that of similar study in a federal medical centre in southeast nigeria is slightly below 830 obtained in a hospital of similar status in northern nigeria 28 29 30 the present study showed that employment status and not level of education had direct significant association with patients rating for overall quality of care higher proportion of employed and retired outpatients rated the quality of care from the hospitals high this to some extent is at variance with the findings of arpey et al who in their recent study observed that patients ses had no impact in the way they are viewed or treated by their physicians 31 however our findings agreed with that of myers et al and bernheim et al who found that physicians as a group perceive and treat low ses patients differently from those of higher ses 3233 maharlouei et al had also reported on how the overall patient experience was associated with different ses 34 the limitations of this study include its inability to capture all the domains of patient care in the hospitals it was restricted to measures of outpatient or ambulatory healthcare services thus the findings cannot be generalized to include that of admitted patients another limitation is the fact that the data collection instrument used both coding and tickbox approaches which could have led to some confusion for the enumeratorsinterviewers however the thorough training that was undertaken by the interviewers before field work ensured that they understood the response formats and could navigate between coding and tickbox approaches coding framework from previous studies was adapted 18 19 20 and pretested in the study area hence the possible occurrence of bias is potentially insignificant although the pretest showed that the instrument worked well within the study context it is recommended that a uniform coding approach be used in future studies conclusion the study revealed how employment status was significantly associated with overall patient experience rating of the quality of care for ambulatory healthcare services in nigeria hospitals it also showed that level of education significantly impacted on how outpatients perceived waiting time and quality of care from nurses and other care givers in the hospital further study will be required to assess other drivers of the rating of quality of care the providerside influences on quality of care and the effect of socioeconomic status on inpatients type of healthcare services in the hospitals recommendations the study has underscored the need to put into consideration the socioeconomic status of patients in the course of providing healthcare services for a given population supplementary information supplementary information accompanies this paper at 1186s12913020053320 authors contributions ha conceptualized and designed the study and coordinated all the research activities including the drafting of the manuscript oa coordinated the data collection oo and io contributed to the design of the study and oversaw the supervision the study cn analyzed and interpreted the data all authors reviewed the study findings read and approved the manuscript before submission funding the data collection stage of the study was funded by the corresponding authors the individual authors time on the research design data collection analysis interpretation and report writing were funded by each authors respectively informed written consent were obtained from all patients that participated in the study for those patients who were below 18 years of age parental written consent were obtained competing interests the authors declare that they have no competing interests

background to determine how socioeconomic factors such as level of education and employment status affect patient experiences on quality of care for ambulatory healthcare services in teaching hospitals in southeast nigeria methods the study is of a crosssectional design and exit poll was used to collect its data a pretested structured questionnaire was administered to clients accessing care in the outpatient departments of three tertiary hospitals in nigeria the assessment of patient experiences for quality of care was based on five 5 domains of care waiting time environment of the outpatient department quality of doctors care quality of care by nursesother health workers and responsiveness of care in addition the overall quality of care was assessed results the mean rating of patient experience for quality of care for ambulatory healthcare services outpatients care was 7431 ± 032 moderate differences were observed between the hospitals assessed for various levels of patients care especially for waiting time quality of doctors care and overall quality of care employment status was a statistically significant p ≤ 005 determinant of overall patient experience rating for quality of care while the level of patients education was an influence on the perception of waiting by the patients and their rating of care from nursesother healthcare providers apart from medical doctors the study showed that educational and employment status measures of socioeconomic status of patients determined how patients receiving ambulatory outpatient healthcare services perceived the quality of care in the hospitals hence in order to ensure equity there is need to institutionalize patientcentered care while full consideration is given to the patients socioeconomic status

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introduction refugees experience multiple forms of trauma including persecution physical and sexual violence and lifethreatening situations prior to and during the process of migration 12 these experiences can have severe and longterm mental health consequences 34 in addition to trauma studies have called attention to the ways in which postmigration stressors tied to resettlement in another country pose significant risk for psychological problems and poor mental health 5 6 7 in contrast to refugees less research examines the mental health effects of trauma and stress at preand postmigration phases for nonrefugee immigrants 89 these limitations can be attributed to the ways in which studies classify foreignborn or migrant groups as immigrants broadly or examine disparities between immigrant and nativeborn populations without accounting for important differences in subgroups of migrants 21011 generally speaking immigrants leave their countries of origin by choice in search of social and economic opportunity while refugees are forced to migrate in search of safety from conflict and persecution yet in the us nonrefugee immigrants often survive conditions characterized by mass violence and traumatic events prior to emigration but do not qualify for legal status as a refugee 912 in the case of immigrants who enter the us without authorization many endure violence during the process of transit including detention verbal and physical assaults and other human rights abuses 13 14 15 a number of nonrefugee immigrants may emigrate under circumstances related to family reunification or other temporary statuses but have also experienced political violence and displacement 16 confounding the issue some individuals who have legal refugee status may reject public recognition as a refugee due to the terms association with stigma and past adversity 17 additionally few studies examine the prevalence and impact of trauma experiences after migration to the us according to the american psychiatric association 18 trauma includes having direct exposure to or witnessing 1 3 an event that involves actual or threatened death or serious injury and violence the voluminous refugee mental health literature often assesses trauma in ones place of origin in the process of flight and during temporary settlement though often without temporal delineations in these events 12 prior research has recognized specific forms of trauma such as intimate partner violence in immigrant populations 19 yet few studies look at trauma experiences broadly after settlement in a new country researchers have long conceptualized the migration process as having multiple stages 12 and described ways in which prior trauma increases vulnerability to subsequent traumas and stress 6 yet the explicit study of trauma after resettlement has not been applied broadly across refugee and nonrefugee immigrant populations to address existing gaps we draw on a usbased representative sample of asian and latino refugees and nonrefugee immigrants to address the following research questions how are traumatic events prior to and after migration associated with mental health problems among refugees and immigrants accounting for trauma exposure what postmigration stressors are associated with mental health problems this study has a number of unique features first with notable exceptions 1011 this paper is among the few to use national data to compare a range of stressors and mental health outcomes for refugees and immigrants of diverse asian and latin american national origins our study builds on prior findings by investigating the contribution of both preand postmigration stress on outcomes that include depressive disorders anxiety disorders and psychological distress furthermore we examine the timing of trauma experiences in relation to resettlement in the us as few studies assess for postmigration trauma after accounting for trauma our analyses also explore mental health outcomes linked to postmigration stressors including acculturative stress discrimination neighborhood factors and family conflict challenges associated with sociocultural adjustment in a new country resulting from dissonance between ones culture of origin and the host culture as well as experiences of racialethnic discrimination are robust predictors of poor mental health 2021 similarly migrants are prone to neighborhood contexts affected by residential segregation and poverty which play important roles in shaping health behaviors and wellbeing 22 finally these adjustment stressors can adversely affect family relationships and lead to family conflict which is strongly linked to psychological distress and mental health in migrant populations 23 in summary the current study examines the mental health effects of trauma and stress prior to and after migration among refugees and immigrants in the us we hypothesize that both premigration trauma and postmigration trauma are associated with greater risk of mental illness and increased psychological distress for immigrants as well as refugees similarly we hypothesize that postmigration stressors will amplify risk for mental illness and elevate psychological distress methods data and sampling data from this study were drawn from the national latino and asian american study an epidemiological survey of mental illness and mental health service use among latinos and asian americans in us the nlaas used a complex threestage stratified sampling design that has been described in detail elsewhere 2425 eligible respondents were age 18 years or older and were not in the military or institutionalized the nlaas recruited a total of 2554 latino and 2095 asian participants between 2002 and 2003 lay interviewers conducted interviews with participants using computerassisted survey instruments in the participants preferred language the final overall response rate for asians was 656 and the rate for latinos was 755 2526 we analyzed data on 3268 respondents born outside the us the use and analysis of the nlaas was approved by the interuniversity consortium for political and social research and the authors university institutional review boards measures depressive and anxiety disorders in the past 12 months participants were classified with dsmiv diagnoses in the past year using the world health organizations expanded version of the composite international diagnostic interview whocidi 27 any depressive disorder included at least one diagnosis of depressive disorder or dysthymia in the last year any anxiety disorder was based on diagnosis of at least one of the following disorders in the past year panic disorder agoraphobia without panic social phobia generalized anxiety disorder or posttraumatic stress disorder psychological distress the kessler psychological distress scale assessed the frequency of experiencing mental and emotional distress in the past month 28 items included how often participants felt depressed hopeless restlessfidgety and tired for no good reason responses ranged from 1 to 5 the index demonstrated high internal consistency premigration and postmigration trauma exposure twentysix items captured whether participants experienced a variety of traumatic events with a subsequent followup item for each regarding the age they first experienced the aforementioned traumatic event taken from the whocidi these items were included in the nlaas to assess ptsd symptoms representative items included whether participants were an unarmed civilian in a war zone a civilian exposed to ongoing war saw injuries or dead bodies were mugged or sexually assaulted as was done in prior research 51011 to determine the timing of preand postmigration events we subtracted participants age of migration from the age they first experienced the traumatic events negative values represented traumatic events prior to migration to the us and positive values represented those after migration to the us affirmative responses were summed for each period discrimination participants reported the frequency of unfair treatment with the 9item everyday discrimination scale 29 representative items ranging from 1 to 6 asked how often participants were threatenedharassed called namesinsulted and treated with less respect than others higher summed scores reflected more frequent experiences of discrimination acculturative stress a 10item scale adapted from the mexican american prevalence and services survey 30 assessed acculturative stress items tapped into strains associated with adjustment to a new country including whether participants felt guilty about leaving familyfriends in their country of origin felt respected in the us compared to their country of origin had difficulty finding work due to latinoasian descent or were questioned about their legal status dichotomous responses were summed with higher summed scores indicating greater acculturative stress family conflict five items drawn from the hispanic stress inventory assessed the relative frequency of perceived family conflict due to incongruent cultural values 31 participants responded on a scale of 1 to 3 to statements including being too close to family interfered with my goals and i argue with family over different customs neighborhood environment a sevenitem scale focused on respondents perceptions of safety and social cohesion in their neighborhood 2432 representative items included whether people in the neighborhood could be trusted get along with each other and help in an emergency two items were reverse coded responses ranged from 1 to 4 with summed scores ranging from 4 to 28 covariates we controlled for gender age ethnicity education marital status duration in the us work status and social desirability to assess social desirability reporting bias a 10item measure assessed respondents agreement to statements such as i never met a person i didnt like i have never been bored and i am not bothered by someone taking advantage of me 33 summed scores ranged from 0 to 10 analysis we conducted all analyses in stata 15 and used the appropriate sampling weights to account for the nlaas multistage survey design 34 after describing and testing for group differences across migrant status in the latino and asian american samples we examined associations between preand postmigration stressors and mental health outcomes we employed logistic regression for binary outcomes and multivariable linear regression to model effects on psychological distress because missing data was minimal we proceeded with complete cases our analyses were stratified by migrant status based on a single item that asked foreignborn participants the following question were you ever a refugeethat is did you ever flee from your home to a foreign country or place to escape danger or persecution this item indicates selfreported rather than legal status as a refugee and has been used in prior research with this data 51011 results table 1 presents characteristics of both asian and latino samples comparing immigrants and refugees respectively within each sample among asians a significantly greater proportion of refugees were older and of vietnamese heritage had lower levels of education and english language proficiency and a longer duration of residence in the us furthermore the proportion of asian refugees who were unemployed was double that of the proportion of unemployed immigrants though refugees had comparatively lower levels of poverty asian refugees had significantly higher levels of premigration trauma and lower levels of perceived everyday discrimination compared to immigrant counterparts there were no significant differences between refugees and immigrants in the rate of 12month disorders or psychological distress among latinos a greater proportion of refugees were male older and of cuban descent compared to immigrants latino refugees had higher levels of education greater english language proficiency higher levels of poverty and were less likely to be uninsured compared to immigrants additionally latino refugees had significantly higher levels of premigration and postmigration trauma than their immigrant counterparts refugees and immigrants did not differ in rates of 12month disorders or psychological distress next we present odd ratios and ols regression coefficients for the associations between preand postmigration stressors and mental health outcomes for asians and latinos among asians premigration trauma was associated with greater odds of depressive disorder and psychological distress for refugees premigration trauma was associated with greater odds of anxiety disorders for immigrants postmigration trauma was linked to depressive disorders for both refugees and immigrants for refugees discrimination was associated with greater odds of anxiety disorders for immigrants discrimination was associated with greater odds of depressive and anxiety disorders as well as psychological distress acculturative stress was linked to lower odds of anxiety disorders and greater psychological distress for refugees but not linked to mental health for immigrants across both refugees and immigrants family conflict increased odds of depressive and anxiety disorders and psychological distress finally there was no association between ones neighborhood context and mental health outcomes among latinos premigration trauma increased risk of psychological distress for refugees premigration trauma was associated with greater odds of disorders and psychological distress for immigrants postmigration trauma was linked to greater psychological distress for refugees postmigration trauma was associated depressive disorders and psychological distress for immigrants discrimination was linked to poorer mental health across all outcomes for immigrants but not associated with mental health outcomes for refugees acculturative stress was linked to elevated odds of depressive disorder for refugees for immigrants acculturative stress was linked to greater odds of depressive disorders and psychological distress family conflict was associated with poorer mental health across all outcomes for refugees and with anxiety disorders and psychological distress for immigrants similar to asians neighborhood context was not linked to mental health outcomes for latino refugees and immigrants discussion this study compared effects of preand postmigration trauma and stress on mental illness and distress across refugees and immigrants in a representative us sample with latino and asian origins in support of our primary hypotheses preand postmigration trauma was linked to mental disorders and distress with varied associations by racialethnic group and migrant status for asians trauma exposure prior to and after migration was similarly linked to poorer mental health across refugee and immigrant groups among latinos our results indicate both preand postmigration trauma had deleterious effects across a broader range of mental health problems for immigrants compared to their refugee counterparts the findings regarding premigration trauma align with prior research demonstrating the destructive longterm mental health consequences of war and political violence migrants face in their countries of origin and in transit 8912 our results are also consistent with the refugee mental health literature indicating traumatic events are the most common premigration factor associated with psychiatric symptoms 35 numerous studies highlight premigration trauma among latino immigrants escaping individual institutional and statebased violence 8 as well as asian immigrants escaping everyday violence tied to repressive regimes in their home countries 1236 in all these data highlight the importance of understanding effects of premigration trauma broadly in migrant populations including those not labeled or seen as refugees a unique contribution of our study was the inclusion of postmigration trauma as a risk for mental health for both asian refugees and immigrants postmigration trauma heightened risk for depressive disorders though the odds for disorder were double for refugees a history of severe war trauma and barriers to appropriate mental health services among for southeast asian refugees has been welldocumented 3738 and these factors combined with contemporary traumas may heighten traumas effects in the asian refugee sample 39 in contrast for latinos postmigration trauma similarly increased risk for psychological distress across refugees and immigrants but also increased risk for depressive disorders among immigrants only though we did not have data on visa type or authorized legal status these findings may partially reflect experiences of undocumented latino immigrants many endure perilous journeys to the us and upon arrival can encounter threats of deportation ineligibility for government services and antiimmigrant rhetoric 40 which can heighten effects of postmigration trauma on mental health other postmigration stressors detracted from mental health outcomes after accounting for trauma exposure aligned with a growing body of literature underscoring the salience of the postresettlement context on migrants health 4 5 6 7 discrimination consistently predicted poorer mental health for asian and latino immigrants this finding echoes the substantial literature illustrating the negative psychological and health consequences of discrimination 4142 people often migrate to the us in search of increased freedoms and economic opportunities in order to provide better lives for themselves and their families arriving with great optimism and hope for their future 43 however immigrants encounter discrimination due to racialethnic religious and language biases in the us as well as harmful social and political discourse regarding immigrants from developing countries although discrimination increased risk of anxiety disorders among asian refugees discrimination largely did not influence mental health outcomes for refugee groups one explanation is that due to refugees experiences with trauma and severe violence in their home countries they may minimize everyday discrimination in the us furthermore despite their potentially greater need for material and social support upon arrival refugees are provided with some financial and housing support from refugee resettlement agencies to ease the transition to a new country it may be that the need to maintain relative safety supersedes refugees concerns with everyday negative treatment in contrast immigrants who leave their homelands with expectations for a better life in the us may be especially vulnerable to the effects of discrimination we found acculturative stress increased risk of depressive disorders for latino refugees and immigrants and contributed to greater psychological distress for asian refugees and latino immigrants these results are consistent with prior literature describing the negative influence of acculturative stress on the psychological adjustment of latino and asian immigrants 4445 however the finding that acculturative stress was associated with lower risk of anxiety disorders among asian refugees was unexpected anxiety is characterized by excessive fear and worry about the future 46 asian refugees in our sample who escaped wartorn pasts might view stressors tied to the cultural adjustment process as a type of immigrant tax 47 paid in exchange for resettlement in the us which nonetheless frames the future with optimism rather than fear research has shown that coping in the form of forbearance or emotional restraint in light of challenges has buffered the stress of discrimination among southeast asian refugees in canada 48 more research is needed to investigate variables omitted in our analysis that may capture mechanisms underlying this anomalous finding the most consistent predictor of negative mental health across all refugee and immigrant groups was family conflict our data parallel the vast literature indicating that family conflict rooted in value differences and acculturation gaps predicts poorer mental health 4950 though value clashes in families are normative migrationrelated stressors and experiences of displacement may uniquely shape problems in migrant family relationships and functioning 51 which in turn detract from mental health thus interventions that address familybased conflict may hold significant promise in reducing risk of mental health problems for individuals in migrant families finally we did not find a link between neighborhood context and mental health many refugees and immigrants in urban areas live in ethnic minorityconcentrated neighborhoods characterized by residential segregation and economic disadvantage 52 however prior analyses with this data have found that coethnic neighborhood density can confer social and cultural resources that benefit health 32 it may be that the inclusion of trauma exposure in our analyses captures some the environmental variability tied to risk for disorder and distress while not the focus of this study additional research is needed to further examine if trauma exposure mediates the relationship between neighborhood context and mental health in migrant populations we acknowledge a number of study limitations first our analyses are based on selfreported refugee status and the extent that selfreported status aligns with legal distinctions of migrant status in the data is unknown this measure is an improvement upon prior studies that may assume refugee status based on country of origin 853 still the lack of reliable data on legal refugee status is pervasive in large nonclinical studies of immigrants and refugees and should be addressed in future research 54 second the measures of traumatic events were based on retrospective accounts and are subject to recall bias due to the sensitive nature of trauma participants could have repressed or forgotten such experiences or chose to not disclose this information to interviewers relatedly higher scores on these measures assessed exposure to a greater variety of traumatic events rather than a higher frequency of trauma exposure these concerns and the relatively low prevalence rates of trauma in our study may reflect an underestimation in the measurement of lifetime exposure to trauma furthermore with crosssectional data we caution against causal statements among variables in our study particularly with regards to postmigration stressors and mental health outcomes the reverse relationship is possible such that refugees and immigrants with psychiatric problems may be vulnerable to the impact of subsequent traumatic and stressful events once they are exposed longitudinal research is needed to confirm directionality in these relationships it is also important to note that most migrants in our sample had lived in the us for more than 10 years and that we do not measure lifetime mental health symptoms thus our data cannot speak to reactions to and processes of adaptation following trauma that can change over time finally we did not have data on refugees and immigrants from parts of the world outside asia and latin america including the middle east and africa because a significant proportion of migrants have origins in these regions future research must include these populations taken together our study findings highlight the importance of understanding preand postmigration experiences as they relate to mental health for refugees and immigrants notably it is critical for research to examine traumas effects on mental health for migrant populations regardless of status as a refugee or immigrant as our results suggests traumatic experiences tied to the migration process are perhaps more common among immigrants than is widely recognized furthermore our results underscore how attention to racial ethnic and cultural factors that shape the experiences of refugee and immigrant populations continues to be imperative for understanding disparities in risk and resilience for psychiatric illness and distress traumainformed culturally grounded interventions as well as humane immigration policies are needed to reduce the risk of psychiatric illness and distress for refugees and immigrants alike in sum the us is one of the leading recipients of the global share of immigrants and refugees with over 43 million foreignborn individuals 55 and various factors influence negative mental health outcomes for these populations community organizations social service agencies and mental health service providers are wellpoised to address the needs of these populations but may need appropriate training to identify mental health issues rooted in trauma before during and after migration to the us world events will continue to create new immigrants and refugees and it is therefore vital that their mental health needs are better understood assessed and supported author contributions c c sangalang led the study conceptualization data analysis and interpretation and writing d becerra contributed to the writing and interpretation of data f m mitchell s lechugapena and k lopez contributed to the writing and theoretical content i kim contributed to the study concept and interpretation of data compliance with ethical standards conflict of interest all listed authors have reviewed and approved this manuscript report no conflicts of interest and will accept responsibility for its content appendix see tables 4 and5

numerous studies describe mental health effects of premigration trauma and postresettlement stress among refugees yet less research examines these associations with nonrefugee immigrants additionally few studies assess the prevalence and impact of traumatic experiences after settlement in a new country using a usbased representative sample of asian n 1637 and latino n 1620 refugees and immigrants we investigated how traumatic events prior to and after migration and postmigration stressors are associated with mental illness and distress premigration trauma posed risk across a broad range of psychological outcomes for asian refugees and latino immigrants deleterious effects of postmigration trauma were notable for both groups of refugees and immigrants discrimination acculturative stress and family conflict increased risk for disorder and distress across groups in complex ways findings highlight the importance of examining trauma and stress at preand postmigration phases across migrant populations including those not labeled as refugees

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introduction many factors influence pregnancy outcome with consequences for maternal newborn and child health thaddeus maine described already in 1994 the three delay model which identifies factors that may inhibit women from accessing antenatal care services in limited resource settings these include delays in seeking care due to womens low status and lack of power in health seeking decisionmaking and lack of awareness of danger signs among pregnant women and their close relatives the model also identifies groups of factors resulting in delays in arrival at a health facility such as long distances lack of arrangements and finances for transportation and poor infrastructure furthermore delays in provision of adequate care at the facility availability of skilled care providers and equipment 1 domestic violence and mens controlling behaviors are also factors that influence womens ability to make decisions concerning their health which could improve their pregnancy outcomes 2 antenatal care from a skilled provider may be able to reduce the risks of maternal and infant mortality and morbidity during pregnancy and childbirth 3 the maternal mortality ratio is a strong indicator of the overall effectiveness of a national health system in nepal the mmr in 2015 was 258 deaths per 100000 live births 4 which was significantly higher than elsewhere in the world and far below the sustainable development goals target of not more than 70 deaths per 100000 live births by the year 2030 5 pregnant women meet the same health care worker such as midwives multiple times which creates an opportunity to build trusting relationships and it has been reported that repeated interviews and screening leads to higher rates of identification of dv 6 a swedish study conducted in antenatal settings examined midwives experiences of womens responses to their questions about mens violence 7 the midwives described their roles as raising awareness of the problem reducing the shame associated with being a victim of abuse giving information and emotional support 7 the same researchers also examined the womens experiences of being asked about violence and they found that most pregnant women were not opposed to midwives asking about their exposure to violence as part of routine identification of risk factors carried out for every pregnancy 8 such disclosures of dv may provide opportunities for health care workers to give information and advice on safety behaviors and how to access safe houses counselling and other support services and to make referrals there is scant evidence of improved rates of midwives detection of dv in lowincome countries however a recent sri lankan study shows that improvements were made in midwives detection of dv and the provision of assistance and knowledge following a training program that targeted intimate partner violence and lowering the barriers to discussing the issue 9 evidence from highincome countries also suggests that the health outcomes and safety of women living with dv can be improved through interventions to identify survivors and introduce contextspecific safety planning methods to women 10 focused antenatal care an approach launched by the world health organization in 2002 11 targets all pregnant women who are at risk of developing complications the fanc approach aims to give holistic and individualized care to all pregnant women in order to maintain normal progress in pregnancy fanc ensures timely guidance and advice on birth preparedness and complication readiness the concept of bpcr addresses the delays described in thaddeus maines model to seeking reaching and receiving health care 1 which result in numerous maternal deaths worldwide 3 nepals ministry of health and population endorses the fanc approach and recommends that all pregnant women receive basic monitoring and care during pregnancy and that information and screening for potential complications be provided to them routinely during all anc visits the mohp has implemented a package of birth preparedness interventions as part of nepals safe motherhood plan the package outlines a number of actions that pregnant women and their families should take to prevent delays in accessing childbirth services such proactive planning is known to save womens lives especially in rural locations 12 worldwide reports of preparedness for childbirth vary from 1265 in studies conducted in ethiopia uganda nigeria and tanzania 13 14 15 16 17 18 to 3562 19 20 21 22 23 in india and 3265 24 25 26 27 in nepal a hypothesis for this study was that womans ability to fulfill the criteria of bpcr can be negatively influenced by experience of dv dv is defined as any form of physical mental sexual or economic harm including acts of reprimand or emotional harm perpetrated by one person against another with whom he or she has a familial relationship 28 one of the main characteristics of dv is controlling behavior which can include control over womens resources when preparing for childbirth and access to anc another characteristic is the significant association between intimate partner violence and numbers of pregnancyassociated suicides and homicides 29 furthermore a womans experience of dv during pregnancy can have detrimental effects for her unborn child 30 a multicountry study conducted by the world health organization revealed that the prevalence of abuse during pregnancy ranged from 1 to 28 31 in campbell garciamoreno and sharpss review of studies conducted in developing countries 32 the percentage of physical abuse during pregnancy is reported as ranging from 35 to 317 according to the nepal demographic health survey made in 2011 22 of women in the age range 1549 years had experienced physical violence at least once since the age of 15 years and 12 of women had experienced sexual violence at least once in their lifetime 12 onethird of the women who experienced any type of dv reported their spouse as the perpetrator of the violence in the same survey estimates of violence during pregnancy ranged from 2 among women with higher education levels to 10 among women who were divorced separated or widowed 12 the ndhs also found that 50 of pregnant nepalese women attended all four recommended anc visits 12 it is clear from the survey that anc serve as a common point of contact between pregnant women and representatives of the health care system in nepal hence pregnant womens attendance at ancs are valuable opportunities for health care workers to identify and respond to women living with dv in order to prevent or reduce adverse maternal and neonatal health outcomes associated with such violence no prior studies of the influence of dv on bpcr have been conducted in nepal two major earthquakes occurred during the process of data collection according to studies from china and japan women are at increased risk of dv after natural disasters 3334 since there is scant evidence of how largescale disasters such as earthquakes may affect womens bpcr we chose to examine associations between womens bpcr status before and after the two earthquakes in nepal hence the aim of this study was to determine if exposure of dv affects womens bpcr and if the cumulative effect of multiple obstacles of barriers interacted materials and methods study setting the study was conducted in the antenatal clinic of dhulikhel hospitalkathmandu university hospital which is located in dhulikhel municipality kavre district 30 kilometres east of the capital city of kathmandu dhulikhels population of 14283 live in a total of 3279 households 35 however the hospital provides services to approximately 19 million people from more than 50 out of 75 districts in the country 36 the antenatal clinic at dhkuh is run by midwives for normal pregnancies high risk cases are referred to obstetricians in 2015 the hospital received women for a total of 14612 antenatal visits and there were 2865 childbirths 37 study design and population from november 2014 to november 2015 a crosssectional descriptive study was conducted at the hospital anc clinic utilizing a selfcompleted questionnaire women visiting the anc clinic during this period who met the studys inclusion criteria and were between 12 and 28 gestational weeks were invited to participate in the study women who were visually orally audibly and mentally disabled severely ill or could not speak or understand nepali language were excluded from the study questionnaire a questionnaire was designed and administered utilizing a colorcoded audio computerassisted selfinterview in a tablet computer the participating women received a tablet and headset and could listen to the interview questions through the headset while also reading the same questions on the tablet this allowed the inclusion of both literate and illiterate women in the study the audiorecording and text were in nepali language the women answered the questions by touching colorcoded buttons on the screen indicating yes or no a fiveitem questionnaire the abuse assessment screen was used to identify dv 38 the order of one of the aas questions was modified in our study rather than starting the questionnaire with the original first question in the aashave you ever been emotionally or physically abused by someone important in the family to youwe chose to begin with the fifth question are you afraid of anyone within your family this modification was based on the assumption that the changed order facilitated a broader and gentler introduction to the questionnaire rather than immediately beginning with the word abuse a questionnaire for birth preparedness and complication readiness developed by the johns hopkins program for international education in gynecology and obstetrics for its safe motherhood and neonatal health program was used to assess the status of bpcr among the pregnant women 338 sociodemographic information and obstetric history were also included in the questionnaire the complete questionnaire was translated from english to nepali separately by two professional translators the first and second authors both nepalese crosschecked the wording in the translated questionnaire before starting data collection and simplified a few words then the questionnaire was recorded and the audio file transferred to the cacasi platform the same technique has been used in india showing both reliability and feasibility for sensitive research topics 3940 to our knowledge this is the first time this questionnaire tool has been used in nepal the cacasi was pretested among pregnant women at kathmandu medical college and teaching hospital and no changes were needed for use in the study setting in dhulikhel sample size over the course of the study nearly 6000 women were potentially eligible for the study but due to staff and software resources it was only possible to approach 1039 of the eligible women of them1033 consented to participate ten women were excluded later as they chose to opt out before answering the questions on violence 11 were excluded as it became apparent they did not meet the inclusion criteria and one was excluded due to missing information therefore data was analyzed from 1011 women or 973 of the women completed the questionnaire the women were only included once in the study in the same pregnancy data collection upon arrival at the antenatal clinic at dhkuh for a routine visit all women met a receptionistmidwife women with high risk factors were directly referred to an obstetrician from each womans anc card the midwife was able to determine her eligibility for the study eligible women were informed about an ongoing study titled womens reproductive health each woman was asked if she would like to receive further details about the study and potentially participate if she agreed she was accompanied to a separate research room in the clinic where the first author or a research assistant provided her with further information about the study as part of the consent procedure if the woman declined she continued with her anc appointment as normal however if she gave consent to participate in the study she was shown how to use the tablet computer to answer the study questionnaire and assigned a study number on her anc card responding to the questionnaire required on average 1530 minutes upon completion the woman was accompanied by the data collector to the regular clinic room for her anc appointment variables birth preparedness and complication readiness the concept of bpcr comprises five activities 1 saving money for birthrelated and emergency expenses 2 identifying the location of the closest health care facility 3 identifying a skilled birth attendant 4 identifying available transport and 5 identifying blood donors in case of an emergency 3 the response alternatives for the questions on bpcr were yes or no in the tablet computer in our definition a woman was considered to be prepared for childbirth and ready for potential complications if she reported having undertaken at least three of the five basic bpcr activities those positively responding to two or fewer activities were considered not prepared this scoring system has been used previously in other studies 171841 domestic violence the fiveitem aas was used to detect dv experienced by pregnant women this originally american screening tool has been tested internationally with lowincome populations and uninsured women in brazil and sri lanka 42 women in our study were classified as having experienced any dv if they reported the experience of fear of and or violence from someone in the family women classified as having experienced fear only are those who gave a positive answer to the question on being afraid of someone in the family but whom answered no to experiencing violence women classified as reporting violence were those with a positive response to any of the questions on physical emotional and sexual violence regardless of reporting fear of someone in the family or not women reporting having been afraid of someone in the family independent of their response to the other abuse questions were classified as having fear women classified as never experiencing neither fear nor violence were considered to be not exposed to domestic violence no domestic violence women who had experienced violence were also asked about the time point in which the violence occurred ever in the last year andor during the current pregnancy sociodemographic characteristics obstetric history and earthquake status the interview included questions about age education the income of the woman and her husband a womans autonomy to use her own income geographic setting and family structure family structure was categorized as either a nuclear family where the husband wife and children are living separately from their inlaws or an extended family where a woman is living with her husband children and inlaws and possibly other members of their families the variables womens own income and autonomy to use income were computed into three categories no income no autonomy income but no autonomy and income and autonomy the women were also categorized based on casteethnicity which was selfreported and in their identification cards members of dalit communities belong to the most oppressed social class in nepal disadvantaged janajati are indigenous groups with little or no social mobility advantaged janajati are indigenous groups with opportunity and access to social mobility and upper castes are traditionally the most privileged groups in the social hierarchy the obstetric variables collected included parity number of antenatal visits gestational age and pregnancy complications of these parity was computed into three categories first pregnancy previous pregnancy without complication and previous pregnancy with complication an earthquake variable was also included following the two major earthquakes that affected nepal during data collection on 25 april and 12 may in 2015 the earthquakes caused extensive damage with reports of nearly 9000 deaths and 23000 injuries 43 inclusion of participants into the study resumed three weeks after the last earthquake adding the preand postearthquakes variables granted an opportunity to investigate the consequences of the natural disaster on womens bpcr data analysis the collected data were analyzed using spss version 22 descriptive analysis was performed to assess the relationships between womens bpcr status and their sociodemographic obstetric earthquake status and dv characteristics and experiences the five bpcr activities along with a composite score for bpcr were compared with experiences of dv and with preor postearthquake status the prevalence rates for different kinds of domestic violence were compared with the bpcr statuses in this study complete case information was obtained from 954 women after adjusting for the variables of womens age education and parity with this population logistic regression analysis was used to identify the factors associated with bpcr by calculating crudes odds ratios and adjusted odds ratios with 95 confidence intervals ethical considerations permission for the study was granted by the regional committee for medical and health research ethics of central norway in norway the nepal health research council and the kathmandu university institutional review committee the objective of the study the principle and practical meaning of voluntary participation and possibilities to opt out of the study at any time without giving a reason were thoroughly explained to the participants before they completed the questionnaires verbal consent was approved by the ethics committees and chosen over written consent due to low literacy rates in the study area in total 40 of women and 14 of men have not received a formal education in nepal 12 the verbal consent of participants was registered by the data collector before participation started the participants completed the questionnaires in a private room to ensure their privacy and confidentiality additionally to ensure safety study participants received an information brochure called safe motherhood produced by the government of nepal they also received an anonymouslooking business card with a common female forename and a telephone number printed on it the card was the contact number for the female psychosocial counsellor employed at the onestop crisis management centre for victims of genderbased violence located at dhulikhel hospital these strategies were designed to assist women in potentially justifying why their visits with the midwives took longer than possibly anticipated for anyone accompanying them to the anc clinic and in the case that the women did not want to disclose information about answering questions on dv as part of the questionnaire all study participants were provided the option of private counselling if needed following the interview but none availed of this the mean age of marriage for women in nepal is 174 years 12 thus in order to include all fertile women in the study we included women under age 18 following the age categories in the ndhs as dv is a sensitive topic and may be hidden from or perpetrated by close relatives parental consent was not sought on behalf of these women this was approved by the ethical committees results among the 1011 study participants 45 resided in urban areas and the remaining in rural settings ninetynine percent were married and in a first marriage and 965 were their husbands only wife the majority 613 lived in extended families the women had a mean age of 244 years and their husbands were a few years older 276 years as shown in table 1 slightly more than threefourths of women 763 were not exposed to dv 14 reported they were afraid of someone in the family but not exposed to violence and 97 had experience of both dv and fear among the women who were prepared for childbirth according to our definition 833 had no experience of violence compared with the women who were not prepared for childbirth of whom 694 had no experience of dv among the women who were not prepared most were from rural areas had no income of their own nor autonomy to use the available means in the family women who were pregnant for the first time and in the second trimester did not prepare for childbirth as consistently as women with previous pregnancy experience the proportion of women who did not prepare for childbirth increased after the earthquakes in total 617 of the women were not prepared postearthquakes compared with 383 before the earthquakes as shown in table 2 half of the women in our study were not prepared for childbirth slightly more than threequarters 776 of the women had identified a health facility for the delivery andor for obstetric emergencies more than half had saved money 645 for the anticipated costs of delivery and emergency if needed half of the participants had identified a skilled birth attendant less than half of the women arranged transportation and 201 had identified a potential blood donor however women with experience of dv were significantly less prepared than those without dv in all of the five activities following the earthquakes women were also significantly less prepared with the most pronounced decline being in arrangements for transportation and identification of a skilled birth attendant approximately onequarter of the women 237 reported experiences of any dv a substantially higher percentage of the women who were not prepared were among the women exposed to dv a total of 203 women 201 reported being afraid of someone in the family at the time of completing the questionnaire while 61 reported having experienced emotional and physical abuse combined 4 physical abuse only 23 physical abuse during the current pregnancy and 16 had been sexually abused in the binary logistic regression analysis for the 509 of 1011 women who were not prepared for childbirth there was a statistically significant association between exposure to violence and not being prepared further being of young age living in rural areas being of dalit or other disadvantaged ethnic group status having no or limited formal education having a husband with low or no education and low income and attending less than four antenatal visits were all positively associated with not being prepared for childbirth however there was no substantial association between age of husband or family structure and bpcr two additional predictors for being prepared were having personal income and the autonomy to use it and having previous pregnancies with or without complication we did not find support for statistical interaction between being exposed to domestic violence and earthquake status and the odds of not being prepared compared with no dv women reporting fear only had a 25 times increased crude odds of not being prepared prior to the earthquake the corresponding odds ratio after the earthquake was 19 compared with no dv women exposed to violence had a 24 times increased crude odds of not being prepared prior to the earthquake the corresponding odds ratio after the earthquake was 32 discussion several factors will influence a womans ability to prepare for childbirth in this study we focused on exposure to dv as we identified a gap in information on this matter in developing countries we found that almost onequarter of the participants had experience of some kind of dv and they were twice as likely not to be prepared for childbirth compared with those who reported no experience of dv vulnerable women in poor social circumstances were more likely to not being prepared for childbirth whereas personal income and autonomy to use it were predictors for preparing for childbirth these factors reflects the influence of womens social and economic position on their ability to preparing for childbirth in a patriarchal society within the health system anc provides services that most women receive during their lifetime also in nepal an ongoing relationship with an anc provider may facilitate the development of the trust needed for a woman to disclose the occurrence of dv and to accept information about safety planning and bpcr much of the evidence on effective interventions to address dv in anc contexts has come from highincome countries without similar knowledge from lowincome settings interventions and guidelines in the health sector may not accurately reflect the realities for millions of women furthermore many women in lowincome settings such as nepal are unable to leave violent relationships and therefore it is critical to mitigate the harm done to them domestic violence our findings that women with experiences of dv did not prepare for childbirth as other women are similar to those from a communitybased study of women with a child under the age of two years in india 44 which demonstrated significant associations between violence and poor birth preparedness this highlights the importance to public health of anc providers routinely asking pregnant women if they are living in violent situations in addition to anc and other health care providers communities can play a role in supporting pregnant womens preparations for childbirth especially those living with dv this was expressed in a recent study in the same community as we studied where men and women of all ages and family roles gave suggestions to the researchers for potential improvements that would benefit women living with dv during pregnancy 2 for example they suggested community awarenessraising programs about the health effects of dv and engaging extended family members to address dv and help women to attend antenatal checkups 2 birth preparedness and complication readiness according to our definition of bpcr half of the women were not prepared for childbirth this is higher than found in a number of communitybased studies of women who had experienced childbirth in nepal 24 india 1923 and ethiopia and tanzania 13144546 in recent years the difference in findings may be due to differences in the study areas or to the implementation of different health programs by government or nongovernmental organizations in those areas 27 hence our results may reflect selection bias since our study was hospital based while the other studies were not it is reasonable to assume that women who attend anc services will be more prepared for childbirth since anc visits are an opportunity for health care workers to inform them about danger signs and risks in pregnancy and possible complications that may arise before during and after birth in recent years 47 nevertheless our finding that half of our study population was prepared for birth is lower than found in a study conducted in an antenatal clinic in kenya 48 our study revealed that the majority of women attending the anc at dhulikhel hospital had identified a health facility for childbirth andor obstetric emergencies and had saved money for such emergencies similar results have been reported from other studies 1417 in addition to identifying a health facility arranging transportation is essential for reducing delays to reaching facilities when birth is imminent or in the cases of emergency due to complications during pregnancy only slightly over onethird 38 of the women had taken steps to arrange transportation which is a low proportion compared with that found in another study in nepal 27 and in studies conducted in the african countries ethiopia tanzania and kenya 144648 and india 2122 the comparative lack of preparation for transportation could have been due to geographic challenges in the study area including poor road infrastructure and limited public vehicles in most rural settings after the earthquakes significantly fewer women made efforts to arrange transportation onefifth of the women had arranged for a potential blood donor which is notably higher than found in other studies among pregnant women in which the same type of preparation was found to be critically low 192447 although these studies were conducted in community settings not hospitalbased ones according to the aforementioned studies only 3 of the pregnant women in ethiopia 5 in nepal and 96 in india had identified potential blood donors in advance of childbirth dhulikhel hospital organizes regular awareness campaigns in many communities through its outreach centers which cover a wide range of public health topics including anc and birth preparedness furthermore it is possible that the women who were attending the hospital had been informed about the importance of finding potential donors for childbirth it is also likely that only those who had received some public health information attended the anc other associated risk factors younger women were three times as likely to be unprepared for birth or complications during pregnancy compared with women who were aged thirty years or older this result is in accordance with findings from previous studies in tanzania 46 and india 23 and illustrates the vulnerability of young married women living in their husbands households as is the cultural custom in nepal furthermore women from rural settings were 15 times more likely to be insufficiently prepared compared with women in urban settings in our study this result is corroborated by two studies from ethiopia 1445 where the odds of sufficient bpcr among women who lived in with urban areas were six and two times greater respectively this finding may relate to the women having less access to health information through different media in rural areas and relatively high barriers due to distance and lack of transportation compared with women in urban areas 45 additionally we found a significant association between bpcr and womens caste and ethnicity in our study the women belonging to the dalit caste were three times more likely to be unprepared compared with women from upper castes this finding is consistent with findings from an analysis of the ndhs survey done in 2011 which revealed that dalit women utilized anc services less than did women of other castes and ethnicities 49 however our finding conflicts with an indian study that was conducted among a population of rural women who had given birth 22 and in which no significant associations were found between bpcr and caste in addition in common with other studies 1314204546 we found that low education levels or no education were notably associated with not being prepared for childbirth or obstetric complications furthermore women who had attended less than four antenatal visits had a statistically significant higher risk of being unprepared for childbirth compared with women who had attended four or more anc visits similar findings were present in tanzania 17 and ethiopia 45 women appear to be disproportionately vulnerable to violence and abuse in the aftermath of natural disasters although research on this topic is limited a chinese study after the earthquake in sichuan province in 2008 indicated that women experienced more violence following the disaster 33 a qualitative study with women in australia describes both new and increased violence from male partners after the black saturday bushfires in 2009 50 in the aftermath of a natural disaster surviving and meeting basic needs will be first priorities furthermore health facilities may be destroyed or become overwhelmed support services for women exposed to dv may be limited or nonexisting and support persons may have to deal with their own emergencies stress related to financial burdens on families may lead to increases in dv 2 due to culturally accepted gender roles women may be tasked as the primary care takers for others in disaster situations this combined with reduced finances and access to transportation presents difficulties in terms of meeting their own and their families basic needs and may be compounded by grief and emotional trauma following the disaster consequently when the earthquakes occurred during our data collection we decided to analyze whether the added burdens of the disaster influenced bpcr in interaction with dv we found an increase in the proportion of women who were unprepared for childbirth after the earthquakes compared with women who did not prepare for childbirth before the earthquakes however we could not detect any interference between dv bpcr and the earthquakes strengths and limitations of the study this is the first comprehensive study of its kind in nepal where exposure to dv during pregnancy is examined as a potential risk for lack of preparedness for childbirth this topic remains underinvestigated in the world as well the strength of the study includes its conduct among a nonselected population of pregnant women attending a hospitalbased antenatal clinic also the size of the study is large allowing for multiple adjustments the knowledge obtained from the study makes a contribution to a previously overlooked topic in the dv research field as well and will guide anc providers to identify and assist women who are vulnerable to inadequate childbirth preparation due to living with dv we also included pregnant women under 18 years in this study a population that is sometimes excluded from reproductive health research due to the helsinki declaration which recommends obtaining the consent of parents or guardians for all participants under 18 years in nepal however the mean age of marriage is 174 years 12 and the vast majority of married women are living independently from their parents including the insights of young women is important for improving anc services for all women experiencing dv in nepal our study therefore contributes to a fuller assessment of the prevalence of dv and bpcr across age groups another notable strength of the study is the use of a cacasi questionnaire which provided an opportunity for women to respond to sensitive questions in a private anonymous and confidential way regardless of their literacy we asked the women about their opinion of the technology after they had completed the questionnaire the overwhelming majority reported that they found the method simple most importantly it allowed for the inclusion of an illiterate population and illiteracy was one of the most significant risk factors for inadequate bpcr this is a crosssectional study which does not allow for cause and effect relationships to be made between potential risks and bpcr the study was hospitalbased and this may have limited our potential to generalize the finding to other settings for example to rural areas with only outreach centers we included pregnant women between 12 weeks and 28 weeks gestation only and women may be more prepared for childbirth or complications at a later stage in a pregnancy women with hearing and vision disabilities or whom did not speak nepali were excluded from the study which is a limitation these women may be vulnerable groups who could have given us more information on possible experiences of dv however as we were using cacasis on a tablet computer in nepali language it was practically challenging to include these women a possible bias in our findings could be related to a qualitative study that was done six months prior to this study in the same community the previous study targeted community members generally and no pregnant women were included also bpcr was not one of the topics specifically discussed in the study rather the focus of the qualitative study was on perceptions of violence against pregnant women however participants in the qualitative study may have discussed the topics raised in the fgds with friends and families and we cannot know if this may have raised general awareness and influenced pregnant womens preparedness for childbirth if pregnancy outcomes were obtained from the same women after childbirth the results could be compared during pregnancy and postpartum this would be a valuable future study similarly we did not obtain any information about womens knowledge of obstetric danger signs this knowledge is important for assessing bpcr and newborn complications however the primary aim of the study was to evaluate if dv influenced the five bpcr activities 3 likewise data were collected based on pregnant womens perspectives since mens involvement is crucial for the realization of birth plans and complication readiness 3 innovative strategies to increase mens awareness of obstetric danger signs and bpcr are required to significantly improve situations for pregnant women 51 finally underreporting of dv in this study is possible in spite of the anonymity provided by the cacasi questionnaire women may not have answered the questions about dv truthfully nor understood their personal experiences to be types of dv as trust between a pregnant woman and her anc providers is likely to increase over the course of several meetings women might be more willing to disclose violence in their family situations at a later anc appointment or stage in pregnancy conclusions this study identified pregnant women attending an antenatal clinic in nepal who had experienced dv which affected their bpcr these vulnerable women may need extra care and attention in the health system in order to reduce the potentially harmful effects of violence on maternal and neonatal health and preparations for childbirth to gain further information about insufficient birth preparedness a followup study on the outcomes of the pregnancies affected by dv is recommended this new knowledge could inform and guide interventions by health care providers and other stakeholders the datasets generated and analyzed in this study are not publicly available due to their sensitive nature and given that release of the information could compromise the participants safety an anonymized version of the data can be made available upon reasonable request the data is stored on supporting information s1

¶ other members of the addressing domestic violence in antenatal care environments advance study group are listed in the acknowledgments

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introduction a major premise of the internet was that it would create a public sphere that fosters democratic deliberation and consensus formation 1 2 3 yet there is increasing concern that the internet actually reinforces processes of opinion polarization as users interact with likeminded individuals 4 a tendency that personalization algorithms installed in search engines and online social networks further intensify 56 these psychological and computational homophily biases fragment online debate into virtual echo chambers 7 formal models of social influence in networks are powerful tools for understanding whether and under what conditions communication in social networks fosters processes of consensus formation or opinion polarization 8 however existing models have been tailored to represent offline rather than online communication here we show that taking into account that online communication is characterized by onetomany communication rather than onetoone communication drastically changes the predictions of one of the most prominent models 9 specifically we show that the onetomany communication regime characteristic of online communication fosters the emergence of isolated individuals and the formation internally homogenous but mutually dissimilar subgroups scholars have long recognized that online communication differs in important ways from its offline counterpart but existing research focused on differences that affect withinindividual processes and largely ignored the complexity arising from the communication between individuals a classical finding from social psychology for instance is that computermediated communication is much less affected by individuals physical appearance which frees individuals from the social roles associated with memberships in high or low status groups 12 this it is argued increases the relative impact that members of lowstatus groups have on collective dynamics decreasing intergroup conflict and fostering consensus formation 1213 likewise research showed that online communication allows shy individuals to overcome the communication barriers that socially isolate them in offline settings 14 t 1onetomany t 1onetoone figure 1 illustration of the intuition that onetomany communication fosters isolation nodes have three characteristics that are open to influence the number of traits shared by two nodes and thus the probability that a sender exerts influence on the receiver is shown by the number of lines connecting the nodes panel shows the initial setup before the topleft agent communicated his shape trait either under the onetoone communication regime or the onetomany regime in contrast to the existing research we focus on the complexity arising from the interaction between individuals rather than on withinindividual processes to this end we study axelrods prominent formal model of communication that was developed for offline social networks keeping all assumptions about individual behavior unchanged but implementing communication between actors in a way that captures typical forms of online communication with analytical tools and simulation we demonstrate that this change in model assumptions drastically changes model predictions and leads to conclusions that challenge insights from research on withinindividual processes contrary to the sketched finding that computermediated communication fosters the emergence of consensus 1213 we find that the online communication regime fosters the emergence of mutually disagreeing subgroups in our simulations likewise while socialpsychological research found that online communication allows some individuals to overcome social isolation 14 we demonstrate that online communication increases the chances that individuals get socially isolated we derive these results using an approach that is very different from socialpsychological research while these studies explored how online communication changes the way individuals behave and respond to each other our work demonstrates that differences between online and offline communication arise through merely a different communication structure in complexity terms we find that the whole changes not because the parts have changed but because the interdependencies between the parts are slightly different axelrods model of the dissemination of culture is one of the most prominent models of consensus formation and the emergence of dissimilar subgroups it is also a typical representative of models implementing offline communication axelrod proposed the model to address what he perceived as a fundamental puzzle in research on social influence asking if people tend to become more alike in their beliefs attitudes and behavior when they interact why do not all such differences eventually disappear 9 pp 203 axelrod then showed with an agentbased model how assimilation at the microlevel of individual interactions can be reconciled with cultural differentiation at the level of society as a whole like most contributions to the literature axelrods model represents individuals as nodes in a network that are described by a set of cultural traits representing individuals cultural preferences furthermore axelrod implemented the socalled onetoone communication regime where in a social encounter one agent always communicates one cultural trait to one of her network contacts this onetoone communication regime mimics the facetoface communication present in many offline contexts but it differs from a form of communication that is ubiquitous on the internet and that we label onetomany communication when internet users blog or post content on online social networks for instance they communicate content to multiple online contacts at once rather than to just one of them this paper was motivated by the following intuition about the complexity arising from onetomany communication consider for illustration the network of four actors depicted in figure 1 all actors are described by three cultural traits shape color and letter the number of lines connecting the nodes represents the number of cultural traits the respective two nodes have in common implementing homophily 41516 axelrod assumed that trait overlap increases the likelihood that nodes will adopt a trait from their neighbor suppose that the topleft agent communicates his shape trait under the two different communication regimes under the onetoone communication regime assumed in axelrods model this agent communicates his trait to one of the two agents with whom he already shares the letter and color traits assume that the topright agent is selected for interaction and this agent accepted the trait figure 1 visualizes this situation showing the increased cultural similarity between receiver and sender as a side effect the cultural overlap between the topright agent and the bottomleft agent decreased but the overall network remains connected figure 1 shows that a different outcome arises when agents communicate under the onetomany regime the same agent communicates his shape trait but let us assume now all actors with whom he has nonzero cultural overlap adopt the communicated trait this has two consequences that we study in this paper first a culturally homogenous cluster forms because after the communication three actors hold identical cultural traits communication did not only increase similarity between the sender and the receivers of the message but also preserve the similarity between the nodes who adopted the trait under the onetoone regime in contrast the two nodes on the righthand side turned less similar to each other second the bottomleft agent no longer shares any trait with the other agents ending up culturally isolated the fact that the bottomleft agent was not influenced by the topleft agent did not only exclude that they grew more similar but also increased the dissimilarity between the bottomleft agent and the other two agents as they did adopt the cultural trait communicated by the topleft agent counterintuitively this stylized example suggests that cluster formation and cultural isolation are more likely under the onetomany communication regime even though there are more instances of social influence than under axelrods onetoone regime the intuition illustrated in figure 1 requires a formal analysis for two reasons first under the online onetomany communication regime the sender transmitted a trait to multiple network contacts while there was only a single act of communication under the onetoone regime it remains unclear whether repeated onetoone communication could account for this apparent difference between the communication regimes or not second the figure focuses on a tiny population with a simple network structure leaving open whether onetomany communication fosters isolation also when larger numbers of agents communicate simultaneously in order to test the validity of our intuition we implemented a onetomany communication regime in axelrods model of cultural dissemination keeping unchanged all other model assumptions that is we included that actors simultaneously communicate a trait to their whole network at once subsequently the alters decide individually whether to adopt or reject the trait according to the rules specified in the original axelrod model we compared the predictions of the new model with predictions of axelrods original model using analytical as well as computational tools first we compared the two models predictions for very small but analytically tractable social networks conducting a markovchain analysis and find that indeed onetomany communication increases the chances that individuals become isolated second using computational methods we show that our conclusions hold also for bigger populations variations in the structure of the underlying social network and higher cultural complexity in terms of the number of cultural traits and features moreover we find that medium sized clusters emerge under onetomany communication at a low but consistent rate literature axelrods model of the dissemination of culture provides a prominent explanation of the emergence diffusion and stability of distinct cultural profiles in this literature an individuals culture is defined as the set of her personal characteristics that are susceptible to social influence 9 p 2067 cultural dynamics unfold from the conjunction of two social forces the selection of culturally similar communication partners and the social influence resulting from communication as social influence increases cultural similarity between communication partners it creates in conjunction with selection a positive feedback loop that results in the emergence of cultural clusters that grow internally increasingly similar and as a consequence mutually dissimilar distinct cultural clusters remain stable when the cultural overlap between clusters drops to zero which rules out subsequent communication according to the selection principle axelrods model shares this critical assumption with many alternative models such as the prominent models of bounded confidence 1819 as summarized in a recent literature review by flache et al 8 many contributions have extended axelrods work 20 testing the sensitivity of his predictions to adjustments in model assumptions about for instance the impact of mass media 21 institutions 22 and the scale of the cultural features 23 24 25 an important advancement was the introduction of noise in the process of communicationpartner selection and social influence 24 26 27 28 it turned out that allowing agents to sometimes deviate from axelrods assumptions with a small probability can cause the system to inevitably move towards monoculture ie perfect cultural homogeneity model predictions are more robust however when agents are assumed to interact only with network contacts that share multiple cultural traits 2529 when network ties to contacts that are culturally too dissimilar are dissolved 30 or when agents are allowed to form institutions bottomup that in turn influence the agents topdown 22 recently battiston et al 31 conceptualized exchange discussion networks as a multiplex system in which different topics are discussed among different peers multiple disseminations of culture models are layered on top of each other creating distinct and robust clusters of cultural identities another extension to the model that can explain the persistence of cultural diversity despite random deviations is the socalled multilateral social influence 32 a form of social influence that is similar to the concept of complex contagion from the literature on diffusion processes in social networks 33 unlike axelrod who modeled influence as a dyadic onetoone process where an agent adopts a cultural trait from a network contact flache and macy 32 assumed that agents always consider the cultural traits of multiple network contacts when they reconsider their cultural profile and adopt the trait that dominates in their neighborhood this manytoone form of cultural communication makes predictions much more robust to noise and is the reverse of the onetomany communication regime that we study here that is while flache and macy assumed that an agent is always influenced by multiple network contacts we consider that an individual agent exerts influence on multiple contacts modelers have also incorporated assumptions about onetomany communication in existing models 3435 however while there are social influence models that implement communication regimes similar to the onetomany communication that we study the literature lacks an analysis of whether and under what conditions onetomany communication generates different cultural dynamics compared to onetoone communication thus unlike earlier contributions we implement onetomany communication in axelrods model keeping all other model assumptions unchanged next we compare predictions of the new model with the predictions of the original approach the model the aim of the present analysis is to test our intuition that onetomany communication generates more isolation than onetoone communication axelrods used a very abstract representation of agents cultural characteristics features can represent something as basic as the persons favorite song or something as complex and multidimensional as the persons music taste likewise it can model the persons view on abortion or her much more complex preference for a specific political party which may be a function of her view on abortion and many other aspects in section 426 we study how the dynamics emerging from onetoone and onetomany communication are affected by cultural complexity measured in terms of the number of features and traits per feature table 1 summarizes and compares the two variants of axelrods model at every time step 𝑡 an agent 𝑖 is selected at random from the population this agent is the source of influence second in the original model one of 𝑖s neighbors is selected for communication with 𝑖 a step that is not necessary under onetomany communication where 𝑖 communicates with all of her neighbors who are open to influence and not yet culturally identical in step one of the cultural features on which there is not yet consensus between agent 𝑖 and her neighbors is selected in axelrods original model this translates into the exclusion of all features where 𝑖 and 𝑗 hold the same trait in the variant with onetomany communication however one of the features where 𝑖 disagrees with at least one of her neighbors is picked unlike in axelrods model with onetoone communication this implies that 𝑖 might transmit a trait to one of her neighbors 𝑗 that 𝑗 already adopted making this dyadic communication ineffective however similar to axelrods model also the variant with onetomany communication excludes that a feature is chosen in which cultural change is impossible as there must be at least one neighbor who disagrees with 𝑖 on the selected cultural dimension step implements social influence and is therefore the part where onetoone and onetomany communication are implemented in axelrods original model actor 𝑗 adopts the selected trait with a probability equal to the overall cultural overlap between 𝑖 and 𝑗 for instance when 𝑖 and 𝑗 hold the same trait on half of the features then the chance that 𝑗 will adopt the trait chosen in step is 50 percent this implements homophily the notion that individuals tend to be influenced by likeminded communication partners empirical research showed that homophily is a strong force both online and offline 43637 the same principle is implemented in the new version of the model but here every neighbor of 𝑗 adopts the selected trait with a probability equal to the pairwise cultural similarity between 𝑖 and the respective neighbor 𝑗 comparison of the two communication regimes we compared the models with two different methods first we studied small populations of only four agents described by only three dichotomous cultural features the simplicity of this setup allowed us to conduct a detailed analysis and provide an analytical proof using a markovchain analysis second we conducted agentbased simulations in order to test whether the conclusions from the markovchain analysis also hold in more complex settings with more agents higher numbers of cultural traits and features different neighborhood sizes and more complex network structures using a larger population size in the second analysis also allowed us to address what axelrod was primarily interested in cultural diversity more precisely we could test in the second analysis how the communication regime affects the degree of and conditions for cultural clustering the coexistence of local consensus and global diversity highlighted by axelrods original analysis markovchain analysis to be able to compare the two models with analytical tools we first analyzed a setting that is very simple but where the intuition outlined above nevertheless suggests that predictions of the two model variants differ according to the described intuition isolation in the onetomany model might arise when an actor 𝑗 is not influenced by a network neighbor 𝑖 but their joint neighbors are influenced clusters form because an actor 𝑗 exerts the same influence on multiple network contacts testing this intuition requires a network consisting of sender 𝑖 receiver 𝑗 and at least two other receivers 𝑘 and 𝑙 that is fully connected furthermore we set the number 𝐹 of cultural features to 3 as this creates sufficient variation in probability that agents influence each other if two agents do not share a trait on any of the three features their communication probability 𝑝 𝑖𝑗 0 if they share 1 trait then 𝑝 𝑖𝑗 13 if they share 2 traits then 𝑝 𝑖𝑗 23 and if they share all traits 𝑝 𝑖𝑗 1 finally we assumed that all three features are dichotomous the system with 𝑁 4 𝐹 3 and 𝑄 2 has a finite number of cultural configurations a cultural configuration is a mapping that assigns to each of the 𝐹 features of each of the 𝑁 agents a value from the set of possible trait values the total number of possible configurations is 𝑄 𝐹𝑁 2 12 4096 the dynamics of this system can be fully represented as a markov chain that assigns to every ordered pair of cultural configurations a probability to move from one configuration to the other within one iteration of the simulation of the model with 4096 configurations this markov model of the system is prohibitively large for an exhaustive analyses however we can partition the set of all configurations into subsets called classes hereafter which have the property that for every ordered pair of configurations 𝑋 and 𝑌 of which 𝑋 falls into class 𝑆 1 and 𝑌 falls into class 𝑆 2 the transition probability from 𝑋 to 𝑌 is the same analyzing the dynamics of the markov chain constituted by these classes and transition probabilities between them is equivalent to analyzing the markov chain of all configurations as we will show we can reduce the system to a number of classes that is small enough to derive analytically the probabilities that cultural isolation arises from a random start under onetoone and onetomany communication respectively to arrive at a partition of the configurations into classes we first observe that each feature 𝑓 is always in exactly one of the three different states consensus all agents adopt the same trait on feature 𝑓 according to rule 3 of both models any future communication changing this feature is excluded because consensus has been reached 13 split one agent adopted trait 𝑞 while the three others have 𝑞 󸀠 22 split two agents share trait 𝑞 while the other two agents adopted 𝑞 󸀠 a first classification of configurations can be obtained from distinguishing configurations that have a different distribution of states over the three features all configurations that have the same number of features in the states c 13 or 22 fall into the same semiclass the number of distinct semiclasses can be obtained from computing the number of possible outcomes if for every feature its state is drawn randomly and independently with replacement from the three possible values c 13 or 12 thus for the case where a feature can be in 𝑟 3 different states and there are 𝑛 3 features constituting a cultural vector this number is given as the number of unordered permutations for a set when sampling with replacement as 𝑟 3 10 however a semiclass can consist of several classes thus the number of classes is larger than 10 the reason is that transition probabilities from a configuration containing features with more than one 13 split or 22 split may be different depending on whether the splits separate the set of agents along the same lines or are asymmetrical we distinguish three degrees of symmetry within the semiclasses with more than one nonconsensus feature and assign the labels symmetrical semisymmetrical or nonsymmetrical 1 for example the 131313 semiclass consists of three different classes symmetrical semisymmetrical and nonsymmetrical examples are shown in figure 2 even though the three configurations are part of the same semiclass they have very different probabilities of communication and transition into another class the symmetrical 131313 class is an absorbing state of the dynamic and is characterized by one cluster of three culturally identical agents and one isolate the isolated agent in this class is different from the same three others on all three features and thus no further communication is possible the configurations 131313ss and 131313ns shown in figure 2 instead allow for communication between some or all agents an overview of all classes and the proportion of states that fall into each class is included in appendix a for both model variants one can identify a partition into a small number of classes of configurations and calculate for every pair of classes the probability that the corresponding transition occurs within one iteration figures 3 and 3 visualize the transition probabilities for both models variants in the figures nodes are colored according to whether they represent an absorbing class a class from which consensus is the only reachable equilibrium or whether more equilibria are still reachable 2 edge color corresponds to the probability that the system moves from one state to another with darker edges indicating higher transition probability recursive paths are not shown both model variants have three possible absorbing classes these are classes that once selected by the dynamics will never be left again the consensus class the isolation class and the polarization class consensus is stable since social influence will never lead to changes in agents features isolation and polarization are group split states they are stable because actors are either perfectly similar or perfectly dissimilar from their neighbors in both cases communication will never lead to changes in the cultural features as can be seen in the transition diagram as well as in the transition matrix diagonal these are the only classes that are sinks with an outdegree of zero in the markov graph given that from every other class there is path towards at least one of the absorbing classes we know that in the long run the system must end up in one of the absorbing classes figure 3 illustrates how isolation can more readily emerge under onetomany communication for example once the system has reached a configuration in which one agent is almost isolated but still agrees with the three others on one single feature and 3 it is under onetomany communication three communication regime class onetoone onetomany ccc 8 0 1 7 1 3 222222s 0 6 4 0 7 3 131313s 1 3 5 2 1 5 times as likely that this agent will end up isolated after the next influence than it is under onetoone communication 3 more generally using the markov chain convergence theorem one can calculate for each of the three absorbing classes the probability to be reached under both communication regimes given the initial distribution of configurations this requires a row vector 𝑞 of the initial distribution of states and the transition matrix 𝑇 the stationary distribution 𝑝 is then given by 𝑝 𝑞𝑇 ∞ table 2 reports the stationary distributions for both model variants given a uniform probability of initializing the system in any of its 4096 configurations these results support our intuition that isolation is a more likely outcome of the dynamics of cultural influence under the onetomany communication regime than under the onetoone communication regime more precisely we find that the probability of the outcome of cultural isolation is about 16 times higher under onetomany communication we also observe that onetomany communication reduces the likelihood of consensus to emerge and thus increases the likelihood that cultural diversity persists despite social influence next we turn to exploring how onetomany communication affects the likelihood and persistence of isolation and cultural clustering in larger populations isolation and cultural clustering in bigger populations the markovchain analysis supported our intuition that isolation and polarization are more prevalent in the onetomany communication regime however with only 4 agents we can not distinguish polarization from cultural clustering into a larger number of distinct local clusters to test whether and under which conditions our analytical finding is robust and generalizes to cultural clustering also in larger networks we conducted computational experiments with bigger populations always starting from a random initial assignment of traits and 1000 independent replications per experimental condition all simulations were executed until dynamics had reached an equilibrium in the following subsections we first compare onetoone and onetomany communication in three different network configurations first we focused on a regular torus network as this is the framework that axelrod used second we compared the two communication regimes in ring networks with different degrees of network transitivity in order to test whether the microlevel intuition illustrated in figure 1 is indeed responsible for the macro differences that we observe in bigger populations using the ring networks we also varied the size of the agents neighborhoods to test whether or not cultural clustering and isolation persist when individuals communication networks grow bigger under onetomany communication next we studied spatial random graphs as these networks have been argued to mimic human social networks better than torus networks and ring networks subsequently we describe idealtypical simulation runs under onetoone and onetomany communication to illustrate differences and replicate our main findings for populations consisting of agents with more features and a higher number 𝑄 of possible traits per feature population size effects there are at least two reasons for increasing the number of agents in the model first already axelrod found that monoculture is virtually unavoidable once population size exceeds a critical threshold 9 pp 2145 because dynamics last longer in bigger populations this increases chances that two subgroups a and b that have grown maximally dissimilar at some moment restart communication because one agent adopted a trait from a third subgroup c that increased cultural similarity between a and b this finding raises the question whether the differences between the two communication regimes persist when bigger populations are assumed second the aim of the present analysis is to contribute to the development of a valid representation of online communication a setting where huge numbers of individuals interact manipulating the communication regime whilst keeping all remaining characteristics of axelrods model unchanged we first compared the two models in the same cellularworld structure that axelrod assumed in his seminal work and that many followup studies adopted that is we assumed that 𝑁 agents are distributed over a wrapped square lattice such that every agent occupies one cell all agents are linked to their neighbors in the socalled moore neighborhood and can thus interact with eight other agents 4 the first simulation experiment focused on populations characterized by a torus network and agents with three cultural features with two possible traits to study populationsize effects we created populations with 𝑚 2 𝑁 agents and varied 𝑚 between 2 and 10 in appendix b we show that our findings are robust when 𝑚 is increased to 30 which translates into populations of 900 agents figure 4 compares the two communication regimes in terms of the share of runs that ended with at least one isolated agent an isolate is defined as an agent that is maximally different from all of her network contacts the blue lines show that isolation still occurs under onetomany communication even in larger populations while isolation virtually disappears in the onetoone regime under the onetomany regime isolation is most likely in very small populations but once population size exceeds 36 the model with onetomany communication generates a constant share of about 12 percent of the runs that are characterized by isolation this finding was confirmed by simulations with populations of 900 agents figure 4 furthermore shows that the proportion of runs that end in monoculture decreases with 𝑁 under onetomany communication while the share of runs generating monoculture increases in population size under the original model axelrod already found that the original model implies more monoculture in larger populations 9 a result that generalizes to various extensions of the model axelrod deemed this a counterintuitive finding confronting it with contradictory empirical evidence from a study of language diversity on islands in the south pacific which found that there is more language diversity on larger islands our results here suggest that onetoone communication plays an important role in the generation of axelods counterintuitive finding in his original model dynamics generate monoculture in big populations because whenever a culturally homogenous region begins to form the emerging local consensus can be disrupted by a single communication event of one member of the region with an outside source of influence in large populations these disruptions are more likely simply because dynamics last longer than in small populations such outside influences are also possible under onetomany communication however the main difference is that onetomany communication offers many more possibilities how a deviant is reached by influences from members inside of the emergent region to which the deviant belongs in axelrods original model the algorithm always randomly picks two communication partners 𝑖 and 𝑗 and in table 1 which implies that the chance that a deviant 𝑗 is influenced back by a neighbor who belongs to the cultural region is only 18 in a population with moore neighborhoods with our implementation of onetomany communication 𝑗 will always be targeted by 𝑖 as 𝑖 exerts influence on all neighbors this greatly increases the robustness of cultural regions further support for this interpretation is given by similar findings that flache and macy 32 obtained with a model assuming manytoone communication to test whether onetomany communication fosters not only isolation but also the formation of clusters figure 5 shows how population size affects the relative frequency of clusters of different sizes even though clusters of size one and size 𝑁 are consistently the most likely outcome to be generated by the model there is a remarkable difference between the two communication regimes under onetoone communication the occurrence of medium sized clusters diminishes as 𝑁 increases whereas onetomany communication does generate clusters of all different sizes at all levels of 𝑁 in the simulation runs with 𝑁 100 for example we found that with onetoone communication 12 of the replication runs end with at least one isolate and 16 of the runs generate medium sized clusters under onetomany interaction the proportion of runs with at least one isolate rises to 77 and medium sized clusters appear in equilibrium for 494 of the runs moreover these medium sized clusters seem to emerge at a similar rate any given cluster size between 2 and 99 has an average probability of exactly 100 to appear in a given run this demonstrates how onetomany communication stabilizes cultural diversity and clustering both communication regimes typically generate cluster size distributions with peaks at both ends of the scale independent of population size however onetoone communication generates more monoculture less isolation and less clustering than onetomany communication figure 6 informs about the effect of the communication regime on the relative size of the biggest subgroup in the population a standard outcome measure in the literature the figure shows that the few runs with bigger populations under the onetoone regime that did not end in monoculture were always characterized by one very big cluster under onetomany communication the size of the biggest subgroups can be much smaller in contrast effects of network transitivity on cultural diversity figure 1 illustrates a key element in our reasoning why onetomany communication fosters both isolation and clustering according to our intuitive argument onetomany communication generates isolation and cluster formation when an agent is not adopting a trait from a network contact but their joint network contacts do adopt the trait and therefore grow similar to each other and dissimilar to the agent who was not influenced such a series of events can only occur however when the sender and the agent that becomes isolated have common friends in other words a high degree of transitivity in the sense that many network triads are closed can be expected to contribute to both cultural clustering and isolation and amplify the difference between the regimes to test whether transitivity is indeed responsible for the differences between the two communication regimes we compared populations characterized by different degrees of network transitivity we replicated parts of the analyses presented in the previous section manipulating the degree of transitivity in the populations social network 5 in this simulation experiment we focused on populations of 100 agents holding three features that could adopt two traits to manipulate the average transitivity in the network we created symmetric ring networks where agents were connected to the four closest neighbors to the right and to the left 38 in the resulting network all agents had the same degree just as in the simulations with the torus network furthermore the network was characterized by a very high degree of transitivity as connected agents tend to be connected to the same nodes next we rewired network links following the algorithm proposed by maslov and sneppen which decreases network transitivity while preserving the degree distribution the maslovsneppen rewiring algorithm first picks two edges 𝐴 ←→ 𝐵 and 𝐶 ←→ 𝐷 making sure that 𝐴 ∉ 𝐶 𝐷 and 𝐵 ∉ 𝐶 𝐷 and that 𝐴 󴀈󴀂 󴀠 𝐷 and 𝐵 󴀈󴀂 󴀠 𝐶 if any of these conditions is not met a new pair of edges is picked otherwise the algorithm removes the links 𝐴 ←→ 𝐵 and 𝐶 ←→ 𝐷 and adds 𝐴 ←→ 𝐷 and 𝐵 ←→ 𝐶 this procedure is repeated until the algorithm has successfully rewired a share 𝑅 of the total number of edges in the graph we studied the two communication regimes for different shares 𝑅 of maslovsneppen rewiring namely 𝑅 10 𝑖10 10 𝑖30 figure 7 visualizes how the share of rewired links translates into network transitivity transitivity is defined as the share of closed triplets in the network or formally transitivity 3 × number of closed triangles number of triplets figure 8 depicts the association between transitivity and the relative size of the biggest subgroup in the population the box plots show that under the onetoone communication regime network transitivity is not meaningfully related to the outcome measure in contrast the bottom panel of the figure shows a strong association under the onetomany communication regime this supports our conjecture that onetomany communication fosters cultural clustering only in networks characterized by a sufficient amount of transitivity note that the scatter plots on the very left and on the very right of the figure represent more simulation runs as the used rewiring algorithm generates more networks with very high and very low transitivity varying neighborhood size so far we have studied networks where all agents had a degree of eight because this resonates with axelrods work however we also tested whether onetomany communication fosters cultural isolation also when agents have more than eight network contacts to this end we studied populations of 49 agents interacting in ring networks as described in section 422 agents were described by three features and two traits per feature to study effects of agents degree we varied the number 𝑘 of neighbors from 2 to 48 in steps of conducting 1000 independent replications per condition thus under 𝑘 2 the network was a perfect ring where every agent had one neighbor to the left and one to the right under 𝑘 4 agents were connected to the two closest neighbors to the right and to the left and so on a degree of 𝑘 48 implemented a complete graph figure 9 informs about how agents degree affected how often we observed cultural isolation or monoculture under the two communication regimes in line with axelrods work the solid lines show that under the classical onetoone communication dynamics tend to generate monoculture when agents have bigger neighborhoods the figure shows only a small difference between the two communication regimes in very sparse networks which supports our conjecture from section 422 that network transitivity is a necessary requirement for generating more cultural clustering under onetomany communication a ring network with 𝑘 2 is a periodic line network with zero triplets as a consequence rejecting a trait communicated by a neighbor does not make agents more dissimilar from their other neighbor which implies that the mechanism responsible for isolation under onetomany communication is not activated in contrast figure 9 shows stark differences between the two communication regimes when agents have bigger network neighborhoods unlike axelrods original model the model with onetomany communication predicts that monoculture is less likely when degree is increased as 𝑘 increases also the number of closed triads in the network rises which sets into motion the isolation mechanism as a consequence the proportion of runs ending in monoculture drops to about 065 under onetomany communication in about half of the simulation runs with a high degree that did not end in monoculture there was at least one isolate figure 10 illustrates how degree affected the relative size of the biggest cultural cluster in the network under onetomany communication the average size of the largest cluster decreases as degree rises from 2 to 8 however the average cluster size rises again when degree is increased further nevertheless even when agents have very high degree there remains a noticeable difference between onetoone and onetomany communication we believe that the nonmonotone effect of degree under the onetomany regime results from the interplay of two processes on the one hand a higher degree increases the proportion of closed triads in the network fostering the extent to which onetomany communication can produce cultural clustering and isolates on the other hand a higher degree also increases the share of the population to which an agent is directly exposed the larger this share the less likely it is that an agent disagrees with all network neighbors the resulting cultural influence pushes the population towards more consensus as already demonstrated by axelrod the combination of both processes generates a dynamic in which cultural clustering peaks at a degree of about 6 with lower levels of cultural clustering observed at both lower and higher degrees spatial random graphs considering that both torus networks and the rewired ring networks are somewhat artificial network topologies we also studied spatial random graphs as these networks have been argued to mimic the structure of human social networks 39 in particular spatial random graphs exhibit many features of real social networks such as low tie density short average geodesic distance a high level of transitivity a positively skewed actordegree distribution and a community structure 40 we conducted a third simulation experiment to test whether the differences between onetomany and onetoone communication found with the torus networks also appear under these less controlled but more realistic conditions like in the previous simulation experiment we assumed that agents are described by three features that could adopt two traits we manipulated population size in the same way as in section 421 and conducted 1000 independent runs per experimental condition we initialized the network in two steps first all agents were randomly assigned two real numbers from the set 0 5 that defined their position on a 5 × 5 plane subsequently we looped over all agents creating 𝑘 ties probabilistically with agents with whom they did not share a tie yet whether a tie between 𝑖 and 𝑗 was created depended on the euclidean distance between the two agents on the plane and the parameter 𝑦 that controls the strength of the relationship between distance and the probability to form a tie we set 𝑘 8 such that each agent had a neighborhood of at least eight neighbors 6 the probability that a tie was formed depended on the value of 𝑓 proportional to the sum of this function over all possible 𝑗s where 𝑓 exp the resulting social networks are characterized by a transitivity value of 0523 on average which is slightly more transitive than the torus graph with moore neighborhoods that we studied in section 4 agent in equilibrium figure 12 shows how the relative size of the biggest cultural subgroup was affected by population size and the communication regime both figures are markedly similar to the two corresponding figures for the torus networks showing that our earlier findings are corroborated also when a more realistic network structure is assumed typical simulation runs figure 13 shows one typical simulation run for each communication regime under axelrods original onetoone regime one can see that the culture that eventually dominates does not diffuse from one strong cluster in all snapshots the dominant culture is present in all regions of the network for the lions share of the total body of simulation events about 13 of all attempted communication events result in a change of culture by an agent in the last stage this rate drops to approximately 17 as the dominant cluster assimilates the last deviants the typical dynamics under onetomany communication differ as figure 13 demonstrates between the outset and the second snapshot the dynamics generate three clusters each located in a distinct region this happens at a high rate of about 1 cultural adjustment per simulation event 7 as a population with three cultural subgroups can never be stable under 𝑄 2 dynamics continue until two cultural groups remain the rate of 𝑠𝑡 drops to 15 until converging to a situation with a majority cluster one minority cluster and one isolate the isolate has been locked inside the majority cluster from a very early stage and remains isolated from communication with other clusters throughout the rest of the run cultural complexity the main innovation of axelrods model was to show how cultural diversity can emerge and persist despite relentless pressures on individuals to assimilate to cultural influence axelrod and many followup studies also demonstrated how in the framework of this model stable cultural clustering is a feasible outcome only in a particular sweet spot in the parameter space in which the cultural space is not too complex meaning that neither 𝐹 nor 𝑄 are too large if the cultural space consists of too many different features this increases the chances that neighboring agents happen to agree on at least one of them by random chance exacerbating the emergence of cultural boundaries and thus promoting monoculture if there are too many different traits per feature it is unlikely that two neighboring agents happen to have the same trait at the outset which precludes interaction between them and entails cultural anomie 926 we wanted to know whether our model can replicate these fundamental results of axelrods model under both communication regimes to establish that besides the differences we have shown the two communication regimes generate consistent behavior for the region where cultural clustering is feasible according to axelrods model we wanted to know whether the larger degree of cultural isolation and cultural clustering for the onetomany regime generalizes to a broader range of parameter values for 𝐹 and 𝑄 than those we have used hitherto for this purpose we compared the two communication regimes under different assumptions about the complexity of the cultural space figures 14 and15 identify the region in which cultural clustering occurs both for axelrods original model and for the model with onetomany communication our results show that clear differences between the communication regimes occur throughout the region in which axelrods original model navigates in between anomie and monoculture in this region the onetomany regime produces more cultural isolation and more cultural clustering than onetoone particularly when both the number of features is small and the number of traits is small or intermediate with high 𝐹 or high 𝑄 the behavior known from axelrods original model is replicated also by the onetomany version in this region the forces pushing towards monoculture or isolation largely overwhelm the distinct effects of the communication regime and strongly reduce the differences between them nevertheless even in those conditions we find a consistent every distinct combination of traits is visualized with its own unique color the top graphs show the initial setup and the bottom graphs show the two populations in equilibrium the remaining graphs visualize the distribution of cultural traits after 33 and 66 of the number of simulation events needed to reach equilibrium 𝑡 is the number of simulation events and 𝑠 is the number of events where an agent adjusted her set of cultural traits but very small difference in the expected direction more cultural clustering and more isolates under the onetomany regime this supports our observation that onetomany communication generates different influence dynamics than onetoone communication in those areas of the parameter space where cultural diversity can be sustained at all under axelrods model discussion and directions for future work public debate about the role that online social networks personalization algorithms and fake news played in recent political events such as brexit and the election of donald already provides a rich arsenal of formal models our analyses demonstrated that it can be misleading to readily adopt models developed for communication dynamics in offline worlds to the analysis of online contexts in particular we compared onetoone communication a communication regime implemented in many models of offline communication with onetomany communication which seems to be a more plausible representation of communication in online contexts such as blogs and online social networks like twitter and facebook we reasoned that onetomany communication fosters isolation and the emergence of cultural clusters because an agent who happens to not be influenced by a message received from a network contact does not only fail to grow more similar to the source of the message in addition the agent also grows more dissimilar to those contacts of the sender who were influenced by the message and adopted the trait of the source building on axelrods culturaldissemination model 9 we implemented onetomany communication where a sender emits one message across his entire local network rather than just a single network contact we started with a markovchain analysis of a simple but tractable part of the parameter space and found support for our conjecture that onetomany communication fosters the emergence of isolated individuals as well as polarization next we conducted a series of simulation experiments to demonstrate that onetomany communication fosters the isolation also in bigger populations that network transitivity fosters the emergence of isolated individuals and cultural clusters and that these findings hold for network topologies that mimic the structure of real social networks these findings add a new perspective to research on differences between online and offline communication earlier research was inspired by a psychological perspective and found that individuals are not affected by the physical appearance of their communication partners when communication is mediated by a computer 1213 as a consequence when communicating online individuals neglect the social roles associated with memberships in high or low status groups which decreases intergroup conflict and fosters consensus formation in contrast to this withinindividual perspective we focused on betweenindividuals effects showing that differences between online and offline communication may not only arise from the fact that individuals behave differently when they communicate online or offline we demonstrated that differences between online and offline communication can arise from differences in communication structure because in many online settings individuals communicate to multiple receivers at the same time this difference in the way communication is structured in many online settings turned out to foster cultural isolation and clustering rather than consensus formation while our results support our conjecture that assuming onetoone communication in models of online settings can lead to false conclusions there is reason to expect that also the model that we studied may still deviate in critical ways from communication in real online settings future theoretical work should therefore explore further to what extent existing models can capture important features of online communication and which further model developments are needed for that purpose we propose three possible directions first a potentially important difference between axelrods model and our extension on the one hand and internet communication on the other hand is that online network ties are flexible on the one hand intuition and earlier modeling work suggests that making networks dynamic will foster cultural diversity as isolated agents and subgroups will cut off ties to their dissimilar network neighbors 30 this should further decrease chances that isolates are influenced by former contacts on the other hand the internet makes it easy to identify and connect to likeminded individuals even when they are geographically very distant 41 this might allow isolated individuals and subgroups to join clusters that still communicate with individuals who are similar to their former connections and thus act as a bridge over the cultural divide given these competing intuitions future research is needed to explore the conditions under which dynamic networks foster isolation under the onetomany communication regime second future theoretical research should explore populations that are more heterogeneous for instance empirical research showed that the degree distribution of the facebook graph is skewed 42 pp 4 which suggests that some users may be more effective than others in spreading cultural attributes across the graph 43 future research should therefore study how variation in neighborhood sizes affects cultural dynamics furthermore internet users differ in their online activity research showed for instance that on facebook politically active users emit more online content than users who are not politically engaged 44 it is an open question how these forms of heterogeneity affect isolation dynamics under the onetomany communication regime a third important direction for future research is the study of onetomany communication with alternative models of social influence unlike axelrods model many alternative approaches represent cultural attributes on a continuous scale and not as distinct categories 8 many political opinions for instance tend to vary between extremes and are thus better described by metric scales models of continuous opinion dynamics can also capture more complex socialinfluence processes such as gradual opinionadjustments 45 negative influence exerted by too dissimilar sources 46 and the reinforcement of opinions when two actors communicate persuasive arguments that support each others views 47 future research should explore whether and under what conditions assuming onetomany communication alters the predictions of these models we expect that the mechanism responsible for isolation and clustering under the onetomany regime is activated also in models assuming continuous cultural attributes if an actor refuses to be influenced by a communication partner he does not only refuse to grow more similar to this actor in addition the actors grows more dissimilar to those joint network contacts that were influenced and therefore were pulled closer to the sources of communication another important avenue of future research is to empirically test our theoretical prediction that onetomany communication fosters isolation and cluster formation we propose a threestep design that resembles the structure of the theoretical analysis in this paper first we propose to study the minimal case that we explored with analytical tools in a computerized laboratory environment with four human subjects discussing their stance on three binary issues in this setting one can manipulate whether subjects communicate in pairs or emit messages to all participants at once with this experimental design one can also test our theoretical prediction against the finding from the psychological literature that computermediated communication fosters consensus formation in demographically diverse groups in particular it would be interesting to test whether the integrating effects of computermediated communication are stronger or weaker when communication is implemented according to the onetoone or to the onetomany regime second laboratory experiments are also a fruitful approach to compare the two communication regimes in bigger populations our theoretical analyses suggest that these experiments should focus on social networks characterized by high clustering and settings with relatively complexity small cultural complexity as the differences between the two regimes were strongest under these conditions third one might try to test macro predictions in the field comparing influence dynamics in online communities with different local network structures contrary to intuition our results suggest that the chances that individuals turn culturally isolated are higher when their local network is characterized by high transitivity there is strong public and scholarly interest on the effects of communication in online worlds on the one hand our results illustrate that the formal analysis of abstract models can contribute to exploring the complexity of online communication systems on the other hand our findings also show that pundits experts scholars political decision makers and also developers of online communication systems need to be very careful when reasoning about the consequences of online communication being based on modeling work and empirical studies focused on offline settings the current scientific state of the art does not yet allow drawing reliable conclusions about the effects of online communication on societal processes of consensus formation and opinion polarization appendix a classes in the 𝑁4 𝐹3 𝑄2 model b replication with large populations in section 421 we studied the effect of population size conducting simulations with populations of up to 100 agents in addition we also analyzed populations of 900 agents conducting 100 independent replications per communication regime under the onetoone interaction regime all replications ended in complete homogeneity under the onetomany interaction regime only 23 replications ended in monoculture and of the remaining 77 replication runs 26 generated at least one isolate figures 16 and 17 compare model outcomes under the onetoone and the onetomany communication regimes both figures show that the results found with smaller population are obtained also in substantially bigger networks onetomany communication generates more cultural isolation and diversity than onetoone communication endnotes 1 nonconsensus features of the same type are symmetrical if the agents who agree on one feature also agree on the other if there are three nonconsensus features of the same type and only two features are aligned we label this class semisymmetrical in principal the alignment on features of different types does not matter for state classification with the exception of the 131322 semiclass where the two 13 split features are not symmetrical here we label the class semisymmetrical if the outliers on the 13 split features are members of the same group on the 22 split feature and nonsymmetrical if they are not 2 consensus is inevitable in the red classes because there is at least one feature on which the agents have reached consensus as a consequence all pairs of neighbors will always exert influence on each other with a positive probability this will eventually generate consensus likewise it is not possible that a state of consensus on one or more features can be left 3 the transition probabilities for going from the 131322s to the 131313s class are 𝑝 33 under onetomany communication and 𝑝 11 under onetoone communication 4 axelrod first used the smaller von neumann neighborhoods but also tested the robustness of his results with a moore neighborhood identical to the one we employ 5 besides manipulating transitivity the implemented method also creates betweennode heterogeneity in their network centrality and decreases the average path length in the graph this might in turn affect the dynamics of our model however due to the inherit interrelatedness of network descriptive statistics there is no method of manipulating transitivity without changing other aspects of the network structure 6 every 𝑖 formed eight ties but a 𝑗 that already possessed eight ties was not excluded from the set of 𝑖 s potential neighbors 7 it is not possible to compare these rates between communication regimes without postprocessing as a senders whole neighborhood can be influenced in a single simulation event in the onetomany model a conservative approximation could be made by dividing the number of successful communication events over the number of iterations times 8 however only the neighbors for whom 0 𝑠𝑖𝑚𝑖𝑙𝑎𝑟𝑖𝑡𝑦 𝑖𝑗 1 can be influenced and this number varies locally as well as over time data availability no empirical data were used for this study disclosure an earlier version of this paper has been presented at the xxxviii sunbelt conference conflicts of interest the authors declare that they have no conflicts of interest

online social networks play an increasingly important role in communication between friends colleagues business partners and family members this development sparked public and scholarly debate about how these new platforms affect dynamics of cultural diversity formal models of cultural dissemination are powerful tools to study dynamics of cultural diversity but they are based on assumptions that represent traditional dyadic facetoface communication rather than communication in online social networks unlike in models of facetoface communication where actors update their cultural traits after being influenced by one of their network contacts communication in online social networks is often characterized by a onetomany structure in that users emit messages directly to a large number of network contacts using analytical tools and agentbased simulation we show that this seemingly subtle difference can have profound implications for emergent dynamics of cultural dissemination in particular we show that within the framework of our model online communication fosters cultural diversity to a larger degree than offline communication and it increases chances that individuals and subgroups become culturally isolated from their network contacts

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introduction due to aging populations and prolonging dying trajectories many countries including sweden are experiencing a growing demand for endoflife care consequently eol care provision has been identified as a public health challenge requiring a shift toward care provided by caregivers in the community a critical prerequisite for increased civic involvement in eol care however is competence and preparedness to engage with dying and death there is therefore a steadily increasing interest for new public health approaches to eol care focusing on competence building in the community general eol competence beyond the purview of care professionals only has recently been conceptualized as death literacy that is a multidimensional construct encompassing knowledge and skills needed to access understand and act on eol care options and preparedness for engaging with eolrelated issues the concept of death literacy was developed in australia from a research by horsfall et al and represents how experiences of caring for and supporting a dying person at home had transformative effects on awareness knowledge and skills in relation to dying and death and attitudes to engaging in eol care provision dimensions of death literacy are said to build on the construct of health literacy therese johansson et al there are several motivations behind efforts to build death literacy one is to balance the professionalization of eol care by emphasizing the role of community support for dying people another is to promote and support proactive eol care measures such as advance care planning furthermore competence building is central to accommodate a shift toward communitybased eol care provision to address growing palliative care needs the death literacy construct is operationalized and measured in the death literacy index developed to measure levels of death literacy in adults and evaluate eolrelated educational initiatives unraveling factors associated with death literacy might be helpful for understanding the construct and how it develops during the instrument development process some sociodemographic variables that is older age having children relationship status religious belief and origin were found to correlate with death literacy older age has also been found to correlate with bugens seminal notion of death competence which involves peoples selfperceived ability to cope with dying and death gender and education level have also been identified as influential factors of the theoretically linked health literacy construct furthermore since death literacy encompasses experiencebased competence it is likely that interactions with the healthcare system either professionally or as a patient or relative might contribute to death literacy as indicated by findings from grahamwisener et al however research about death literacy is scarce and its association with sociodemographic health and experiential factors has not yet been thoroughly examined the aim of this study is therefore to explore factors associated with death literacy as measured by the swedish version of the dli an additional research question was examined what are the relationships between factors we also present a model of posited explanatory pathways which might guide future research methods study design this crosssectional explorative study analyses data from an online survey the study was approved by the swedish ethics review authority and adhered to the ethical principles of the helsinki declaration the death literacy index as illustrated in fig 1 the original australian dli encompasses 4 main scales practical knowing which consists of the subscales talking support and handson care learning from experience factual knowledge and community capacity which contains the subscales accessing help and community support groups the dli contains 29 selfreport items that are answered with ordered categories on a 5point likerttype scale often ranging from do not agree at all to strongly agree the dli is scored by calculating transformed mean scores ranging from 0 to 10 for the full instrument each scale and subscale higher scores indicate greater death literacy and the total composite score represents overall death literacy the validity of the factor structure has been supported and the dli has demonstrated good internal consistency reliability for example cronbachs alphas of scales ranging above 08 in the original australian context similar psychometric properties were recently found with a sample in the united kingdom the original englishlanguage dli is provided in supplement file 1 the swedish version of the death literacy index in 2021 the culturally adapted swedishlanguage dli was developed and tested in sweden the multistep translation and adaptation process is beyond the scope of this article but is described in detail elsewhere the dlis was found to exhibit good validity in terms of content response processes and internal structure with satisfactory psychometric properties for internal consistency testretest reliability and factor structure the dlis and its backtranslation to english are provided in supplement file 2 participants and procedure data were collected online during septemberoctober 2021 through a survey distributed by a survey agency with an existing panel of approximately 100000 adults in sweden the sampling plan is shown in figure 2 survey invitations were sent to a quota sample from the panel stratified by gender age and region to consider the heterogeneity in the swedish population panel members are compensated at the rate of 1 sek per minute and can convert accumulated compensation to gift vouchers or charity donations participants were informed about the studys aim topic and procedure and their right to withdraw at any time and provided informed consent before being able to access the survey in total 503 participants completed the survey which consisted of the dlis followed by questions about sociodemographic characteristics and eolrelated experiences these questions are presented in supplement file 3 risk to participants was considered low while survey questions about the eol have been found to possibly affect immediate mood cause of lasting harm is unlikely all data were pseudonymized by the data collection agency prior to researcher access data analysis statistical analyses were performed in spss with statistical significance set as p ≤ 005 participants total dlis score was used as the outcome measure of death literacy sociodemographic health and experiencebased factors were used as explanatory variables country of origin was not included due to the low counts and heterogeneity within the foreignborn participant group direction and strength of bivariate associations between variables and death literacy were assessed using linear regression models polychotomous variables were dummy coded or combined to create mutually exclusive variables only variables with statistically significant bivariate regression coefficients were retained for continued analysis hierarchical regression analysis was used to estimate the collective and relative association of retained variables with death literacy to select parameters for the regression model a directed acyclic graph also called causal diagram was created using dagitty in these graphs explanatory and outcome variables are represented as nodes with arrows between them indicating a causal relationship assessed on the basis of assumptions about temporality face validity and theory absence of an arrow indicates no suggested relationship in this study the dag served as a template to postulate pathways both direct and indirect between explanatory variables and outcome this process summarized in supplement file 4 enabled more informed decisions for constructing the regression model by distinguishing potential confounding and mediating variables to control for based on the dag a hierarchical regression analysis was conducted with 3 blocks the model in the first block examined the influence of sociodemographic and health factors in the second block professional care background and eolrelated education or training were added to the model in the third block experiential factors were included in the model homoscedasticity of variables in the regression model that is whether residuals are equally distributed was supported through visual inspection of pp plots multicollinearity was evaluated using paired spearmans 𝜌 correlation coefficients between variables and variance inflation factors for each variable results descriptive statistics the 503 participants ranged in ages from 18 to 86 further participant characteristics are presented in table 1 there were no missing values as a mandatory response procedure was used requiring all survey questions to be answered for participants to continue total dli scores were normally distributed in the sample the mean total dlis score in this sample was 515 bivariate regression analysis results of bivariate linear regression analyses between death literacy and explanatory variables are shown in table 2 two variables distant personal loss and attending endoflife event were excluded from further analysis as their correlations to death literacy were not statistically significant since only one category being widowed was significant from the variable household composition it was recoded as a separate dichotomized variable in the regression model hierarchical regression analysis multicollinearity was found not to be problematic with all variables having a vif 5 the matrix for pairwise correlation coefficients is presented in supplement file 5 there was one strong correlation between widowhood and tertiary education which likely resulted from the low number of widowed people making the percentual differences large even if the counts are not all variables were therefore retained for continued analysis as depicted in figure 3 the dag illustrates an exploratory model of posited direct and indirect paths between death literacy and 16 explanatory variables the results of the hierarchical model are shown in table 3 the final model accounted for 405 of the variance in death literacy f 1475 p 0001 the first block included the sociodemographic factors age gender education health status widowhood and religious belief which together accounted for 137 of the variance in death literacy in the second block professional care background and eol education or training contributed an additional 158 of variance in the third block eolrelated experiences were included accounting for another 110 of variance in this final discussion main findings using bivariate and hierarchical multivariable regression analyses this study shows associations between sociodemographic health and experiential factors and death literacy in a swedish sample building on theoretical assumptions and leonard et al s empirical research our findings support the hypothesized relationship between direct lived experiences of eolrelated situations and death literacy whether in formal or informal care contexts furthermore this study highlights associations between a number of sociodemographic factors and higher death literacy primarily older age widowhood and identifying as religious or spiritual we did not however find a significant association to gender or education level which have otherwise been shown to correlate with higher awareness of palliative care in the general public internationally and in sweden being widowed regardless of gender showed the single strongest association with death literacy in our final model while widowhood is theoretically linked to several direct eol experiences for example supporting someone with lifethreatening illness providing care at the eol and loss the effect was still strong after controlling for these factors this suggests that there may be additional experiential aspects of widowhood that contribute to death literacy but were unaccounted for in this study one such aspect could be that the closeness of the relationship with the dying person might influence the level of involvement as well as the salience of the experience a close relationship likely entails greater involvement in care decisionmaking which should in theory increase the factual knowledge scale furthermore a close relationship might heighten the emotional impact of an eol experience thereby potentially affecting a scale like learning from experience the suddenness of death and duration of illness might also alter the influence of widowhood such underlying aspects of widowhood and their association with death literacy remains a question to explore in future studies overall our study complements the existing literature by providing data from a new context that further support the assumption that death literacy is primarily associated with experiential factors for example there were several variables that were no longer statistically significant when experiential variables were entered into the hierarchical regression model the significant negative association between health status and death literacy that is participants with poorer health had higher scores did not remain when experiential factors were added curiously the same tendency was found with experiences of lifethreatening illness neither experience of own illness nor supporting someone else remained significantly associated with death literacy when other variables were accounted for the significant albeit weak association between religiousspiritual belief and death literacy shown here support previous australian findings religiosity has been shown to affect death attitudes in older people with chronic illness and influence engagement in advance care planning sweden however is known for being among the most secularized countries in the world nevertheless hagevi has showed that religiosity is more prevalent in sweden when defined broadly as spirituality by including beliefs in some kind of life force our study supports this although it should be noted that the sample is not representative of the swedish population for example regarding proportion of foreignborn persons and the proposed model may therefore underestimate the role of religiosity one possible explanation for the association found could be that experiences of dying and death might awaken religiosity or spirituality alternatively the association might be explained by more exposure to reflection and conversation about dying and death in religious or spiritual contexts such as eolrelated volunteering it should however be recognized that palliative care is generally publicly funded and run in sweden and there is relatively little public engagement in the form of volunteerism and charity work thus potential mechanisms for these findings also demand further exploration implications for practice selfperceived eol competence is known to affect both professional and family caregivers 6 therese johansson et al behavior and health the death literacy concept encompasses several dimensions of knowledge and skills of importance for how eol competence can be understood and developed both in the general public and organizations the growth of communitybased eol care initiatives and increasing reliance on social care staff and family caregivers to support dying people further emphasizes the necessity for competencebuilding efforts in these contexts where increasing ability to access understand and act on eol and death care options will be central objectives experiential factors were found to influence the relationships between explanatory variables and outcome thus lived eol experience rather than training in care provision appears to be crucial for death literacy development this finding raises questions about whether and how death literacy can be fostered through educational initiatives for example is it enough to encounter situations related to the eol or is reflection or other forms of facilitated integration needed to build death literacy furthermore what level of engagement in eol situations is prerequisite andor optimal for death literacy development leonard et al argue that some of the skills that make up death literacy may not be easily translated into didactics we have previously shown that exercises that promote reflection introspection and knowledge exchange supported development of eol competence in eldercare overall this study adds to prior literature suggesting that death educational initiatives targeting eol attitudes and preparedness benefit from focusing on experiential learning rather than information transfer our results suggest that a similar approach might be useful for death literacy development there might also be other modes of engaging with dying death and bereavement with potential to enhance death literacy development for example prior research has highlighted the use of art and play and storytelling to help addressing eolrelated issues which could aid knowledge exchange in particular this study suggests that volunteering might promote death literacy which aligns with existing literature further research is needed to investigate what this might mean in practice our findings contribute to an understanding of circumstances that foster death literacy and identify several influential variables that are amenable to change this is useful to consider when designing future public health programs for eol competence building for example as direct experiences were found essential for death literacy this study indicates that inclusion of people with lived eol experience such as widows may benefit knowledge exchange there is growing international support for the validity of the dli to date it has been validated in australia the united kingdom and turkey with studies ongoing in for example belgium the netherlands and china while the crossnational validity of the dli remains to be explored its international spread provides opportunity of using it to evaluate and compare educational programs based on inclusive approaches to eol care encompassing professional and lived experiences such as the scottish endoflife aids skills for everyone or last aid such studies would add to the understanding of how death literacy might be developed on the individual and collective level the dli is also currently being used as one measure to evaluate an educational intervention about proactive eol conversations in swedish residential eldercare strengths and limitations using established methods for exploring provisional causal inference from crosssectional data this study generated new knowledge about factors related to death literacy in the general public adhering to recommendations by ferguson et al we constructed a dag to conceptualize a model outlining the direction and strength of putative explanatory variables associations with death literacy which were tested statistically using a hierarchical regression model was considered advantageous as it controls for the effect of chosen variables thereby enabling differentiation between total effect and changes in net effect as the studys aim was to explore possible associations between variables and death literacy and not generate population estimates neither the use of nonprobability sampling nor the low response rate was judged to pose a problem for the internal validity the sample size was considered sufficient for adequate statistical estimation given the number of variables in the model still the results should be interpreted with caution as the variable for widowhood had a very low count and therefore might have had a distorted influence in our model future studies might wish to use stratified sampling to explore the association between being widowed and death literacy further it is also possible that there may be unmeasured confounding variables our final model accounted for 405 of the variance suggesting both that influential sociodemographic and experiential factors have been accounted for but that additional variables may also be of significance for explaining death literacy the presented model thus constitutes a theoretical premise for future studies and requires further testing to assess both fit in other contexts as well as overall explanatory power furthermore we have only investigated the effect of the variables on the overall dlis score and not on specific scales and subscales it is possible that variables influence scales and subscales differently resulting in distinct explanatory pathways to death literacy additional research is needed to disentangle the role of the different dimensions of death literacy longitudinal and experimental studies would be useful to address some of the remaining questions regarding causality in death literacy such as residual confounding and temporality in addition it is not clear how participants differentially interpreted questions about their experience of caring for or supporting someone at the eol therefore it is possible that some participants may have had eol care experiences that were not conceptualized as such for example because they had not engaged in care provision directly or did not identify themselves as carers in future research these questions may need adaptation to better distinguish between them conclusions the findings in this study demonstrate the individual relative and collective relationships between sociodemographic health and experiential factors and death literacy overall our results support the notion that death literacy builds primarily from prior encounters with eol care and deathrelated situations such as caring for a dying person or supporting a grieving person specifically the impact of working in health care and attending eol education was shown to be influenced by direct experiences this suggests that initiatives aiming to develop death literacy need to encompass components of both knowledge as well as reflection about lived experiences to adequately build competence and preparedness for eol care still further research is needed to account for the variance left unexplained by the model in this study as there may be additional factors to consider to better understand the death literacy construct and how its development may be supported in both community and organizations supplementary material the supplementary material for this article can be found at palliative and supportive care author contributions joachim cohen and ida goliath authors share last authorship competing interests the authors declare that there are no competing interests

objectives death literacy is a recent conceptualization representing both individual and community competence for example a set of knowledge and skills for engaging in endofliferelated situations little is yet known about which factors are associated with death literacy a crosssectional survey using the swedish version of the death literacy index the dlis was therefore conducted to explore associations between death literacy and sociodemographic health and experience variables methods a quota sample of 503 adults mean age 4995 ± 1792 recruited from an online swedish survey panel completed a survey comprising the dlis and background questions results a hierarchical regression model with 3 blocks explained 405 of the variance in death literacy f 22 477 1475 the sociodemographic factors age gender education widowhood and religiousspiritual belief accounted for 137 of the variance adding professional care factors contributed to an additional 158 of variance with working in health care being significantly associated with death literacy including experiential factors explained another 110 of the variance of which experiences of caring for and supporting dying and grieving people both in a work volunteer or personal context were positively associated with death literacy significance of results this study contributes a tentative explanatory model of the influence of different factors on death literacy outlining both direct and indirect associations our findings also support the hypothesized experiential basis for death literacy development in the swedish context the moderate degree of overall variance explained suggests there may be additional factors to consider to better understand the death literacy construct and how its development may be supported

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how are teachers with little background in the visual arts supposed to ask their students questions that the ontario ministry of education suggests that they ask when they do not know the artists work nor have the materials on hand with which to teach how can teachers of visual arts develop an aesthetic understanding of the artists work when they are not provided with any resources or background with which to do this and there is no other information available how are students to interpret the works of others either individually or in a group as ontario ministry of education documents require if it does not state in the guidelines how teachers and students are to interpret the artworks or what their interpretations are to be based on and when there is no information available on any of the artists nor suggested ways to go about finding out building students identities while supporting teachers has been a focus of this project both teachers and students need open online data banks of videos and teaching resources where they can readily access research on local artists i wanted to offer students and teachers a landscape of multiple possibilities and a lived experience of curriculum wherein the curriculum is experienced enacted and reconstructed through creating exemplars inspired by local artists work in ontario and in canada generally visual arts from kindergarten to grade 8 is not taught predominantly by specialists but by generalists who have minimal training in the subject area and who often teach numerous subjects to the same group of students in elementary school when the browning jcacs 107 subject of visual arts is undertaken it is mostly being taught by teachers who do not feel comfortable to teach this subject discipline gaps in the curriculum itself are not helpful so while the ontario ministry of education encourages critical thinking in the visual arts program and proposes many questions for teachers to ask their students there are no guidelines as to what an acceptable answer would be lacking in art education materials in particular at the time of research project were descriptions of local artists work websites to refer to and suggested texts to read in the ontario curriculum teachers and students were not being encouraged to research lesser known artists who in fact comprise most of the artists in northern ontario there are very few catalogues published by art galleries in smaller communities in northern ontario furthermore even if published the catalogues are often difficult to find especially if the teacher has not bought one at the time of the exhibition while art exhibitions are a lot of work often no traces remain of the exhibition not all artists have websites or books published nor do all artists have publications of their artwork with quality fullcolour photographs which teachers and students in schools can access for deep discussions of artists works all of this pointed to the everincreasing need for digital videos on local artists work particularly from more remote areas like northeastern ontario it is imperative that teachers and students identify with artists in their own community and one important way is through digital videos and digital still photography these could be made readily available through libraries or online through the ontario ministry of education and associations like the canadian society for education through art the canadian society for studies in education or the national art education association however the central problem has been that there are many canadian artists particularly in smaller communities who are not mentioned in ontarios curriculum guidelines during the writing of the ome curriculum guidelines for the arts i attended meetings in which i requested that the guidelines include national artists with a focus on local artists in fact my participation in these curriculum meetings was instrumental in getting aboriginal artists particularly ojibway mentioned for example artists such as daphne odjig and norval morrisseau 2009 p 156 carl beam and carl ray i suggested others too for example inuit artist kenojuak ashevak cree artist tomson highway as well as emily carr who lived in the forest and was inspired by indigenous ways of knowing aboriginal cultures in canada were also included as a result of these discussions however many lesser known aboriginal and métis artists were not included nor were contemporary artists who bring a postmodern digital perspective nor did the ome guidelines include francophone artists or artists from smaller communities as much as i was thankful for the many suggested artists who were included there remained many who were not these gaps still need to be addressed one question preoccupying the research therefore concerned what and who was not mentioned in the curriculum another question concerned access how can art educators teach students about constructing personal and cultural identity or developing a sense of self and a sense of the relationship between the self and others locally nationally and globally if there is no online data bank containing lists of suggested books as well as links to videos accessible to teachers and students accessible data banks of videos of local artists talking about their art were not available at the time of my research project youtube and art 21 cannot bridge this gap as they lack information on artists in rural areas i therefore also requested that the ministrys online data bank include biographies still photography and video examples of artists works as well as of artists talking about their work it would be a bank created for teachers and students and made accessible to them while teachers may be able to organize a trip to an art gallery actually seeing digital videos and still photography of these artists work is extremely important teachers and students whether in schools or universities need to be able to access data banks of digital videos where artists from every region are using multimedia tools to share their images and ideas theoretical framework rurality and digital videos the research project that informs this article combined theories of rurality and place with recognition of the importance of digital media 2 according to corbett rural communities occupy an important place on the canadian educational landscape rurality is located in the way it represents the intersection of people and place jokela hiltunen andhärkönen in discussing the north have pointed to the special conditions of the rural and semirural urban places outside the cities and culture centres to rectify the imbalance corbett refers to castells and urrys notion of spaces of place as a concept which needs to be better understood explored and developed for art education curricula from rural communities by offering a greater abundance of information on rural artists we might redress the paucity of information currently available and try to match the richness of resources readytohand with respect to urban communities we have long known that digital video has the power to translate experience into new forms that media are the primary vehicles through which we come to know ourselves and others and yet very little digital video research has been done in this area particularly on artists in remote areas the gulf islands film and television school british columbia has published some work these types of programs offer curriculum possibilities in video not readily available in regular educational settings teachers and students need to be able to access data banks of digital videos where artists are talking about their work with cutin digital photographs which help exemplify these descriptions according to briggs video production involves still and moving images texts animations visual transitions and effects and a soundtrack that may feature audio that is tied to the visual track sound effects that are overdubbed andor voiceover narration teachers can teach students to learn about some of the elements and principles of design and begin to describe how the elements are used by the artists this as per ministry guidelines adams believes that digital tools can help rural communities in particular to better understand practices to enact tangible changes in their community however in order to do so teachers and students need ready access to information about local artists introducing the 14 videos project i am a producerdirectorresearcher of the 14 videos project and worked in partnership with the director of the laurentian university film studio dr hoi cheu who acted as the videographereditor we created videos that were intended to support the implementation of the visual arts in ontarios curriculum the arts grades 18 the arts grades 9 and 10 and the arts grades 11 and 12 the videos featured 14 local artists accompanied by fourteen teachers facilitation guides the facilitation guides included previewing and postviewing questions which could help in teaching and also be used across a variety of other subject disciplines including to name but a few technology indigenous studies environmental studies womensfeminist studies media studies curriculum studies history english literacy studies and geography as already stated the purpose was to add to the knowledge base of artists in canada particularly with respect to more remote areas like northern ontario this through videos linking and online sites for information access the completed video series has received the curriculum services canada seal of approval and the canadian network for innovation in education excellence and innovation in the integration of technology in the k12 classroom award teachers who have taken my workshops describe how with these resources they can show a clip talk about the environment discuss indigenous perspectives or have their students create a piece of art music or dance or write a poem or story methodology of the 14 videos project i approached the development of the 14 videos project as a multicase qualitative research study after initial telephone andor email contact followed by written permissions i met each of the artists conducting standardized yet openended interviews hoi cheu digitally videotaped our exchanges all artists were asked the same thirty questions however artists elaborated in their own ways on such subjects as their creativity as children educational and artistic influences how media has evolved sources of inspiration use of technology teaching and future goals the videotaped interviews took place in galleries artists studios artists homes and outdoor locations it was important to interview the artists where they felt comfortable and could best represent their artwork the videotaped interviews and thick descriptions included field notes thus forming a broad basis on which i could later develop digital stories by conducting inductive comparative analysis of emergent categories using grounded theory a method i had used elsewhere nvivo was helpful to compare video clips for commonalities i also digitally photographed the artists and their artwork which was later cut into the digital video footage to get the best possible highresolution images of their work i worked together with the editor to include footage which clearly told each artists story we aspired to a respectful inclusive process all artists were given a copy of their video after initial editing their suggestions were considered prior to making final edits final versions were test screened revised exported mastered and copied before being distributed to the partners to create a video library and online data banks for research and teaching purposes the partners included the ontario ministry of education the knowledge network for applied education research and laurentian university with links on the websites of associations such as the ontario art education association the canadian society for education through art the canadian society for the study of education and inspire links are also included on the teaching federations sites such as the elementary teachers federation of ontario the ontario secondary school teachers federation and the ontario english catholic teachers association the videos were streamed at laurentian university with links to knaer and the artists themselves the project was attentive to a creative research process final videos of 10 to 20 minutes in length involved shooting up to 7 hours per artist while the very lengthy process of editing took as much as 20 times that from raw footage to final cut further as part of the creative research process specific editing styles were chosen for different artists frenchswiss film director jeanluc godards jump cut method was preferred by francophone artist mariana lafrances video as this fastpaced editing style suited her contemporary artwork specific music was selected for each video that could support the artists work for which musical permissions were acquired i also sought out and included specific musicians that the artist requested for example jon butler requested ian tamblyns music jon was one of the organizers for a project which included 45 artists who wanted to save the willisville mountain from becoming a quarry the artwork created for this exhibition travelled to five different locations in northeastern ontario bringing attention to the beauty of the white quartzite mountain as well as the need for its preservation the project was successful as the mountain was saved for generations to explore this project the artists and artwork created was later published as a book entitled the willisville mountain project ian also performed and created a cd of music about the mountain a similar approach was used in presenting many of the other artists and their work aboriginal artist mark seabrook had a rock band called no reservations its music and lyrics worked well with his video the music of phenomenonsemble was used for nick dubeckis work as well as for the videos i created to describe this groups performance artwork music and musical instruments métis artist will morin sang and played a drum while his artwork was videotaped whereas métis artist christi belcourt requested traditional songs by elder alowhite terrance witzu was hired to create music for mariana lafrances contemporary photography in short each video combined the work of local artists with the music of local musicians to create a complexly layered resource that celebrated the creative communities in and around sudbury and that could serve to show students the richness of their rural identities exemplifying rural creative culture regionally developed resources can play a special role in art education by focusing on the unique diversity of cultures and themes in the sudbury area and by extension highlighting the importance of developing regional resources to support art education outside of the big urban browning jcacs 111 centres the research gathered exemplary artists and shared their work in digital forms that were affordable accessible and enriching not only to teachers and students in the region but provincially nationally and internationally the project also offered a method by which to do so through the videos created the fourteen artists exemplified creative culture around sudbury even as they discussed their relationship to the landscape and described environmental projects for instance in her video the urban connection francophone artist mariana lafrance talked about what it was like to grow up on manitoulin island how she identified with sudbury and how the city affected her she offered new perspectives of place understanding translation and anxiety for his part in his video repairing beauty métis painter and sculptor will morin discussed misconceptions about aboriginal people and the importance of educating others about indigenous culture he talked about his own art and how it gave him confidence as well as about his education and influences on his art for instance he spoke about elements found in his artworks referring to a modern expression of a raven sculpture and explained the significance of ravens in the ojibway culture will also explained the sudbury green stairs project wherein he worked with local schools to display students artwork so it can be heard and seen in public places he created the frames from recycled materials in which the students artwork could be displayed annually his goal was to inspire youth will went on to describe his reappropriation of images in his totem pole sculpture that is created out of car parts the car parts are made by companies that use names of aboriginal tribes he has created many sculptures from recycled materials that can be found throughout sudbury will believes in reusing materials so as to reduce the pressure on the environment by viewing the work of these selected artists students and teachers can gain a sense of design relationship with the land and the cultures that make up this vital northern community having now provided the objectives the rationale the rurality of place the background and the methodology of the project i will next discuss the ways in which this online videos series inspired bed students to create innovative exemplars and conceptualize curriculum for teaching visual arts students creative responses to the 14 videos project i teach primaryjunior grades k6 and juniorintermediate grades 410 visual arts in mandatory preservice bed courses there are mostly physical education majors in my courses the majority of students have very little experience in visual arts and have not used a variety of media before one assignment called the artists video curriculum planning project inspires students to use the artists works as catalysts for their own creation through creating art and making exemplars for teaching in a variety of media the student teachers conceptualize curriculum while being better able to see what and how to teach students in groups select artists whose artwork speaks to them while creating and cocreating curriculum that works in relation to each other and the artists they research and investigate how to best represent their ideas and the artists works including the plurality of their voices the students are transformed through this process and many feel it to be cathartic multimodal artwork uses several modesmedia materials placement and organization of the content all create meaning communicated through multimodal visual literacy corbett suggests that it multimodality may be a more academic creativitybased and innovationfocused curriculum that fits best with this new reality and the real challenge for 21stcentury rural education as in berry hawisher and selfes borndigital book the digital video project was conceived to encourage digital literacy by helping students understand the artistic perspectives of localhere ruralartists combining ideas through recomposition allowed the studentscreators to understand their local artistic community through a lived experience inspired by video this transformative process was accomplished by using stills of the artists work from the videos while understanding the message in that mode and using it as inspiration to create something new video clips were incorporated into powerpoint presentations students also learned how to download video clips and still photographs from streamed sites and dvds and integrate them into their powerpoints students cut and pasted from windows and mac computers using a variety of paths to import video stills and clips from the online streamed videos which were then embedded in their presentations these streamed linked and libraryaccessible videos were then reimaged one student even created and included her own video of how to do quilling in her powerpoint students also used the teachers facilitation guides artists websites and dvds the resulting group assignments were presented with artists background information images of their inspirations photographs of their exemplars explanations of the relationship to the arts guidelines lessons for schools and assessment tools each student in the group created in a different media while choosing a different inspiration from their chosen artist students were encouraged not to mimic the artists work each student chose a different artwork by the groups selected artist to inspire them through my research and in my teaching i have helped students learn how to interpret artists works and create art that informs their professional teaching practice students can create reflect analyze and critically discuss these artists works by using these digital videos which support presenting responding exploring and valuing visual forms thus offering a sense of identity in cultural contexts while making connections beyond the classroom this rich student art education experience has encouraged others in turn to use these ideas and resources in their classrooms while making connections with their own communities the following are some examples of artists stills from the videos and inspired exemplars that jcacs 114 in his video visions of light landscape painter john stopciati was inspired by the beauty of northern ontario landscapes and historic structures he discusses how he became a painter and the imagery that inspires him to create amber was inspired by the red chairs in john stopciatis painting she then photographed her painted clay chairs in front of different backdrops and also placed the chairs looking out her university residence window she encouraged others to get their students to create in clay and then make backgrounds that can be drawn painted photographed or photoshopped inspired by jon butlers photography jordan went and took a photograph that reminded him of jons work student jordan walkermartin when describing his lesson jordan suggested that teachers • show students exemplars of butlers sunrise work and ask them to explain colour relationships and the feelings they get out of looking at the photos • get students to take photos of the sunrise when theyre getting ready for school or of the sunset before they go to bed • allow them to create either a digital or print photo montage with their group members • have students present a brief twominute presentation of what feelings their montage is portraying and how it relates to butlers work conclusion through my research that resulted in the 14 videos project i hoped to facilitate student teachers being able to interpret artists works in a rural cultural context particularly artists in northern ontario where there is otherwise very little information available the artists gathered as cases for the videos in this study exemplify from the creative culture around sudbury the 14 artists discussed their relationship to the landscape and to environmental projects it is imperative that teachers and students in schools identify with artists in their own area and one way is through online digital videos knowledge of the presence and practices of local artists can in turn inspire students to create art then becomes a part of the students own experience as a part of their community not just an experience in the classroom or an occasional gallery experience specifically the 14 videos project was used to inspire students to create reflect analyze and critically discuss northern artists works the videos then supported the student teachers themselves in presenting responding and exploring visual forms offering a sense of identity in cultural contexts while making connections beyond the classroom the 14 videos project inspired students to create in a variety of media thus extending their understandings of multimodality as it becomes more common in classrooms through the creative use of technology when students are exposed to a variety of stimulating artistic activities reflect onand give meaning totheir artistic learning and celebrate their success thus reinforcing their identity building and their positive relationship with art the canadian teachers federation reminds us learning can become meaningful and relevant leading to exploration investigation use of various materials creation and problem solving the preservice bed students confirmed that the research project embodied the essence of the artistic ways of knowing of these fourteen artists while also resulting in the creation of artworks that exemplified their understandings of the artists aesthetic in a smaller community students and teachers using these videos now have a better understanding of the sense of place which affects these aboriginal métis francophone and anglophone artists and what it means to be creatively living and working in a rural community in northeastern ontario as with adams i believe that insights gained from such research can better inform us about the potential of digital tools and spaces and how we might foster similar applications elsewhere it is the start of a much larger curriculum project wherein videos of other artists work can be contributed from other rural areas where there is also a lack of information and resource materials artist mark seabrook student anthony scola during her presentation mackenzie described both marks and her artworks through the elements and principles of design emphasizing unity and showing how her photographs work together as they are all about the environment and create visual harmony • music choose a piece of music that you feel represents your artwork photographer jon butler in his video the zen of la cloche describes the importance of composition in his photography jon also writes haiku poetry to invoke the sounds and sensory details in his landscapes artist jon butler

the article begins with a description of the awardwinning online artists video project 14 videos of visual artists in greater sudbury and concludes with a presentation of my preservice bed students creative use of this digital resource the video series was conceived and created with the aim of filling a gap in materials that were sorely lacking to teachers of visual arts in ontario the video series includes aboriginal métis francophone and anglophone artists and highlights the artists interconnections with the local community the streamed linked and libraryaccessible videos see served as inspiration for student teachers creation of their own innovative curricular exemplars in the article i describe the complex inner workings of the research project in order to establish a context for the students work i show how the students were able to conceptualize curriculum through being able to better see what and how to teach through creating art and making exemplars in a variety of media using the artists work as a catalyst the students worked in groups selecting artists whose artwork spoke to them while creating exemplars and cocreating curricula that would be meaningful the article concludes with student exemplars that offer insights into the value of focusing on local artists in order to better meet art education curriculum goals in ontario and by extension elsewhere in canada

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of due process in ones country with regard to suspected terrorists the present research examines this phenomenon and asks whether insights from work on collective action among the disadvantaged can be generalized to collective action among the advantaged this is an important question because any action among the advantaged on behalf of the disadvantaged would appear to go against the advantaged groups objective selfinterest to maintain the status quo indeed such actions challenge the very social inequality that provides the basis for their beneficial position in society this does not imply however that the advantaged never act against social inequality in this article we explore a novel psychological mechanism that helps to explain how the advantaged come to challenge social inequality specifically we propose that moral convictions against social inequality motivate the advantaged to challenge social inequality because moral convictions are experienced as strong and absolute stances that do not tolerate exceptions to the higherorder principle any violation motivates individuals to actively change that situation importantly we propose that seemingly individualistic moral convictions can have collective consequences because any violation increases identification with the victims of social inequality specifically it is the absolute condemnation of social inequality that propels further actions on their behalf such identification with the disadvantaged group is the psychological basis for collective action thus providing a conceptual bridge between seemingly individualistic moral convictions and groupbased predictors of collective action identified by the social identity model of collective action according to this model identification with a relevant group provides the psychological basis for the experience of groupbased anger and group efficacy beliefs that motivate collective action as such violated moral convictions can powerfully motivate collective action among the advantaged we tested this novel and integrative line of thought in two empirical studies motivations for collective action among the disadvantaged generalize to the advantaged although theory and research on collective action are a multidisciplinary enterprise the past decades of research have converged on the conclusion that the psychology of collective action is crucial to its understanding in fact objective economic circumstances and societal events appear to be pretty poor predictors of collective actionsuch objective conditions are only one of several factors that determine how individuals become motivated to actually engage in such action this implies that the study of social influences that propel individuals toward collective action is both important and consequential in the psychological literature collective action is typically defined as any action enacted as a representative of the group aimed at improving the groups conditions in keeping with this definition very different types of action can be classified as collective action ranging from participation in protest demonstrations and strikes to seemingly individualistic acts such as signing a petition the definition also accommodates the possibility that advantaged group members may engage in collective action as long as these individuals perceive themselves to be a representative of a particular group and perceive collective action as aimed at improving that groups conditions further in line with the definition theory and research suggest that identification with a group facilitates individuals selfcategorization as a group member for these reasons the key variable in the psychology of collective action among the disadvantaged is the relevant group that individuals identify with however the relevant group here is not necessarily the ingroup for example for disadvantaged group members relevant groups may include the disadvantaged group but also more specific organizations that fight on their behalf in the present article we propose that among the advantaged identification may even be felt with an outgroup which enables collective action on their behalf indeed simca suggests a central role for group identification in the psychology of collective action simca predicts that such identification increases collective action directly but also indirectly it increases collective action directly because higher identifiers with the group are generally more committed than lower identifiers to achieve group goals and conform more strongly to group norms about shared action to achieve them moreover group identification predicts collective action indirectly because a shared identity validates and thus increases feelings of groupbased anger and increases a sense of group efficacy can simca be generalized to the advantaged some theory and research suggest that this might be problematic because members of advantaged groups tend to protect their objective group interests through their subjective motivation to maintain social inequality however theory and research in the social identity tradition suggest that the relationship between ingroup identification and outgroup discrimination is highly contextdependent and thus one cannot speak of generic motivations to maintain or challenge the status quo either way we propose that moral convictions against social inequality have the psychological power to motivate the advantaged to challenge social inequality the key reason for this is that moral convictions are experienced as strong and absolute stances on moralized issues that tolerate no exceptions to the higherorder principle as a consequence any violation of a moral conviction motivates individuals to actively change that situation which effectively overrides other concerns or motivations it is for this reason that moral convictions can be extremely influential in motivating advantaged group members to challenge social inequality moral convictions motivate the advantaged to challenge social inequality moral convictions are defined as strong attitudes that are experienced as absolute stances on moralized issues indeed the aspect of moral absolutism has sometimes been referred to as one of the hallmarks of morality consistent with this line of thought any violation of moral convictions leads individuals to experience strong feelings of anger towards the transgressors seeking to punish and exclude them in order to defend ones conviction moreover individuals may feel the need to reaffirm their moral stance by acting on it this increased tendency to act is amplified because individuals moral convictions legitimize and even necessitate action however this line of work has focused exclusively on individual behavior and thus neglects how individuals come to act as group members on the basis of their group identities this is precisely what we examine in this article one of the reasons why the moral conviction and collective action literatures have largely remained disconnected from each other is that they differ in their conceptualization of identity we believe that the two literatures can be integrated by considering that although moral convictions might develop on the basis of group identities and group norms their acceptance as subjectively universal and thus as absolute standards transcends group boundaries in this sense moral convictions are extrapolated from the normative systems and codes of conduct within groups they may arise out of or are imbued with social meaning through a process of consensualization but the subject of these moral concerns is unique they may develop within specific groups but once they acquire a moral status they become subjectively universal and thus transcend group boundaries similarly the tendency to accept moral judgments as absolute is subject to the same social construction processes however once an individual has developed moral convictions their violation overrides any lowerorder concerns or motivations moral convictions demand adherence irrespective of the actor or subject that concerns them the intriguing paradox here is that although moral judgments are no doubt constructed much like other norms they carry the seeds of social change by virtue of being placed on a higher level of importance than personal identity social identities and any other relational process that may account for social order moral convictions against social inequality thus demand absolute adherence to this principle of equality when advantaged group members who have such convictions are confronted with a disadvantaged group this constitutes a violation of their moral conviction which motivates them to change the situation indeed because of their absolute condemnation of social inequality individuals will increase their identification with that group which enables collective action according to simca identification with the relevant group increases groupbased anger and group efficacy and all three variables predict collective action thus the advantaged can become motivated to challenge social inequality on the basis of their violated moral convictions against social inequality because they identify with its victims hypotheses our line of thought can be summarized in three hypotheses first we predict that moral convictions against social inequality at least when violated increase the motivation to challenge social inequality effectively overriding any other concerns or motivations we refer to this hypothesis as the moral motivation hypothesis which we test in both studies second we predict that the violation of moral convictions against social inequality leads to increased identification with the disadvantaged group we refer to this hypothesis as the identification hypothesis which we test in study 2 third we predict that the same psychological processes that simca predicts to explain collective action tendencies among the disadvantaged are also in play among the advantaged thus on the basis of a relevant social identity group identification groupbased anger and group efficacy predict collective action tendencies while group identification also predicts groupbased anger and efficacy we refer to this pattern of predictions as the simca hypothesis which we also test in study 2 together these three hypotheses represent our predictive model we tested our hypotheses and predictive model in two relatively similar studies that employed different contexts and populations from the netherlands and hong kong both studies focused on advantaged group members moral conviction against social inequality their group identification groupbased anger group efficacy beliefs and their willingness to engage in collective action against social inequality because only study 2 included identification with the disadvantaged group studies 1 and 2 test the moral motivation hypothesis whereas study 2 tests the identification hypothesis and the simca hypothesis in the netherlands we focused on how the nonmuslim dutch responded to a situation about discrimination towards dutch muslims in the netherlands in hong kong we focused on the salient intergroup relation between the hong kong chinese and the mainland chinese finding support for our hypotheses across these quite different contexts would generalize support for our model and for the general point that moral convictions motivate the advantaged to challenge social inequality because a violation thereof increases identification with the disadvantaged group study 1 method participants and procedure eightyone nonmuslim dutch participants of nonimmigrant descent were recruited from a university campus to participate in exchange for a chocolate bar participants were informed that the research was carried out by a dutch university the study began by asking participants to indicate their moral stance on the issue of discrimination against dutch muslims participants then read a newspaper article describing an instance of discrimination against dutch muslims after reading the article participants responded to a set of questions that included our dependent measures all measures employed 7point scales with two anchors the newspaper article focused on an instance of discrimination against dutch muslims that occurred in 2007 the source was a respected dutch newspaper which reported that a muslim woman who did cleaning work on a high school applied for a job at the same school as a canteen worker she was not hired the dean of the high school was quoted as saying that he was fine with the muslim woman working at the school after hours but that he was not fine with her working at times when students were present as this would lead to too much contact and exposure to her religion the article reported that the woman had filed a discrimination complaint and was awaiting the outcome measures moral conviction all participants first indicated whether they were in favor of social inequality or against it all participants were against it moral conviction was measured with three items 1 these items reflect what we view as the essence of moral convictions namely the combination of a strong and absolute stance on an issue principal axis factoring with oblique rotation extracted as expected one factor that explained 6384 of the variance with factor loadings 74 predictors of collective action tendencies derived from previous work we measured groupbased anger with three items and group efficacy beliefs with two items we measured identification with the advantaged group with two items principal axis factoring with oblique rotation extracted as expected three factors that explained 6268 of the variance with factor loadings 58 collective action tendencies derived from previous work we measured collective action tendencies with seven items principal axis factoring with oblique rotation extracted as expected one factor that explained 6368 of the variance with factor loadings 66 thus across the board the construct validity of our measures was adequate results we tested the moral motivation hypothesis with a series of multiple regression analyses in line with predictions results showed that moral conviction strongly predicted collective action tendencies groupbased anger and group efficacy also as expected moral conviction did not predict identification with the advantaged group in the next step we regressed collective action tendencies onto moral conviction groupbased anger group efficacy and identification with the advantaged group results showed that although the effect of moral conviction was now considerably weaker as expected groupbased anger and group efficacy predicted collective action tendencies further in line with predictions identification with the advantaged group did not predict collective action tendencies thus individuals identification with the advantaged group was completely unrelated to their moral conviction against social inequality and their collective action tendencies taken together we found support for the moral motivation hypothesis we performed bootstrapping analyses to test for the simultaneous mediating roles of groupbased anger and group efficacy between moral conviction and collective action tendencies results showed that the total indirect effect was statistically significant and that the unique contributions of groupbased anger and group efficacy were statistically significant thus both indirect paths were statistically significant because the above analysis does not explicitly test the relationships between identification with the advantaged group groupbased anger and group efficacy we tested two models through structural equation modelling the first model represents a model that should not fit the data because it assumes that identification with the advantaged group is the psychological basis for the effects of moral conviction on groupbased anger group efficacy and collective action tendencies this model in fact did not fit the data well other fit indices corroborated this evaluation of the model cfi 79 gfi 90 srmr 10 rmsea 37 this evaluation was further supported by the fact that both the lagrange multiplier and waldtests for model modification suggested that paths could be added or removed to improve model fit however even adding the direct effect of moral conviction on collective action tendencies did not result in a fitting model the second model we tested represents a model that should fit the data because it assumes that identification with the advantaged group is completely unrelated to moral conviction groupbased anger group efficacy and collective action tendencies and that moral conviction predicts collective action tendencies directly this model fits the data well other fit indices corroborated this evaluation of the model cfi 100 gfi 98 srmr 06 rmsea 01 this evaluation was further supported by the fact that both the lagrange multiplier and waldtests for model modification suggested that no paths could be added or removed to improve model fit this model thus shows that the relationships between identification with the advantaged group on the one hand and groupbased anger and group efficacy on the other could be set to zero discussion the study 1 results supported the moral motivation hypothesis among the advantaged in dutch society moral convictions against social inequality predicted collective action tendencies through groupbased anger and group efficacy importantly moral conviction did not predict identification with the advantaged group and this identification in turn predicted neither collective action tendencies nor groupbased anger nor group efficacy this is consistent with the idea that identification with the advantaged group is not the relevant group identity on which to challenge social inequality this might also be indicative of the power of violated moral convictions to override other concerns or motivations however our results show a striking gap between identification with the advantaged group and the other simca variables it is also striking that moral conviction seems to easily fill this gap and in fact shows the very same relationships with the simca variables as a relevant social identity would yet this is fully in line with our argument that moral convictions against social inequality at least when violated breach existing group boundaries and increase individuals identification with the disadvantaged group study 1 however did not include a measure of identification with the disadvantaged group in study 2 we therefore included such a measure which enabled a test of the identification hypothesis and the simca hypothesis these suggest that violated moral convictions increase identification with the disadvantaged group and that such identification is the psychological basis for groupbased anger group efficacy beliefs and collective action tendencies study 2 further as in study 1 the newspaper article focused on a report about structural discrimination in society in the study 2 context this represented discrimination against mainland chinese in hong kong society the source of the article was a respected hong kong newspaper which highlighted the case of a mainland chinese woman who was not hired for a job because of her mainland chinese background furthermore the article reported an increasing number of such incidents and asked the hong kong government to intervene measures moral conviction all participants first indicated whether they were in favor of or against social inequality as in study 1 moral conviction was measured with three items reflecting the strong and absolute stance that it represents principal axis factoring with oblique rotation extracted as expected one factor that explained 7266 of the variance with factor loadings 74 predictors of collective action tendencies as in study 1 we measured groupbased anger with three items and group efficacy beliefs with two items 2 we also measured identification with the advantaged group with four items and new as compared to study 1 identification with the disadvantaged group with four items principal axis factoring with oblique rotation extracted as expected four factors that explained 7363 of the variance with factor loadings 67 collective action tendencies finally we measured collective action tendencies with seven items principal axis factoring with oblique rotation extracted as expected one factor that explained 6495 of the variance with factor loadings 75 thus across the board the construct validity of our measures was again adequate results as in study 1 we tested our predictions with a series of multiple regression analyses in line with the moral motivation hypothesis results showed that moral conviction predicted collective action tendencies groupbased anger and group efficacy as in study 1 moral conviction did not predict identification with the advantaged group moving beyond study 1 and in line with the identification hypothesis moral conviction predicted identification with the disadvantaged group in the next step we regressed collective action tendencies onto moral conviction groupbased anger group efficacy identification with the advantaged group and identification with the disadvantaged group in line with the simca hypothesis results showed that the effect of moral conviction became nonsignificant and that groupbased anger group efficacy and identification with the disadvantaged group predicted collective action tendencies positively by contrast identification with the advantaged group did not predict collective action tendencies we then performed bootstrapping analyses to test for the simultaneous influence of the three possible mediators of the link between moral conviction and collective action tendencies results showed that the total indirect effect was statistically significant and that the unique contributions of identification with the disadvantaged group groupbased anger and group efficacy were all statistically significant these results replicate study 1 and provide more support for our hypotheses in a final step we used eqs 61 to test the fit of our integrative model this model represents the most comprehensive test of our set of hypotheses by specifying that moral conviction predicts collective action tendencies through identification with the disadvantaged group groupbased anger and group efficacy beliefs whereas identification with the disadvantaged group reflecting the relevant social identity also predicts groupbased anger and group efficacy the model fit the data well with a nonsignificant chisquared statistic other fit indices corroborated the evaluation of the model as quite good cfi 99 gfi 99 srmr 03 rmsea 08 this evaluation was also supported by the fact that the lagrange multiplier and waldtests for model modification suggested that no paths could be added or removed to improve model fit all parameter estimates were significantly different from zero except for two the first was the parameter estimating the predictive effect of moral conviction on groupbased anger this is consistent with our integrative analysis and more specifically with the idea that the predictive effect of moral conviction on groupbased anger is fully explained by identification with the disadvantaged group this provides evidence for the idea that identification with the disadvantaged group is the psychological basis for groupbased anger among the advantaged the second nonsignificant parameter estimate in the model is the predictive effect of identification with the disadvantaged group on group efficacy this finding is inconsistent with predictions and more specifically with the idea that a stronger group identification raises the efficacy of the group to achieve social change we will return to this unexpected finding in the general discussion to enable a comparison with study 1 we tested a model with identification with the advantaged group at its heart as expected this model fit the data less well than our hypothesized model with a marginally significant chisquared statistic indicating that the hypothesized covariance matrix differed somewhat from the actual covariance matrix other fit indices corroborated this evaluation of the model cfi 95 gfi 98 srmr 04 rmsea 15 both the lagrange multiplier and waldtests for model modification suggested that paths could be added or removed to improve model fit which also suggests that this model is not the best fit to the data thus a model with identification with the disadvantaged group at its core fit the data best discussion the results of study 2 replicated support for the moral motivation hypothesis provided novel support for the identification hypothesis and showed support for the simca hypothesis results suggest that among advantaged group members in a different context than in study 1 moral convictions against social inequality again predicted collective action tendencies through groupbased anger and group efficacy study 2 also replicated study 1 by showing that moral conviction was unrelated to identification with the advantaged group and moved beyond study 1 by showing that moral conviction was positively related to identification with the disadvantaged group indeed together with groupbased anger and group efficacy identification with the disadvantaged group fully explained the link between moral conviction and collective action tendencies structural equation modeling showed that as predicted by simca groupbased anger was based in identification with the disadvantaged group but against predictions group efficacy beliefs were not based in this group identity the integrative model also showed a good fit to the data both studies 1 and 2 thus show that the same psychological variables and processes that simca identifies as key to collective action among the disadvantaged are also important in explaining the motivation to challenge social inequality among the advantaged moreover study 2 suggests that identification with the disadvantaged group is the relevant group identity on which to challenge social inequality in this context general discussion two studies supported simcas extension to collective action against social inequality among the advantaged and its integration with the power of moral convictions to motivate the advantaged to challenge social inequality both studies showed that moral convictions against social inequality at least when violated predict groupbased anger group efficacy beliefs and collective action tendencies on the basis of a relevant social identity results further showed that this relevant social identity was individuals identification with the disadvantaged group our findings thus offer a strong pointer toward the importance of seemingly individualistic moral convictions in explaining collective action among the advantaged importantly our results imply that individuals moral convictions should be taken into account when thinking about social influence attempts to mobilize the advantaged to challenge social inequality below we discuss these and other implications of our findings as well as limitations of the studies and directions for future research theoretical and practical implications our findings support the general idea that there are no necessary qualitative differences between the disadvantaged and the advantaged in terms of the psychological variables and processes that predict their collective action against social inequality indeed groupbased anger group efficacy beliefs and identification with the relevant group all predicted collective action against social inequality these results fit with an accumulating body of work on collective action among the disadvantaged and suggests that integrative models such as simca are appropriate frameworks to compare collective action against social inequality among the disadvantaged and the advantaged however one apparent difference concerns which social identity is the relevant psychological basis for challenging social inequality through collective action for the disadvantaged group the relevant social identity is the disadvantaged ingroup identity or the more specific social movement organization that fights for the groups interests by contrast for the advantaged group the results of both studies show that it is not identification with the advantaged ingroup but with the disadvantaged outgroup that is most relevant for predicting collective action in this sense the apparent difference between the advantaged and disadvantaged is overpowered by a strong commonality for members of both groups collective action against social inequality is predicted by their identification with the disadvantaged group this is consistent with our argument that moral convictions transcend existing group boundaries to the extent that their violation increases identification with the disadvantaged group which according to simca enables collective action against it through groupbased anger and group efficacy it should be noted that our studies did not aim to uncover the exact psychological process that underpins advantaged group members identification with the disadvantaged and hence it is important to compare our line of thought on violated moral convictions with at least three other lines of work 3 first some may wonder how moral convictions are different from injunctive group norms although there are certainly commonalities between the constructs the key difference in our view is that moral convictions proscribe standards for anyone whereas injunctive group norms proscribe standards for ingroup members in particular in this sense we agree with and apply turiels distinction between moral judgments and social conventions in sum the element of moral absolutism is much more essential to the concept of moral conviction than to the concept of injunctive group norms but despite this difference it is also clear that the two are related we believe that injunctive group norms may be an important step toward developing moral convictions such oughts may develop within specific groups but as soon as they acquire the status of moral convictions they transcend group boundaries one of the major questions for future research therefore is when and how this transformation from injunctive group norm to moral conviction takes place in the context of collective action against collective disadvantage second recent work on opinionbased groups which are defined as groups that revolve around a shared opinion and develop through interaction and normative alignment would suggest that the reason why the advantaged identify with the disadvantaged is that their moral convictions represent a community of believers or a moral community that sympathizes with the victims of social inequality in our view the key question here is whether such a moral community is necessary to explain our current results our explanation that violated moral convictions increase identification with the relevant group does not require such a moral community and thus represents a more parsimonious account of our findings the question of how moral convictions relate to opinionbased groups and moral communities is nevertheless an intriguing question for future research finally recent work by subasic and colleagues on political solidarity may suggest that the reason why the advantaged identify with the disadvantaged is that their moral convictions derive from the values and standards of a superordinate social category in line with common ingroup and dual identity approaches subasic and colleagues argue that the advantaged are more likely to display political solidarity with the disadvantaged when they categorize the outgroup as part of a superordinate category that also includes their own group admittedly we did not measure identification with the superordinate category in either study and we thus do not have the data to test the validity of these ideas but a priori moral convictions would not need to be embedded in a hypothetical superordinate category to enhance identification with the disadvantaged our explanation therefore again seems to be more parsimonious of course future research is necessary to provide more conclusive evidence for these interesting ideas across the two studies we encountered only one unpredicted finding that is study 2 showed that identification with the disadvantaged was unrelated to group efficacy beliefs in the light of the large number of correct predictions we do not want to attach too much value to this finding we note in this respect that recent research among the disadvantaged shows that the relationship between group identification and group efficacy may be more complicated than previously thought this work shows that the relationship between these variables is likely due to the causal effect of group efficacy on group identification this implies that this aspect of simca might be in need of some revision although we do not know at present whether these recent results generalize to the advantaged another possibility however is that the meaning of group efficacy beliefs in the context of collective action is even more complicated among the advantaged than among the disadvantaged for the disadvantaged group efficacy beliefs typically refer to the disadvantaged group the advantaged however may be motivated to challenge social equality in part because they believe that the disadvantaged group s efficacy is too low to achieve social change on their own thus the groups efficacy for them might represent the joint forces of the advantaged and the disadvantaged future research can explore this interesting suggestion practical implications practitioners of collective action against social inequality might find simca a useful overarching structure that identifies the key psychological predictors of individuals motivation to challenge social inequality indeed the model suggests that they should try to socially influence individuals sense of group identity groupbased anger and group efficacy this claim is validated by the accumulating evidence for its generalizability across different contexts as well as across disadvantaged and advantaged groups simcas first key recommendation to practitioners is that one needs to focus on individuals as group members indeed increasing the selfrelevance and salience of a social identity is a crucial start to any mobilization campaign on which basis one can try to further increase individuals groupbased emotions and group efficacy beliefs moreover previous and current findings suggest that it is very important to target the relevant group identity as the current work shows the relevant group is not necessarily the ingroup van zomeren postmes and spears proposed in this respect that a strong normative fit between the moral conviction in question and the normative content of a social identity is what makes the identity become selfrelevant and thus a basis for collective action the second key recommendation to practitioners is that one should try to unleash the psychological power of moral convictions against social inequality by communicating the absolute immorality and thus the moral condemnation of their violation indeed those who seek social change should target existing moral convictions about social inequality among the disadvantaged as well as the advantaged this implies that making reference to the absolute nature of their moral convictions about social inequality and the zerotolerance for violations thereof motivates both advantaged and disadvantaged group members to challenge social inequality this might even lead to a coalition of members from both disadvantaged and advantaged groups that unite around a moral conviction against social inequality that increases identification with the disadvantaged group limitations and directions for future research one limitation of the current research is its relatively low internal validity due to the correlational nature of the two studies our theoretical rationale for the hypotheses and the model is based however on a synthesis of many primary studies that view social identity groupbased anger and group efficacy as predictors of collective action this is in part because there is very little evidence available on the consequences of collective action moreover given that moral conviction is treated by definition as an individual difference measure the specific limitation of the current studies is that we cannot be certain that moral conviction feeds into the identity emotion and efficacy variables or vice versa or both this once more calls for future research on the question of how moral convictions develop a second limitation of the current set of studies is that we did not measure actual behavior however there are two reasons to expect that this is not problematic for the interpretation of the results first van zomeren postmes and spears employed such a measure and found that the simca variables explained collective action through individuals collective action tendencies second van zomeren postmes and spearss metaanalysis suggested that although the predictive effects of the simca variables on collective action were smaller than on positive attitudes or intentions toward such behavior these effects were still positive and significant this suggests that using proxy measures such as action tendencies to some extent overestimates the size of the obtained effects but does not invalidate their interpretation we have already noted a number of interesting directions for future research that flow from our current work another promising avenue of research lies in experimentally manipulating moral conviction itself although one might believe that individual difference measures such as moral conviction are hard to manipulate in the laboratory we see great promise in manipulating the absolutist mindset that is so central to the experience of moral conviction preliminary results from our lab suggest that inducing an absolutist mindset indeed increases identification with a relevant group as far as we know this constitutes the first experimental evidence that moral absolutism is directly related to group processes such as identification as such we believe that a more comprehensive and integrative understanding of how seemingly individualistic moral convictions can have collective consequences is within reach in conclusion we proposed in this article that moral convictions against social inequality motivate the advantaged to challenge social inequality because their violation increases identification with the disadvantaged group as a consequence and in line with simca such identification enables individuals from the advantaged group to engage in collective action against social inequality through groupbased anger and group efficacy moral convictions against social inequality are therefore key to predicting and explaining collective action among the advantaged against social inequality notes 1 in both studies we specified the relevant group in the items tapping moral convictions this may constrain our claims about whether individuals moral convictions tap universal beliefs nevertheless at least two of the items focus on whether individuals believe that their opinion should apply anywhere or at all times which in our view is strongly suggestive of the moral absolutism so central to the concept of moral conviction 2 in both studies we decided not to operationalize groupbased anger and group efficacy by referring to a particular group we reasoned that if our argument about moral convictions special link with individuals identification with the disadvantaged group was correct our measure of identification with the disadvantaged group would show a positive relationship with our measures of groupbased anger efficacy and action tendencies results largely supported this line of thought 3 we thank three anonymous reviewers and the guest editor for raising this important point biographical notes martijn van zomeren is associate professor of social psychology at the university of groningen the netherlands his research interests revolve around the psychology of collective action including issues of morality social identity injustice emotions and efficacy tom postmes is professor of social psychology at the university of groningen the netherlands his research interests include intraand intergroup processes such as the formation of social identities russell spears is professor of social psychology at groningen university the netherlands his research interests fall broadly in the field of social identity and intergroup relations karim bettache collected part of the data reported in this article in completing his masters degree his research interests include morality intergroup relations and crosscultural psychology

the literature on collective action mainly focuses on the protests demonstrations and petitions of disadvantaged groups klandermans 1997 van zomeren postmes spears 2008 in press however disadvantaged groups often attract considerable support from members of the advantaged group as wella phenomenon that has only recently become the subject of systematic empirical research eg

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introduction the concept of family functioning can be viewed as the general quality of the family environment and the relationships among its members different family theories such as beavers system theory mcmaster family functioning mode theory and family therapy theories have proposed different but conceptually related dimensions of family functioning for example beavers system theory proposed six dimensions of family functioning including family structure mythology goaldirected negotiation autonomy family affect and global health pathology besides the mcmaster family functioning model theory proposes six dimensions of family functioning such as effective communication clear family roles and appropriate affective responses studies have revealed the positive impact of positive family functioning on the developmental outcomes of children and adolescents such as engagement in learning happiness mental health and proper behaviors to assess family functioning researchers have adopted different assessment methods such as direct observation interviews and selfreported instruments like olsons family adaptability and cohesion evaluation and epstein et al s mcmaster family assessment device in fact selfreported family functioning scales are commonly utilized to examine the perceived family functioning of people as such the development of family functioning measures with sound psychometric properties is of paramount importance for clinical and research purposes however most of the studies are weird studies with data collected from western educated industrialized rich and democratic societies as most of the family functioning measures have been developed in the west researchers have translated and adapted these measures into their local languages like portuguese and german nevertheless other researchers have challenged crosscultural adaptation of these measures because of crosscultural differences such as differences in individualistic versus collectivistic values in different cultures in sumari et al s study the authors found that some factors of their indigenous family functioning scale were the same as those identified in the family assessment device and family environment scale however these factors had different meanings based on malaysian local cultural understanding and interpretations for instance the communication and cohesion factors have the elements of courtesy and tolerance respectively and this reflects the importance of the preservation of family harmony in malaysian collectivistic culture besides other researchers have constructed indigenous measures to assess the perceptions of family functioning in their own countries such as the japanese version of survey of family environment and korean version of family dynamic environment scale with specific reference to mainland china there is rapid growth of family interventions in mainland china the increase in the research on the importance of improving family functions for parents and children has called for the development of validated assessment tools to objectively examine family functioning in mainland china nevertheless there are very few holistic validated family functioning instruments despite the fact that chinese people constitute roughly onefifth of the world population after checking with the psycinfo database using family assessment in abstract in november 2023 we found 27967 records however we found only 32 records of family assessment using family assessment and mainland china and 121 records of family assessment using family assessment and hong kong besides while there are validated translated instruments such as the chinese version of family assessment device some important indigenous concepts of chinese family functioning such as mutuality and avoidance of family conflict are lacking besides although there are some existing chinese family assessment tools most of them are not comprehensive and only assess either family interaction or parenting of chinese families furthermore few studies have examined factorial validity of the different family functioning measures in china responding to this gap based on focus group data and integration with the family science literature shek developed the chinese family assessment instrument to assess the perceived family functioning of hong kong adolescents specifically the data gathered from focus groups with adolescents and their parents illustrated that the absence of conflict family harmony mutuality sense of belonging and good parentchild relationships were regarded as vital elements of a healthy family whereas emotional expression and communication were least emphasized as important constituents of an optimal family past research has revealed that the cfai possesses good reliability and validity in particular the five dimensions of the cfai were validated by exploratory factor analysis and confirmatory factor analysis there was also support for its convergent validity and reliability however the supporting evidence was confined to hong kong in view of cultural disparities between hong kong and mainland china the applicability of the cfai to assess the perceived family functioning of adolescents in mainland china deserves further exploration under the principle of one country two systems hong kong does not possess the same economic and social systems as those in mainland china for example children acting in a nonfilial manner will be publicly sanctioned in mainland china substance abuse in young people is also unique in hong kong besides there are other differences between hong kong and mainland china including hong kong is more individualistic whereas mainland china is more collectivistic hong kong is a capitalistic society whereas mainland china is a socialist society with chinese characteristics mainland china is still more susceptible to traditional chinese values as such exploration of the psychometric properties of the cfai which was originally developed and validated using hong kong adolescents as the sample is warranted for preadolescents and adolescents in mainland china besides there are several gaps in the existing literature in this field first validated family functioning measures in mainland china are very limited second as mentioned above compared to hong kong research on family assessment is relatively inactive in mainland china third there are very few family assessment materials and methods participants and procedures in this study we conducted a 3wave longitudinal research on the psychosocial adjustment of chinese preadolescents and adolescents with data gathered at three different time points a baseline six months later and one and a half years later from the baseline in 2020 there were 623 elementary schools 317 junior secondary schools and 156 schools admitting both elementary and junior secondary students in chengdu all of them were public schools prior to the onset of the covid19 pandemic a cluster sampling method was used to select five schools to participate in this study among these participating schools two were situated in southern suburban areas two were in northern suburban areas and one was in the downtown area in the scientific literature there are studies in which data from elementary and secondary school students are collected in sum a total of 11154 students from five selected schools participated in this study among them 3019 students completed the survey at either one wave 2008 students completed the survey at either two waves and 6127 students completed the survey at all three waves students were asked to answer an identical questionnaire containing a chinese family assessment instrument in class during the survey for primary school students the questions on the questionnaire were read aloud to the students item by item by the class teacher in each class this practice is commonly used in similar studies in the field as such the class teacher could help clarify any misunderstandings when asked questions by students for high school students students read the questions and responded to the questions on their own before starting the survey we got consent to take part in the survey from parents and students in addition to ethics permission for research from sichuan university moreover some vital principles such as anonymity and voluntary participation were told to students after the survey students data at 3 waves were matched to understand the research questions for students in the period of preadolescence and early adolescence we primarily examined the responses given by students aged 10 and above in the matched sample aged 10 and above there were 1938 primary school students at wave 1 there were 1794 high school students at wave 1 instrument the students responded to a questionnaire assessing psychosocial adjustment in children and adolescents it contains a 33item chinese family assessment instrument which has been employed to investigate the perceived family functioning of chinese adolescents it has five dimensions including mutuality communication harmony and conflict parental concern and parental control these five dimensions encompass the primary characteristics of positive family functioning in chinese families involving absence of conflict mutuality and effective communication among family members in addition to favorable parentchild and spousal relationships students responses were assessed using a 5point scale all positively worded items were reverse coded as such an item score and the level of functioning of chinese families was positively correlated cfai has been found to be a valid and reliable tool for assessing family functioning in past studies using hong kong adolescents besides the chinese family assessment scale three additional items were employed to evaluate the convergent validity of the cfai mutual support among family members degree of understanding of family members regarding the situations of each other and relationship between the participant and hisher caregivers students were asked to respond to the first two questions along a 6point scale and along a 10point scale for the last question moreover three additional items theoretically unrelated to family functioning were added to assess the discriminant validity of the cfai involving the items measuring the amount of time for sleeping and doing exercise and the amount of sweet drink students take in per weekmonth in the literature researchers have used this approach to assess the discriminant validity of a measurement instrument data analysis in this study we performed confirmatory factor analysis and measurement invariance tests to assess the factorial validity convergent validity discriminant validity and reliability of the cfai and its stability across groups and over time cfa and mi tests were conducted using structural equation modeling techniques via lisrel 854 parameters were estimated by utilizing maximum likelihood estimation and robust maximum estimation methods rml was chosen because it could reduce standard errors of the estimates caused by the violation of multivariate normality of the data convergent and discriminant validity of the cfai were assessed using pearson correlation with the aid of spss 260 the present investigation implemented five sequential steps first cfa was performed to assess the factor structure of the cfai using three waves of data individually as stated by brown the factor model of the cfai fits the data adequately when the values of the standardized rootmeansquare residual and the rootmeansquare error of approximation are less than 008 and the values of the nonnormed fit index and the comparative fit index are more than 090 second after identifying the factor structure of the cfai and establishing its factorial validity we assessed the stability of the factor structure of the cfai across groups initially the total sample at each wave was randomly divided into two subsamples based on cases multigroup confirmatory factor analysis was then used to assess the measurement invariance of the cfai across subsamples at each wave following the steps outlined by dimitrov the levels of measurement invariance were assessed in the following order separate groups configural invariance weak measurement invariance strong measurement invariance and strict measurement invariance these steps are commonly followed when testing the measurement invariance of a scale hence a series of models ranging from least restrictive to most restrictive models were compared at the beginning a fivefactor model of the cfai was assessed separately for each group then the fivefactor structure of the cfai was evaluated simultaneously across groups to establish configural invariance in the analysis the models were specified with no restriction in factor loadings intercepts and uniqueness of the corresponding indicators between groups afterwards weak measurement invariance was examined with the same models of configural invariance except the equality of factor loadings was imposed between the corresponding indicators of both groups later strong measurement invariance was investigated with the same models of weak measurement invariance except the equalities of factor loadings and intercepts were imposed between the corresponding indicators of both groups finally strict measurement invariance was examined with the same models of strong measurement invariance except the equalities of factor loadings intercepts and uniqueness were imposed between the corresponding indicators of both groups after establishing measurement invariance of the cfai structural invariance of the 5factor correlated model of the cfai was further explored by testing invariance in factor variances and factor covariances of the cfai model invariance in factor variances was examined with the same models of strict measurement invariance except the equalities of factor loadings intercepts and uniqueness were imposed between the corresponding indicators and the equality of variances between corresponding factors was imposed between corresponding factors of both groups furthermore invariance in factor covariances was assessed with the same models of factor variances invariance except the equalities of factor loadings intercepts and uniqueness were imposed between the corresponding indicators and the equalities of variances and covariances were imposed between corresponding factors of both groups for each form of factorial invariance the model was compared with the model that preceded it as chisquare difference tests tend to reject the null hypothesis of no difference between two nested models in large samples even though the difference is trivial changes in cfi and rmsea values were also commonly used to assess model fit for the factorial invariance of the cfai an acceptable model fit for more restrictive invariant models is based on the change in cfi value that is not more than 0002 and the change in rmsea value that is not more than 001 third after confirming the stability of the factor structure of the cfai across groups we further tested whether the factor structures were stable across time identical factor analytic procedures and criteria for the fit of invariant nested models mentioned above were conducted to assess the stability of the factor structure across three waves of data with autocorrelation of uniqueness specified among same observable indicators in wave 1 wave 2 and wave 3 fourth apart from investigating the factorial validity and invariant properties of the cfai we also assessed the convergent and discriminant validity of the cfai the convergent validity of the cfai is demonstrated when the average variance extracted for each factor at all waves was more than 050 it means that each construct explained more than 50 of the total variance in their respective indicators and hence the convergent validity of the 5factor structure of the cfai was supported besides the convergent validity frontiers in psychology 05 frontiersinorg of the cfai was illustrated when the total score of the cfai is correlated significantly and substantially with the scores of three conceptually related items in the questionnaire including there is mutual support among family members family members know to understand the situations of each other and relationship between you and caregivers on the other hand the discriminant validity of the cfai was illustrated when the total score of cfai did not show any substantial correlation with those of items unrelated to the measurement of family constructs such as the items tapping the amount of time for sleep and doing exercise and the amount of sweet drink the participants take in per week and month this approach was adopted in previous studies to examine the convergent and discriminant validity of a measure lastly we examined the reliability of the cfai using composite reliability in which the acceptable value for it is 070 and above moreover we utilized cronbachs alphas and mean interitem correlations of the cfai to further examine the internal consistency reliability of the subscales and the total scale of the cfai a value of cronbachs alpha greater than 07 indicates acceptable reliability while the value of mean interitem correlations inbetween 03 to 07 illustrates adequate internal consistency of the scale results descriptive statistics means standard deviations skewness and kurtosis of each item of the cfai were assessed the range of mean and standard deviation was 344449 and 094151 respectively all items were normally distributed because the absolute values of univariate skewness and kurtosis values were not more than 2 and 7 respectively factorial validity of cfai table 1 summarizes the results of cfa according to the sample at wave 1 wave 2 and wave 3 the findings of this study illustrated that the fivefactor correlated model of cfai with four error covariances fitted the data of each wave adequately nevertheless it is noteworthy that the rmsea and srmr values in the model of each wave represented fair fit only although nnfi and cfi indices illustrated good fit apart from two items which had the loadings less than 034 factor loadings of all other items were higher than 040 and significant at 005 level as such hypothesis 1 was supported multigroup invariance across subsamples a series of invariance tests were conducted across two subsamples at each wave to assess multigroup invariances of the cfai as indicated in table 2 the fivefactor correlated model of the cfai showed an acceptable fit to the data of the subsamples at each wave with nnfi and cfi values ranging from 093096 and 094097 respectively as such a series of factorial invariance tests were conducted across two subsamples in each wave of data subsequently as the result of the chisquare difference test is too sensitive to large sample size a practical approach was adopted for demonstrating the measurement invariance property of the cfai in the present study the findings of this study revealed equivalent fit indices between all pairs of the more restrictive model and the comparison model since changes in cfi and rmsea values were less than the cutoff values of 0002 and 001 respectively as such cfai is measurement and structural invariant across subsamples of three waves of data multigroup invariance of the cfai was confirmed and hypothesis 2 was supported specifically the most restrictive model of the cfai supposing equality in factor loadings intercepts uniqueness of indicators factor variances and covariances illustrated fair fit indices at wave 1 to wave 3 in spite of good fit demonstrated by nnfi and cfi indices longitudinal invariance across time after confirming the multigroup invariant property of the cfai its longitudinal invariance was further explored as the fivefactor correlated model of the cfai demonstrates an acceptable fit to the data of each wave a series of measurement invariance tests were conducted over three waves of data subsequently to investigate the longitudinal invariance of the cfai in table 3 model 1 demonstrated a good fit to the observed data suggesting the generalizability of the factor structure of the cfai over time then a more restricted model for assessing the weak measurement invariance of the cfai was performed in model 2 factor loadings were specified to be the same across three waves of data as the change in both cfi and rmsea values between model 1 and model 2 were less than 0002 the weak measurement invariance of the cfai was supported given all factor loadings of items were invariant strong measurement invariance of the cfai was examined in this form of invariance test factor loadings and intercepts were specified to be equal across three waves of data in model 3 since there was no change in cfi and rmsea values between model 2 and model 3 the strong measurement invariance of the cfai was also supported given all factor loadings and intercepts of items were invariant strict measurement invariance of the cfai was examined in this form of invariance test factor loadings intercepts as well as uniqueness of indicators were constrained to be identical across three waves of data as the change in cfi values between model 3 and model 4 was 0003 which was greater than the cutoff value of 0002 the strict measurement invariance of the cfai was not supported in sum the findings of this study indicate that the factor structure of the cfai remained consistent across time demonstrating longitudinal invariance additionally latent means could be compared without bias this confirmed hypothesis 3 in sum cfai has good factorial convergent and discriminant validity regarding convergent and discriminant validity of the cfai the findings revealed that the average values of ave for all factors across three waves ranged from 053 to 061 which were higher than the cutoff value of 050 in addition the total score of family functioning correlated significantly and substantially with three conceptually related indicators in each wave of data including there is mutual support among family members family members know to understand the situations of each other and relationship between you and caregivers as 6 on average how much sweet drink do you take in per week month 016 012 017 the correlation coefficient inside the bracket is insignificant such hypothesis 4 was supported and the convergent validity of the cfai was demonstrated regarding discriminant validity of the cfai the findings revealed that the total score of family functioning did not correlate substantially with other three conceptually unrelated indicators including amount of sleep per day amount of time for doing exercise per day and on average the amount of sweet drink which you take per week month consequently hypothesis 5 was supported and discriminant validity of the cfai was confirmed reliability table 5 illustrates the reliability of five subscales and the total scale of the cfai the findings of this study showed that the composite reliability of the subscales and the total scale ranged from 072097 at wave 1 074097 at wave 2 and 075097 at wave 3 they illustrated that the cfai was reliable the reliability of the cfai was further supported by cronbachs alpha and mean interitem correlations as such hypothesis 6 was supported in sum the factorial convergent and discriminant validity as well as the reliability of the cfai were confirmed in addition longitudinal and multigroup invariance of it were evident as such cfai is a psychometrically sound measure to investigate adolescents perceived family functioning in mainland china discussion this study aimed to examine the factor structure convergent validity discriminant validity and reliability of the cfai as well as its invariance across subsamples and time among children and adolescents residing in mainland china one of the primary features of this work was its use of a longitudinal research approach with a large sample size to perform a construct validation study of the cfai as such the stability of the factor structure of the cfai over time was explored it is important because the longitudinal invariant property of the cfai is largely neglected in previous studies using family functioning measures besides apart from adopting rml estimation to address multivariate nonnormality of the data this study recruited a large sample for investigation this would lower standard errors of the estimates and hence enhance the accuracy and credibility of the findings in addition as most of the selfreported family functioning measures focus on adults instead of children and adolescents this study provided empirical support for the usefulness of the cfai to assess subjective family functioning among preadolescents and adolescents in mainland china in response to the question about the factor structure of the cfai among preadolescents and adolescents in mainland china our findings offered empirical support for the fivefactor structure of the cfai hence supporting hypothesis 1 it echoes the findings of siu and sheks and shek and mas study which revealed the same factor structure of the cfai among adolescents in hong kong as stated by cultural atlas editors even though there are some social and cultural differences between people in hong kong and mainland china confucianism still serves as the foundation of the cultural roots of people in both places some important confucian values such as filial piety are still prevalent among children and adolescents which in turn determine their perceptions of a good and healthy family for instance under the filial piety tradition children and adolescents will follow and respect their parents while parents will take care of and accept their children as such family harmony would be preserved by developing mutuality among family members moreover as the dimensions of the cfai identified in this study have high similarity to three important dimensions of family functioning in western studies which are cohesiveness communication and flexibility these three aspects of family functioning seem to be universal across both western and chinese cultural contexts nonetheless similar to the findings using hong kong adolescents the conflict and harmony dimension identified in this study reflects that the absence of conflict is also viewed as an important element of a good family for children and adolescents in mainland china in addition parental concern and parental control factors are associated with the functioning of parents which in turn reflects the significant role of parents in determining the functioning of families in mainland china in sum as stated by wong et al there are two perspectives to conceptualize family functioning including processoriented and resultoriented perspectives the former perspective classifies families into different kinds based on the features of the family annular mode model of family functioning while the latter perspective is mainly concerned with the essential components for the development of healthy families mcmaster family functioning model the dimensions of the cfai involve both resultoriented and processoriented elements which would offer holistic insights into the development of positive family functioning in mainland china for the second research question our findings supported hypothesis 2 that the dimensions underlying the cfai were invariant across random subsamples it is consistent with the findings of shek and mas study which illustrated strong measurement invariance of the cfai across subsamples based on case numbers however the results of this study offered additional empirical evidence in support of the strict measurement invariance and structural invariance of the cfai across random subsamples these findings suggest two random subsamples have same interpretations of cfai items and the factor and observable means of the level of family functioning between two subsamples could be compared without bias moreover the relationships among the five factors of the cfai were equally applied to two subsamples as such two subsamples have the same conceptual understanding of the areas of functioning in chinese families for example the mutuality and communication factors would be highly correlated because effective communication among family members would promote their mutuality the findings of this study indicate that the factor structure of the cfai remained consistent throughout time hence providing support for hypothesis 3 this finding provides evidence for the longterm stability of the cfai please be advised that the use of cfai has been observed in longitudinal research conducted with teenagers in mainland china the longitudinal invariant property of the cfai has not been well addressed the strict longitudinal invariance of the cfai found in this study adds to the extant literature and supports the fact that the cfai assesses the same family functioning construct at different points of time as such cfai could be used to assess agevarying changes in the subjective family functioning of chinese people from childhood to adolescence to adulthood especially during the period of adolescence in which teenagers may have negative relationships with parents in addition as mentioned in the review article by dai and wang research on the development of family functions at different periods during the life of a family is very limited cfai would be a promising family functioning measure to address this gap and assess changes in the functions of a family over the life course apart from supporting the factorial validity of the cfai the construct validity of the cfai was further confirmed by establishing its convergent and discriminant validity regarding the fourth research question the present results revealed substantial correlations between the total score of the cfai and the measures of family support hence supporting hypothesis 4 convergent validity of the cfai was confirmed the results of gaspar et al s research align with the findings presented here demonstrating a significant positive association between parental emotional support and family functioning among a sample of 1757 parents from portugal besides the present results did not reveal substantial associations between the total score of cfai and theoretically unrelated constructs and thus supported hypothesis 5 as such discriminant validity of the cfai was also confirmed as stated by strauss and smith construct validity of a measure is commonly regarded as a unifying form of validity for psychological measurements and hence encompasses cumulative sources of evidence supporting specific interpretations of a score from a measure the establishment of the convergent validity lastly the findings of this study illustrated acceptable reliability of the total and subscale measures of the cfai hence supporting hypothesis 6 it is consistent with the findings of hu et al s and lam and chens study which showed the total scale of the cfai and its subscales were reliable in sum cfai is a valid and reliable measure of perceived family functioning among children and adolescents in mainland china it is a stable family functioning instrument that would be utilized to compare the latent means between groups and detect the changes of latent means across time implications theoretically this study provided empirical support to an indigenous conceptualization of family functioning in the chinese context as stated by dai and wang theoretical models of family functioning in china are mainly focused on translated literature and the westerndeveloped models may not be culturally appropriate in the chinese culture therefore the development of unique chinese family functioning models is of paramount importance hence the study is an innovative attempt using rigorous conceptual arguments and research methods this study also paves the way for the development of more sophisticated family functioning models for chinese people basically family functioning theory is classified into two categories in the west the first one is resultoriented family functioning theory which defines family functioning by special features of the family such as family intimacy and family communication styles another one is processoriented family functioning theory which describes family functioning in terms of tasks families need to complete such as affective involvement and behavior control of the child in the family literature review has illustrated that a theoretical model of family functioning with both resultand processoriented elements is very rare however the conceptual model underlying the cfai is composed of both resultoriented elements and processoriented ones this conceptual model of family functioning would add to the literature and serve as an innovative reference model to facilitate the crosscultural examination of family functioning in different cultural contexts practically cfai would serve as a psychometrically sound family functioning instrument to identify family problems and hence support clinical practices in mainland china and hong kong in light of the increase in family problems youth education problems and psychological problems in mainland china in recent years the demand for family therapy and intervention has been raised by leaps and bounds as such the provision of family therapy and intervention has been greatly increased nevertheless quek and chen commented on the applicability of westernbased family therapy approaches and screening instruments to the chinese context as cfai has been developed in the chinese context it could be utilized to conduct family functioning research in mainland china and hong kong appropriately in fact hu et al have already utilized the cfai to identify families with different levels of family environment dysfunction and subsequently explored the effects of the family environment on nonsuicidal selfinjury among secondary school students in mainland china cfai would be used to help counselors and family therapists to identify the problematic areas of family functioning in an unhealthy family and subsequently provide appropriate intervention and treatment to clients in addition as the current findings illustrated that the cfai exhibited favorable psychometric properties it could be utilized as an objective reference tool in future studies on family functioning within various asian contexts thereby contributing to the broader international research landscape limitations there are certain limitations of the study first we only used threewave data to assess longitudinal invariance of the cfai to delineate a holistic picture of measurement invariant property of the cfai over time future research should aim to collect more waves of data over an extended period of time second multigroup invariance of the cfai was assessed using random subsamples only as family functioning has been found to be associated with gender and family ses of the participants future research should explore whether the cfai is invariant across gender and family ses among children and adolescents in mainland china third the study sample was limited to preadolescents and adolescents residing in chengdu although studies focusing on a single province have been conducted it is necessary to replicate the generalizability of the current findings across diverse populations in various regions of china conclusion this innovative study aimed to examine the factorial validity convergent validity discriminant validity reliability and measurement invariance of the cfai in preadolescents and adolescents in mainland china based on rigorous conceptual arguments and utilizing advanced research design and methods the results of this study provided support for all kinds of validity of the cfai and its multigroup and longitudinal invariance as such we conclude that cfai is a valid and reliable tool to assess perceived family functioning among children and adolescents in mainland china the present findings provide support for an integrated indigenous chinese model of family functioning besides in view of its sound psychometric properties the practical significance of the findings is that family practitioners and researchers can utilize the cfai to identify different problematic areas of the functioning in chinese families and implement effective intervention and treatment to their clients data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation shek et al 103389fpsyg20231290224 frontiers in psychology 11 frontiersinorg ethics statement the studies involving humans were approved by ethics research committee of sichuan university the studies were conducted in accordance with the local legislation and institutional requirements written informed consent for participation in this study was provided by the participants legal guardiansnext of kin funding the author declare financial support was received for the research authorship andor publication of this article the study and this article are financially supported by wofoo endowed professorship as well as the matching fund from the hong kong polytechnic university and research grants council 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

regarding the assessment of family functioning in chinese people there are several research gaps first although there are some instruments in the field there are very few validated instruments second while some translated measures have been developed there are very few assessment tools based on indigenous chinese concepts third compared to hong kong research on family assessment is relatively inactive in mainland china fourth there are very few family assessment tools to assess perceived family functioning in older children and early adolescents fifth few studies used large samples to validate family assessment tools sixth researchers seldom utilized longitudinal data to examine the psychometric properties of family assessment tools finally few studies have examined factorial validity across samples and time to demonstrate the stability of chinese family assessment measures in hong kong based on focus group data ie indigenous concepts of family functioning and an integration with the family science literature we have developed the chinese family assessment instrument cfai to assess perceived family functioning according to the perception of adolescents results showed that the cfai possessed good reliability and validity specifically five dimensions of the measure mutuality communication conflict parental concern and parental control were supported via exploratory factor analysis and confirmatory factor analysis convergent validity and reliability of the cfai were illustrated to understand the psychometric properties of the cfai in mainland china we collected three waves of data from students in the period of preadolescence and early adolescence in mainland china n 3732 based on the data we examined the psychometric properties of the measure particularly factor invariance in different samples and at different times confirmatory factor analysis provided support for the five dimensions in cfai including factorial invariance in terms of configuration factor loading intercepts and over time there was evidence for convergent validity and discriminant validity of the measure finally reliability analyses showed that the total cfai scale and its subscales are internally consistent the present findings suggest that family researchers and practitioners can use the cfai to objectively assess perceived family functioning in preadolescence and early adolescence in different chinese communities

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background uganda is a lowincome country with one of the highest prevalence rates of hiv worldwide 1 it is estimated that 130000 children under the age of 14 in uganda were living with hiv in 2016 2 although the development of antiretroviral therapy has made hiv a manageable chronic illness 3 adherence to art needs to reach 95 in order to reach the desired treatment outcomes 45 however research shows that art adherence level in uganda is still low among people living with hiv with only 66 reporting the desired adherence outcomes 6 moreover in rural areas adherence rates are much lower with only 55 adhering to their medication 7 furthermore the art coverage for children in uganda is estimated to be only 47 of the target population 8 yet low art adherence can result in increased viral duplication rapid disease progression reduced life quality and even premature mortality 9 therefore suboptimal art adherence among children in uganda is an urgent health issue that needs to be addressed against this backdrop this study examines family factors that impact art adherence selfefficacy among perinatally hivinfected adolescents in southern uganda so that more targeted interventions can be put in place to improve art adherence medication adherence and selfefficacy in the context of hiv art adherence is defined as the degree to which an individual adheres to taking the prescribed antiretroviral drugs 4 observable art adherence levels depend on a range of factors 10 including selfefficacy ie the persons perception of their own ability to accomplish a behavioral task 11 which influences a persons development or maintenance of a health behavior at the affective cognitive and motivational levels 12 more specifically adherence selfefficacy defined as the confidence in ones ability to adhere to treatment plans has been documented as an important predictor of medication adherence in the treatment of hiv and other medical conditions 13 for example an individual who feels able to successfully fulfill medication regimes as prescribed in addition to following a specified diet as well as executing recommended lifestyle changes 14 will be more likely to achieve positive health outcomes moreover individuals tend to be more motivated if they perceive that their actions can be completed 15 indeed adherence selfefficacy has been linked to positive outcomes among patients with hypertension 16 asthma 1718 diabetes 1920 pain management 21 and depression 22 among plwh selfefficacy has been corelated with adherence outcomes 23 24 25 26 27 28 29 for example a metaanalysis examining the predictors and correlates of art adherence found that adherence selfefficacy was positively associated with the initiation and maintenance of art adherence 23 in another study in south africa a strong association between selfefficacy and art adherence was found in the nonadherent participants explaining 98 of the variance 24 in the united states and puerto rico nokes and colleagues 25 found adherence selfefficacy to be a robust predictor of art adherence and a mediator between environmental influences and cognitive or personal factors however few of these studies have been conducted in ssa and none have focused on children and adolescents living with hiv 24 yet for children who depend on their caregivers to meet their adherence expectations it is important to examine and understand their cognitive and motivational influences affecting medication adherence including selfefficacy social support and adherence several studies have documented the role of social support especially from family members in influencing adherence outcomes 30 31 32 33 34 35 36 37 38 for example a metaanalysis of studies examining social support and patient adherence to medication showed that art adherence was 174 times higher in patients from cohesive families and 153 times lower in patients from families experiencing conflict 30 in uganda family cohesion and social support from caregiversfamily were associated with selfreported adherence to art among hivinfected adolescents 31 in another study examining the benefits of family and social relationships for health and mental health of plwh family functioning significantly contributed to art adherence and quality of life 32 thus strengthening positive family support and minimizing negative family interactions are crucial for increasing adherence rates 33 despite the unique developmental needs of children and adolescents few studies have specifically focused on family systems among hivinfected children and adolescents in ssa 313435 moreover these studies do not explicitly explore the relationship between family support and adherence selfefficacy two factors that are critical to hiv management and adherence to treatment protocols among plwh including children and adolescents 36 thus to bridge this gap this study examines whether family factors such as family cohesion childcaregiver communication and perceived childcaregiver support are associated with art adherence selfefficacy among hivinfected adolescents in southern uganda we hypothesize that these family factors will be positively associated with positive art adherence selfefficacy levels over time methods study sample and context this study utilized data from the suubiadherence study a longitudinal randomized clinical trial funded by the national institute for child health and human development the suubiadherence study examined an innovative familybased economic empowerment intervention on art adherence among perinatally hivinfected adolescents in southern uganda a region heavily affected by hivaids uganda has a national hiv prevalence rate of 73 among adults aged 1549 with higher prevalence rates of 12 in the southern region where the study was implemented 1 the suubiadherence study followed 702 hivpositive adolescents between 2012 and 2017 participants were identified and recruited from health clinics in the greater masaka region associated with reach the youth uganda and the masaka diocese all health clinics were accredited by the uganda ministry of health to provide art to all adolescents living with hiv in the region the inclusion criteria for these adolescents were 1 1016 years old 2 hivpositive and know their hiv status 3 prescribed antiretroviral therapy 4 living within a family not an institution and 5 enrolled in one of the 39 health centers or clinics in rakai masaka lwengo lyantonde bukomasimbi and kalungu districts in the study area detailed information on participants recruitment and selection process as well as the study intervention is described in the study protocol and in our other publications 3738 data collection data were collected using a 90min interviewer administered survey at baseline 12 24 36 and 48months post baseline survey instruments and all research related documents were translated into lugandathe most widely spoken language in the study regionand back translated into english to ensure accuracy this process was overseen by certified language experts at the makerere university in uganda all interviewers completed the collaborative institutional training initiative certificate and nih certificate for protection of research participants prior to participant contact in addition the study team received training on good clinical practices so that sensitive research activities were handled appropriately details on data protection are provided in the study protocol 37 measures the dependent variable in this study is adherence selfefficacy assessed by the hiv treatment adherence selfefficacy scale 13 the scale measures adolescents confidence in integrating prescribed art plan into their routine life and maintaining optimal adherence levels the scale was previously tested among people living with hiv in the southern region of uganda with a high reliability score 39 there are nine integration questions such as in the past month how confident have you been that you can stick to your treatment plan even when side effects begin to interference with daily activities and three perseverance questions such as in the past month how confident have you been that you can continue with the treatment plan your physician prescribed even if your tcells drop significantly in the next three months the rating range is between 1 and 10 with a higher rating representing higher levels of adherence selfefficacy the scale has a high reliability family support factors were measured by three indicators 1 family cohesion 2 perceived childcaregiver support and 3 childcaregiver communication all adapted from the family environment scale 40 and the family assessment measure 41 all these measures were tested in our previous studies in uganda among children affected by hivaids 31 42 43 44 family cohesion was assessed by an 8item scale that measures the degree of commitment help and support family members provide for one another participants were asked to rate how often each item occur in their family on a 5point scale sample items include family members ask each other for help before asking nonfamily members and family members like to spend free time with each other the scale had a strong internal consistency summary mean scores were created with higher scores indicating high levels of family cohesion the perceived childcaregiver support scale assesses social support on two dimensions acceptance and warmththe extent to which the child perceives the caregiver as involved in their life and psychological autonomythe extent to which the caregiver employs a noncoercive democratic discipline and encourages the child to express individuality within the family participants were asked to rate the adults they live with on each of the 18 items on a 5point scale sample items include child can count on parentguardian to help in case of a problem and parentguardian explains why they want the child to do something summary mean scores were created with higher scores indicating high levels of perceived childcaregiver support the childcaregiver communication scale assesses discussions between the child and the caregiver on 12 items related to issues such as puberty cigarette smoking sexual risk taking puberty hivaids educational plans etc participants were asked to indicate how often they discussed the specific topics with their caregivers on a 5point likert scale summary mean scores were created with higher scores indicating high levels of childcaregiver communication control variables included in the analysis were participants gender age total number of people in the household total number of children in the household primary caregiver school enrollment hiv disclosure status to other individuals other than the primary caregiver medication regimen and study condition analysis procedures all analyses were conducted using stata version 15 bivariate analyses were conducted on baseline sociodemographic and household characteristics adherence selfefficacy and family support factors baseline results were compared between the control and treatment conditions multilevel analysis was used to examine the relationship between adherence selfefficacy and family support factors over time based on the formula yij ¼ β0 þ β 1 x 1 ij þ β 2 x 2 ij þ β 3 x 3 ij⋯ þ β p x p ij þ ξij where β0 is intercept x2ij through xpij are covariates and ξij is a residual the models were built with mixed command using vce option in stata that has the advantage that the estimated standard errors are valid even if the level1 errors are heteroskedastic or autocorrelated 45 this method was used to study adherence selfefficacy over time personlevel 2 characteristics that influence initial adherence selfefficacy and change over time this approach did not require individuals to have equal numbers of measures and can handle both time invariant and timevarying covariates first the analysis started with building unconditional threelevel model to determine betweenperson and withinperson variability in adherence selfefficacy scores second level1 family factor variables were added to the unconditional model like for many other psychological constructs that lack a clearly interpretable or meaningful zeropoint 46 we used centered within cluster variables to establish a useful zero point 47 to accommodate possible endogenous timevarying covariates that are correlated with the randomintercept ζj the model was fitted allowing for different within and between effects for timevarying covariates by including both subjectmean centered and the occasionspecific deviations from the subject means as the subjectmean centered covariates are uncorrelated with ζj by construction and the corresponding coefficients could be consistently estimated 45 finally we fitted the model with all the control variables statistical significance was determined at the 5 level that they never keep their hiv status a secret however about the same number of adolescents reported that they always keep their hiv a secret the majority of participants had to take their hiv medication at least twice a day in terms of family support factors participants reported moderate levels of communication with their caregivers and perceived childcaregiver support higher levels of family cohesion were reported with mean score of 318 adolescents reported higher levels of adherence selfefficacy with an average score of 9428 no statistically significant differences were observed between the control and treatment conditions table 2 presents results from a multilevel unconditional model conducted to determine betweenperson and withinperson variability in adherence selfefficacy scores the variance in adherence selfefficacy over time for each child was 3917 explaining 83 of total variance the variance of the true selfefficacy averaged over time was 793 while variability of clinic means around the grand mean was only 275 the intraclass correlation for individual level was 0173 and 0006 at the clinic level the likelihood ratio test indicated that there was evidence that using a random intercept model could explain the variance in adherence selfefficacy even in the absence of any covariates 15304 p 0000 further analysis showed that there was no significant difference between 3level and 2level models 165 p 0198 thus analysis was continued with exploring 2level models table 3 presents results from the multilevel model with sociodemographic and household characteristics participants age was statistically associated with adherence selfefficacy in addition hiv status disclosure whether sometimes or always was also associated with adherence selfefficacy group assignment was not significant the overall model was statistically significant 842 p 0000 the variability of selfefficacy over time for each child slightly decreased to 3898 from 3911 and variance of the true selfefficacy averaged over time also slightly decreased to 627 from 643 table 4 presents results from the full multilevel analysis models conducted to determine the association between family factors and adherence selfefficacy controlling for sociodemographic and household characteristics family cohesion and childcaregiver communication were both positively associated with adherence selfefficacy perceived childcaregiver support was not statistically significant the entire model was statistically significant 17729 p 0000 in comparison to the previous model with sociodemographic and household characteristics only the variability in adherence selfefficacy changed even more specifically over time selfefficacy for each child decreased even more to 3843while variance of the true selfefficacy averaged over time decreased to 539 indicating that family factors can play significant role to define adolescents adherence selfefficacy discussion this study examined the family factors associated with art adherence selfefficacy among hivinfected adolescents in southern uganda findings from our study indicate that family cohesion and communication represent emotional support from family members towards hivinfected adolescents and is felt by adolescents through daily communication and care expressed by family members although adolescence involves developing independence as a developmental stage the supportive relationships and connections with family and caregivers continue to be protective factors specifically for hivinfected adolescents family is the primary source of financial physical and emotional support moreover most adolescents rely on their family members especially caregivers to access hiv care and help administer medication regimes 4849 as such family members assistance in helping with hivrelated concerns or problems encountered by adolescents can contribute to improving adolescents selfefficacy in integrating treatment plans into their daily routines this finding underscores the protective role of family and provides further evidence for transitioning from individualbased to familyfocused health interventions orphanhood status was not associated with adherence selfefficacy this finding somewhat deviates from past research in other subsaharan african countries which showed that orphaned children were more likely to be art nonadherent 5051 one possible explanation for this finding could be that given that all adolescents included in this study were living within a family they were already being supported by family members to access and adhere to their medication regardless of their biological relatedness this finding also points to the fact that extended family networks in uganda are very supportive which is in line with the cultural norms where the extended family is expected to assume caregiving responsibilities following parental death 42 lastly this study substantiates for the reasonable application of adherence selfefficacy concept and social cognitive theory in art adherence the study findings respond well to the reciprocal determinism of social cognitive theory and highlight family cohesion and childcaregiver communication as significant environments for improving art adherence among hivinfected adolescents in lowresource communities even with these findings a few limitations are worth pointing out with a general aim to explore the outcomes of the suubiadherence study this study examined adherence selfefficacy rather than participants art adherence theoretically adherence selfefficacy is an important determinant of art adherence behavior however it may not reflect the actual behavioral outcome 52 in addition family is an emotional unit that profoundly influences its members thoughts and actions but the dynamics between individuals and their family systems are complicated although we examined family cohesion and childcaregiver relationship in this study further research using systems thinking to demonstrate how the suubiadherence project can contribute to adherence selfefficacy improvement through enhancing protective functions of family is needed conclusion study findings underscore family as a microsystem for hivinfected adolescents in southern uganda that provides both tangible and emotional support to enhance adherence selfefficacy family cohesion a composite concept representing family closeness and functioning as well as communication are both positively associated with adherence selfefficacy hence our findings provide further evidence to consider including familiesbiological and extendedand targeting family cohesion in interventions aiming at increasing art adherence among hivinfected adolescents especially in subsaharan africa abbreviations art antiretroviral therapy plwh people living with hiv ethical approval and consent to participate participation in the suubi adherence study was voluntary all caregivers provided written consent for their children to participate in the study similarly all adolescents provided written assent to participate obtained separately from their caregivers to avoid coercion the study received institutional review board approval from columbia university from the uganda national council for science and technology and from the makerere university school of public health higher degrees research ethics committee the study is registered in the clinical trials database consort the study adheres to the consort guidelines full study protocol authors contributions pn and bc wrote the manuscript cd managed the study data and dd led the data analysis process fms wrote the grant and obtained funding for the study osb and fms reviewed the manuscript for intellectual content and made significant additions to the manuscript all authors read and approved the final manuscript funding the suubi adherence study was funded by the eunice kennedy shriver national institute for child health and human development nichd had no role in the study design data collection analysis interpretation of findings and preparing this manuscript the content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the nichd or nih competing interests the authors declare that they have no competing interests

background adolescents living with hiv in subsaharan africa are a vulnerable group at the intersection of poverty and health disparities the family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy art adherence in this study we explore the association between family factors and art adherence selfefficacy a significant psychological concept playing a critical role in art adherence methods data from an nihfunded study called suubi adherence an economic empowerment intervention for hiv positive adolescents average age 124 years in southern uganda was analyzed we conducted multilevel regression analyses to explore the protective family factors measured by family cohesion childcaregiver communication and perceived childcaregiver support associated with art adherence selfefficacythe average age was 124 years and 564 of participants were female the average household size was 57 people with 23 children 18 years controlling for sociodemographic and household characteristics family cohesion β 0397 p 0000 and childcaregiver communication β 0118 p 0026 were significantly associated with adherence selfefficacy to artfindings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence selfefficacy among adolescents living with hiv trial registration this trial was registered with clinicaltrialsgov registration number nct01790373 on 13 february 2013

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direct engagement with communities is a vital learning experience for students students gain knowledge and learn skills relating to curricular objectives through community engagement a social learning approach stresses facilitating opportunities for students to work with practitioners for learning the norms routines and latest practices of a professional field some recent pedagogical studies in mass communications suggested that service learning could help develop future journalism curriculum madison applied social learning to journalism practicum pedagogy this article argues that neither a service learning nor a social learning approach alone is adequate to encompass the complexity of journalism education in which engagement with both citizens and professionals is important the findings provide insights into why service learning in journalism succeeds when students get the opportunity of social learning and work with professional journalists collaboration for journalism education in an open letter to the us university presidents in 2012 six foundations that provide funds to journalism schools called for massive and immediate changes in journalism curricula to succeed in playing their vital roles as news creators and innovators some warned that journalism schools along with the industry might face a dangerous fate if they dont change as journalism education is up against a difficult future a future that is full of innovation and creative disruption some scholars and professionals agree that collaboration among journalism educators citizens and professionals is a key for journalism schools to tackling the upcoming challenges the accrediting council on education in journalism and mass communications requires journalism schools to be actively engaged with alumni professionals and professional associations to keep curriculum and teaching whether on site or online current and to promote the exchange of ideas for the councils accreditation journalism students are expected to develop an understanding of diversity of peoples and cultures as well as an understanding of best professional practices such as accuracy and fairness the acejmc recommends that a journalism school contributes to its communities through unitbased service projects and events service learning of its students and civic engagement of its faculty mensing noted that communitycentered teaching could provide a way to conceptualize a reconstitution of journalism education to match that taking place in journalism beyond the university jarvis asked journalism educators to develop and encourage new thinking about the roles of journalists in the society creating and partnering with new kinds of news ventures to not only teach but make more journalism jarvis also recommended that journalism schools create media outlets that would serve small communities bradshaw argued that discussion on journalism education often overlooks some significant areas he claimed that this discussion revolves around the view of media industrialists who want changes in journalism education because the industry now requires a different set of skills according to bradshaw what is often ignored are the way journalism education is organized the information environment that students now operate in and the relationship between media industry and academia giles suggested that students be trained to report on increasingly complex society journalism schools should invest in their students a spirit of intellectual depth and versatility and a desire for continuous learning over a working lifetime overholser also put emphasis on stronger connection among scholars and practitioners she also suggested that schools need to work as labs where students will experiment and test new techniques of journalism newton identified four trends in journalism schools across the us first journalism programs reach out to other departments and launch a teamteaching model these programs are putting scholars and professionals together to work with new media second journalism programs push for innovationboth technological innovation and entrepreneurial innovation third journalism programs adapt a collaborative model of storytelling that focuses on increasing collaboration among journalists businesspeople and programmers fourth journalism schools use a teaching hospital model where students learn by doing in a newsroom in these schools students get reallife experience and get familiar with actual content from the industry theoretical framework scholars have applied several pedagogical approaches to examine collaborative projects at different universities the prominent approaches include service learning or experiential learning learnercentered teaching and social learning this study has built a theoretical framework by combining the service learning and the social learning approaches this framework allows researchers to examine student engagement with the communities they serve as well as the community of practice that they are members of service learning the service learning approach is rooted in the work of john dewey who proposed a multistep process of learning challenging the traditional approaches to education dewey described the learning process as a logical inquiry that starts with a learner experiencing a realworld problem and exerting efforts to solve it to solve the problem the learner formulates questions about the problem gathers information makes hypotheses and tests them and draws conclusions in other words learning occurs within a meaningful context and matures through reflection later work of several notable scholars provided support for deweys approach lewin and piaget believed that learning is an active process that occurs through ones interactions with the surrounding environment and reflection these ideas have later been developed into the pedagogical approach known as service learning and applied across a variety of disciplines including business communication journalism sociology and medicine despite disagreements over the definition of service learning scholars across disciplines agreed that the key components of service learning were experience reflection and reciprocity as service learning refers to a wide range of experiential education across disciplines it is difficult to find a comprehensive definition of the term jacoby provided a definition that covered much of the literature on the topic servicelearning is a form of experiential education in which students engage in activities that address human and community needs together with structured opportunities intentionally designed to promote student learning and development service learning is distinguished from other forms of learning and community service by its equal emphasis on both service and learning on one hand and reciprocity of benefits on the other moore an advocate of a poststructuralist approach to education suggested that service learning allows students to examine various systems of meaning and investigate critically the power relations among powerful social institutions kendall noted that service learning enables students to learn about the historical sociological cultural and political contexts of the need or issue being addressed the main objective of service learning is to boost critical thinking skills and enable students to integrate theory with practice through direct engagement with the communities service learning helps students better relate their knowledge to the world outside of classrooms widely accepted as a form of experiential learning service learning incorporates students involvement into the dynamics of experiential learning and the rigors and structure of an academic curriculum muturi et al also noted servicelearning is viewed as a means to better citizenship and a greater understanding of community needs and also exposes students to the problems facing their communities and encourages their involvement in finding solutions previous pedagogical research found evidence that service learning helped students develop a sense of social responsibility and become more tolerant towards diversity and able to relate learning experience to the community service learning was found to increase students ability to analyze complex social problems einfeld and collins found that participants in a servicelearning project developed several multicultural skills while interacting with their clients such as empathy patience attachment reciprocity trust and respect researchers found that service learning helps reduce negative stereotypes in the community and increase awareness among students about the complicated social issues boylebaise suggested that servicelearning is collaborative in intent responsive to local needs and helps those who are marginalized in the society service learning was adopted widely across various disciplines as it empowered students to bring about positive social change it does not only engage students and faculty members in meaningful dialogues around important community issues such as equity tolerance and power but also builds bridges between schools and communities a social learning approach lave and wenger offered a theory of social learning that explains how old and new members coconstruct professional communities this framework based on situated learning suggested that learning is a social process and it is defined by legitimate peripheral participation that means drawing attention to the point that learners inevitably participate in communities of practitioners and that the mastery of knowledge and skill requires newcomers to move toward full participation in the sociocultural practices of a community lave and wengers approach is different from albert banduras social learning theory that suggested individuals learn from observation of others experience banduras attentionretentionreproductionmotivation process applies to a broad range of people while lave and wengers approach applies specifically to professional communities that may include students aiming to join a particular community banduras theory provides an explanation of how individuals learn while lave and wenger explains how seniors in a professional community create and maintain standard practicesknowledge of which is essential for those who want to join that community lave and wenger an anthropologist and a computer scientist noted that newcomers in a professional community must be introduced to and become grounded in the norms routines and standard practices madison who applied the theory to journalism education suggested that professional communities create and maintain jargon to solidify their shared concepts elders in the community act as gatekeepers elders must grant access to newcomers newcomers may also need to wage a campaign to gain the interest and acknowledgment of community elders to gain access to the established community according to lave and wenger entry of interns or new graduates to a professional community is called peripheral participation this participation comes to be called legitimate participation because senior members of the profession sanction the entry of newcomers and train them a combination of service and social learning the service learning and the social learning complement one another a combination of these two approaches can provide a better framework to explain collaboration among educators citizens and journalists for instance the focus of service learning is on the communitythe citizens this approach helps students know the community better encounter real life problems and find ways to solve them but it is also important to note that most university graduates enter a community of practice and follow their established practices to serve citizens success often depends on how closely the new practitioners can follow the existing practices developed by the elder practitioners in the particular community of practice the social learning approach helps explain this part journalism is considered a social practice journalists are members of a community of practice best journalistic practices in serving citizens are determined by participants in the practice pursuing excellence communities of practices have their own routines developed over time in relation to other practices initial success of newcomers in a community of social practice depends on how aware they are of existing best practices as well as routines therefore this study combines service learning and social learning to analyze the case under study using this framework this study asks the following research questions rq1 how did the collaborative project enhance students understanding of communities rq2 how did the collaborative project enhance students understanding of professional practices method this study uses case study method to analyze a collaborative project between the gaylord college of journalism and mass communication at the university of oklahoma and a nonprofit news organization in oklahoma called oklahoma watch the oneyear project starting in summer 2014 had adopted elements of both service learning and social learning to give students an opportunity for indepth public affairs coverage participating students accompanied by professional journalists visited three lowincome neighborhoods in oklahoma city interviewed citizens about community problems and prepared multimedia stories that were later published on a publicly available website the students were exposed to a largescale effort to draw attention to a community issue involving numerous partners and means of engagement including not only interviews with community residents but also interviews with officials in response to the problems they raised participating students included those enrolled in five journalism classes as well as students working as interns for oklahoma watch study design case study is a form of empirical inquiry that investigates a contemporary phenomenon in depth and within its reallife context it emphasizes an understanding of people events and processes in their natural settings case study researchers might examine documents observe activities and conduct interviews to answer research questions the authors of the article had access to important project documents such as project proposal and list of participants both authors were directly involved with the project and therefore able to observe the activities of the project very closely the authors also conducted 11 indepth interviews with project participants including students professors and professional journalists a protocol was developed to analyze the interviews case study is a preferred method when how or why questions are being posed the investigator has little control over events and the focus is on a contemporary phenomenon within a reallife context the first and third of these were true of this project and the investigators though involved in the project did not have control over most details of how it was carried out case studies have been done about decisions programs the implementation process and organizational change as noted this study seeks to answer the following research question how did the collaborative project enhance students understanding of communities and professional practices based on a preliminary analysis of the project this study proposed that collaborative educational projects in journalism are more likely to succeed if two conditions are met students are exposed to the communities they serve and students are given an opportunity to work with professional journalists these professionals guided students through the entire process from selecting a neighborhood to visit to publication of stories therefore data collected by interviewing members of this project fit the proposition and can appropriately answer the research question the unit of analysis is the collaborative project described above results two major themes emerged from the interviews based on literature on service learning and social learning understanding of the community and understanding of journalism practices close reading of the transcripts based on knowledge from observation of the project and project documents led to identification of major categories within each theme understanding of the community the interviews suggested that both students and professional journalists who participated in the project grew in their understanding of the communities from the perspective of citizens there was also evidence that some students grew in their understanding of the community from the perspective of officials while also encountering some roadblocks to their understanding perspective of citizens meeting and interviewing residents over their concerns about community problems helped to undo stereotypes and uncover blind spots about community needs and challenges a reporter who worked as a liaison between the professional news organization and students and faculty noted that the areas where they did interviews have negative stereotypes connected with them but we actually go out into these communities you see that there is really there is not a lot of truth to the stereotypes … yeah maybe there are some bad crimes that happened in the areas but thats not reflective of the entire community thats not what this people…really not what this community wants similarly one student said he learned that everyone doesnt fit neatly into a box for example he found collegeeducated people living in one lowincome neighborhood because they wanted to and white families who loved living in the predominantly africanamerican neighborhood students also discovered neighborhood issues and challenges they would not have expected one student from an affluent background was surprised that a resident raised lack of swimming pools as a concern and was happy to go on camera for about 45 minutes talking about it and its impact another student commenting on the same issue said thats not something you think would turn out to be an acute problem but it really is because just for peoples safety they should be learning how to swim a third student said she learned about the difficulty of getting seemingly small problems such as street congestion fixed problems that affect daily living residents fear of raising problems publicly and lack of trust also came to light one student said they just dont trust us with the information and a lot of people were afraid that if they would say something then it would get back to their community and it would reflect them in a bad light and then they would be in danger perspective of officials talking with officials who were also interviewed in the project in connection with each residents concern provided some insight on community issues one student said the officials did provide a different perspective however she said it was difficult for a number of students to get officials to respond to them at all another student said she had to learn how to keep probing with questions once she had an opportunity to interview an issue connected with the second category understanding of journalism practices understanding of journalism practices the interviews also indicated that students gained a greater understanding of journalism practices this finding was particularly evident in relation to interactions with people but also to a lesser extent in relation to understanding of technology interacting with people a faculty member and the reporter for the professional news organization both commented on how students grew in their understanding of how to interact with people they didnt know the professor noted that students were trying to interview residents who were not used to dealing with the media he pointed out that there is a trust factor that you have to build as a journalist they were able to do that another student also commented on the work involved in overcoming the trust barrier trying to give residents the confidence to go on camera and let them know that what they will be doing we will be helping not hurting the reporter said he watched students develop in their interview skills gaining comfort with talking to people he mentioned the example of one rather shy student who became a lot more outspoken in the course of the project that same student talked about speaking to people with different experiences and the benefit to them as well as to the journalist if you go out and you talk to people that arent like you you wont start writing stories and pieces that arent true you wont have headlines you wont have stories that disenfranchise groups students also learned from the experience of interacting with officials they were interviewing for responses to concerns raised by neighborhood residents they learned about the need for persistence and for building relationships with officials to enable access one commented you would ask something and they have their script of what they want to say and i was making sure to keep them on track and sometimes they would just talk so long you dont get the chance to ask another question and so i just kind of interrupt and make sure that they knew this is what i am trying to ask another student said they learned the value of thinking through questions and anticipating possible roadblocks to answers interacting with technology in addition to understanding of journalism practices related to other people some interviews suggested improvements in understanding of practices related to technology one professor said the students learned a new way to report a story by using mobile devices for interviews he said they also learned the value of using a less intrusive device than a large video camera or dslr because they are less intimidating to interviewees some students reported gaining understanding of video editing one of them commented on how helpful the professional reporter was in learning to edit to make a compelling story a student also commented on learning how a tripod would have improved shooting of longer interviews because the video with a handheld camera would get shaky discussion this case study has examined how a collaborative project involving students faculty and a nonprofit news organization on coverage of community problems enhanced students understanding of communities and professional practices interviews with 11 participants suggested that students developed in their understanding of the communities primarily from the perspective of the residents who were interviewed on video through insights that helped to undo stereotypes and identify community needs and challenges that were not obvious or expected interviews also pointed to learning about journalism practices in particular students learned the basic journalistic essential of talking with strangers including people with backgrounds that contrasted with theirs and building trust from a practice standpoint their interactions with officials taught them how to persevere build relationships and get meaningful answers in a project in which technology was central it is notable that students talked most about what they learned about dealing with people however they also learned from interacting with technology for example the value of using mobile devices because they are less intrusive and the impact of video editing on the power of the story the combination of learning about the communities and learning about professional practices places the project at the nexus of service learning and social learning by experiencing the real problems of these lowincome communities through interviews with residents in the context of the communities themselves and discussing possible solutions with officials students engaged in the kind of learning process that scholars have identified with service learning students gained in critical thinking as they saw their preconceived notions about community residents and their needs challenged thanks to immersion in the world away from campus alongside this service learning students were engaging in social learning by working under the guidance of faculty and an editor and particularly reporter from the nonprofit news organization oklahoma watch with which the school partnered the faculty and journalists served as elders of the professional community by helping to describe and model professionallevel practices for students in the field particularly those students who worked directly with the reporterwho proved to be the key figure on the ground in inculcating professional practices learned norms of how to interact with community residents effectively and routines for approaching officials they also had the opportunity to practice these themselves and get feedback in line with the expectation of professional practice notably on the technology learning side the engagement about norms and practices involved initial engagement of the reporter with news organization interns together to do preliminary test mobile video interviews over the summer before the classes started on the project in this way working with a technology that is relatively new to both professionals and students the elders and learners worked together to lay a foundation that was crucial to subsequent student learning they thus moved closer to leaving the peripheral participation stage to legitimate participation than the other students later unlike previous studies this project brought together these two theories as a framework for discussing the implications of student faculty and professional engagement in a collaborative journalism project the study thus adds conceptually to previous work and suggests a dual lens for performing future studies of the burgeoning collaborative partnerships at journalism schools service learning provides a valuable grid for examining projects that involve intensive engagement with communities but it does not emphasize the particulars of professionals and professional practices in this learning social learning complements service learning by providing a framework for considering the dynamics of interaction of professionals to be working professionals and faculty members steeped in the profession and its norms the focus of this case study was on a collaborative project at one school and it is limited by this and the fact that the students interviewed were primarily those most highly engaged in the project less engaged students may have had a different experience of learning future research could address the service and social learning aspects of other cooperative projects that schools have undertaken across the country through case studies involving examination of the projects themselves related documents and interviews with participants

this study examined how a collaborative project involving students faculty and a nonprofit news organization in oklahoma on coverage of community problems enhanced students understanding of communities and professional practices it applied a theoretical framework that combines two pedagogical approachesservice learning and social learningto analyze the case indepth interviews were conducted with 11 project participants including students professors and journalists the findings suggest that service learning in journalism succeeds when students get the opportunity of social learning and work with professional journalists

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background depression is one of the most common diseases worldwide and has a heavy socioeconomic burden 12 depression has been ranked third on the world health organizations list of medical conditions with the greatest disease burden worldwide and is expected to top that list by 2030 the 1year prevalence of a major depressive disorder was reportedly 66 in the usa 3 29 in japan 4 and 25 in korea 5 an epidemiological study in korea found that major depression had a high disease burden with a disabilityadjusted life years value of 1287 years representing 49 of the burden of all mental diseases 6 moreover depression significantly influences health outcomes such as disability premature mortality comorbidity with chronic disease and decreased quality of life in both western countries 7 and korea 8 despite the high prevalence and social burden of depression only a small percentage of people with depression use psychiatric services 49 furthermore the majority of adults with mental disorders including depression do not seek help from mental health services 1011 in order to provide effective treatment for people suffering from mental health problems it is critical to identify the barriers that they face when accessing mhss 12 previous studies have revealed that such barriers include structural factors and attitude factors 1314 these attitudes toward mental disorders differ according to sociodemographic characteristics such as age gender and education level 1415 therefore the individuals sociodemographic characteristics may directly or indirectly influence their use of mhss 16 several previous studies have found that men 1617 adolescents and seniors 10121618 with a low socioeconomic status 121819 or living in rural areas 20 were less likely to access mhss factors influencing the use of mhss are various according to studies as mentioned above because each country has a unique healthcare delivery system the korean health insurance system is mainly run by the national government as in european countries but most of health service providers are private hospitals people pay the insurance dues differently in grade based on their income and medical services for recipients of livelihood program are free of charge while medical care is equivalent 21 many studies have investigated the barriers to the use of mhss in european union countries and the usa however very little has been uncovered about the factors that affect mhs use for depression in asian countries and particularly in korea the aims of this study were to determine the use conditions of mhss and to identify the sociodemographic factors associated with mhs use after considering the effect of mental health related factors among adults with a depressive mood using a nationwide representative korean sample methods data source and study samples the data used in this study were obtained from the fourth korea national health and nutrition examination survey which was conducted during 20072009 by the korea centers for disease control and prevention the knhanes is a nationally representative and reliable study that assessed health status health behaviors and nutritional status the survey used a stratified multistage probabilitysampling design to represent the entire korean population the knhanes is composed of the health interview survey the health examination survey and the nutrition survey the health interview survey was performed using selfadministered structured questionnaires to obtain information regarding sociodemographic characteristics health status health service use and health behaviors trained interviewers visited each household and assisted the participants with specific items in the selfadministered tool the knhanes iv surveyed household members aged over 1 year from a total of 9421 households all subjects in the survey participated voluntarily with informed consent and the survey protocol was approved by the institutional review board of the kcdc this study is in compliance with the helsinki declaration and was exempted from the evaluation of seoul national hospital institutional review board in 2014 this study ultimately included 2735 subjects aged ≥19 years that had continuously experienced a depressive mood for more than 2 weeks within the previous year measurements depressive mood was assessed by a yes or no answer to the question have you felt sadness or despair affecting your daily life for more than 2 weeks over the past year 22 the use of mhss included subjects who had visited healthcare institutions or had received consulting services by phone or via the internet for mental health problems the questions were as follows have you visited any healthcare institutions or have you received consultation through the internet telephone etc due to your mental health problems during the past year have you experienced inpatient treatment for depression during the past year have you experienced outpatient treatment for depression during the past 2 weeks sociodemographic factors included gender age region education level employment status monthly household income national health insurance type and marital status in addition smoking status and alcohol consumption status were included and the subjects mental and physical health status were also assessed perceived usual stress was measured by the question how do you usually feel stress in your daily life with responses provided on a 4point likert scale subjective health status was measured by the question generally how is your subjective physical health status with responses provided on a 5point likert scale finally chronic conditions such as arthritis diabetes hypertension angina and asthma were included each disease was organized into clinically diagnosed cases by selfreporting for example have you been diagnosed with diabetes by a physician was categorized into two groups yes or no statistical analyses given the complex sampling design of the knhanes iv weighted values were applied by using the surveyrelated procedure of spss software version 21 in all analyses for variable selection we included all sociodemographic variables as well as healthrelated variables associated with substance use stress and chronic disease from the survey data the general characteristics of the study sample were tabulated a chisquare test was used to compare the differences in sociodemographic factors health behaviors and healthrelated factors between the two groups according to the use of mhss among the subjects with a depressive mood univariate and multivariate logistic regression were used to estimate the odds ratios and 95 confidence intervals of mhs use for each measure specifically a multivariate logistic regression model was used to investigate sociodemographic factors associated with the use of mhss after fully adjusting for all evaluated covariates such as sociodemographic and healthrelated factors the level of statistical significance was set at p 005 results characteristics of the subjects of the 18406 subjects aged ≥19 years who participated in the knhanes iv 2735 had experienced a depressive mood that hindered their daily life during the previous year among these subjects 1953 were women they were aged 4800 ± 044 years and elderly aged ≥65 years accounted for 204 of the sample of the 2735 subjects who had experienced a depressive mood only 96 had used mhss 327 had an education level of ≤6 years 188 were divorced or widowed and 552 had the lowest monthly household income furthermore 609 usually felt high or very high levels of stress in their daily life 387 perceived that their health status was poor or very poor and 353 had a diagnosis of at least one or more of five chronic diseases use of mental health services according to sociodemographic and healthrelated factors table 2 lists the differences in the use of mhss according to each sociodemographic or healthrelated factor among subjects with a depressive mood use of mhss was significantly lower among men compared to women older subjects those living rurally and those with a lower level of education appeared less likely to use mhss but these findings were not statistically significant however the use of mhss was significantly higher among the unemployed compared to those who were in work and among those with a poorer subjective health status and the highest perceived usual stress association between use of mental health services and sociodemographic factors the results of the multivariate logistic regression analyses are presented in table 3 in the adjusted model the or for the use of mhss by the elderly relative to subjects aged 1934 years was 255 but the difference was not found to be significant in the unadjusted model moreover subjects with a lower education level were less likely to use mhss compared to those with a higher education level conversely the or for the unemployed group relative to the employed group was 047 there was a significant affect of gender in the unadjusted model in that men were less likely to use mhss however this result was not statistically significant after adjusting for all factors finally being elderly in the lower education group and employed was strongly associated with a lower use of mhss discussion people worldwide suffering from psychiatric diseases including depression exhibit a low rate of mhs use as shown in the present study in which only 98 of adults who experienced depressive moods for more than 2 weeks over the previous year had used mhss in the epidemiological survey of mental disorders in korea the prevalence of mhs use was 153 among people who had one or more psychiatric disease 5 in the usa the prevalence was 13 for those reported with a depressive mood 23 573 for major depression 3 and 19 for a substance use disorder 10 demonstrating a low treatment rate among psychiatric patients however korean adults with psychiatric problems demonstrated a far lower usage rate than their counterparts in the usa which suggests that the obstacles to mhss accessibility are more serious in korea than in the usa obstacles to the use of mhss include lack of awareness of the necessity of mhss 10 patients attitudes regarding selftreatment low recognition of their diseases belief in natural recovery negative perception and prejudice against the use of mhss and economic burden 11 using a nationwide representative korean sample the present study demonstrated an association between sociodemographic factors and mhs use in subjects aged over 19 years who had experienced a depressive mood according to andersens model the use of healthcare services is affected compositely by predisposing factors and promoting factors 24 variations in the sociodemographic characteristics of individuals create differences in the use of mhss 16 furthermore the severity of psychiatric disease is considered an important factor in mhs use 12 25 26 27 that is the rate of mhs use increases with the disease severity it is therefore important to consider the disease severity in order to clearly evaluate the effects of sociodemographic characteristics or odds ratio ci confidence interval if or 1 then less use of mental health services and or 1 then more use of mental health services a adjusted model adjusted for sociodemographic and healthrelated factors on service use 1228 in this sense a major limitation of the present study was that the severity of the depressive mood could not be evaluated the present findings show that after fully adjusting for all evaluated factors such as sociodemographic and healthrelated factors age education level and employment status significantly influenced the use of mhss previous studies have found that mhs use differs according to gender specifically that women use mhss more than men 1625 however in the present study service use by women was only higher than that of their male counterparts in the unadjusted analysis regarding this gender difference it has been acknowledged that women are more open about their psychiatric problems and generally have a more positive attitude toward mental diseases 29 in particular there are fewer stigmas associated with depression among women than men 14 therefore women are more likely to recognize the necessity of mhss 101718 prejudice and stigma toward mhss are strongly correlated with actual service use 15 the lower prejudice and more positive attitudes among women in this regard may explain their high mhs use however some researchers argue that the gender difference is mainly attributable to the exposure to depression being greater for women than for men 30 and that once socioeconomic variables are adjusted the difference reduces or disappears 11 similarly although in the present sample there were more women with a depressive mood than men the gender difference disappeared after adjusting for sociodemographic factors differences in mhs use between the age group regarding the difference in mhs use between the age groups some previous studies have produced varying results among the adolescent middleaged and elderly 10111618203132 while others have found that age was not associated with mhs use 27 however those aged over 65 years in the present study were less likely to use services than their younger counterparts according to previous reports the elderly are less sensitive to psychiatric symptoms and confuse such symptoms with those of the natural aging process thus preferring treatment at general medical centers rather than at specialized mhs institutions 20 in contrast younger people are more aware of the necessity of mhss resulting in middleaged people to use services more frequently 10 an exception to this pattern was found in a study conducted in iceland in which the elderly were found to have visited more mental health institutions and sought help from psychiatrists more frequently however these results were explained by favorable conditions in iceland namely an increase in free time and a lowcost health insurance system available to those aged over 67 years 16 on the other hand while stigma against depression varies little with age the effect of the stigma associated with mental illness has a stronger impact on certain age groups 14 and particularly among the elderly with depression stigma is a significant obstacle to their use of mhss 31 the rapidly expanding aged population and depressionrelated suicide among the aged have recently emerged as growing social problems in korea 33 to effectively deal with these problems greater public health strategies such as education counseling and campaigning for older people are required to promote their accessibility to mhss differences in mhs use between the education levels education level is an important indicator of an individuals socioeconomic status 12 and is considered one of the predisposing factors toward the use of healthcare services 24 many studies have found that those with a higher education level use mhss more frequently 1216181932 the findings of the present study concur with that finding in that the subjects with education that extended beyond the high school level were more likely to use such services than those who left the education system before high school furthermore those with higherlevel education preferred specialized mhs institutions to primary care centers 1934 in addition one study found that patients with college degrees or higher who suffered from depression were more likely to receive care from a psychiatrist 16 thus the type of mhs institution and service provider could vary according to education level however this factor could not be considered in the present study since the type of mhs used was unknown it should be noted that higher education was found to be associated with low prejudice against mental diseases and particularly depression 14 those with a higher level of education generally have a positive attitude toward the effectiveness of psychiatric treatment 1534 which enhances their use of mhss conversely the economic burden associated with service use is generally higher 1519 and the level of awareness for psychiatric problems and treatment lower for those with less education thus hindering mhs use in that group 12 therefore in order to enhance the use of mhss among relatively uneducated people suffering from depression an education program that includes information on the detection of depression symptoms and mhs use should be provided to improve their mental health literacy differences in mhs use between income levels income which like education level is an indicator of socioeconomic status 12 is also a factor that promotes the use of healthcare services 24 however the present study found that the use of mhss did not differ significantly with the monthly family income similar results have been reported elsewhere 111235 like many european countries korea also has a comprehensive health insurance program that covers almost the entire population for mental healthcare thus people with psychiatric diseases and a low income can use mhss without suffering an excessive financial burden 11 by contrast the severity of psychiatric diseases was reported to be higher among those with a low socioeconomic status 1128 leading to more frequent use of the mhss 2627 as a result mhs use is higher among the lowincome population limitations this study was subject to a few limitations first the severity and the duration of a depressive mood and the presence of comorbid mental health issues such as anxiety which may act as strong confounders regarding the association between sociodemographic characteristics and mhs use could not be considered also the type of mhs institutions and service providers used were not determined second the use of data from a national health survey may suffer from respondent bias the use of selfreport measures for both depressive mood and mhs use may lead to biases either due to recall or perceived stigma there would be the discordance in time periods for outpatient use and the measure of a depressive mood third these survey data prevented us from exploring important information on the use of pharmacotherapy such as antidepressants therefore observed differences in the mhs use may not directly reflect differences in the need of mhs use fourth subjects with a depressive mood were not screened using a standardized assessment tool since the data were collected from a general health survey and not a specialized mental health survey depressive moods were assessed by a single question in this study previous studies have investigated the accuracy of such a singlequestion method such as a yale study measuring the accuracy of the following question do you often feel sad or depressed the study showed that this question had a sensitivity of 86 a specificity of 78 a positive predictability of 82 and a negative predictability of 82 in screening for depression in patients with recent stroke 36 thus a single question has the potential to be a rapid and reasonable alternative to more lengthy questionnaires in surveys involving large samples 37 despite these limitations this nationwide representative study provides detailed information on the current status of mhs use among subjects with a depressive mood according to their sociodemographic factors and identified vulnerable social groups for mhs use in korea furthermore since the knhanes is conducted every year future studies will be able to monitor the trend of mhs use among subjects with a depressive mood conclusions the findings of this study suggest that the use of mhss differs among korean subjects with a depressive mood according to sociodemographic factors the elderly adults with a lower education level and the employed were less likely to use mhss this study shows the relationship between sociodemographic factors and the mhs use in korea by using a nationwide representative data despite some strong limitations including recall bias and lack of measuring important confounders the results in this study may be a useful data for policy makers and mental health professionals in improving the public strategy of the mental health delivery system in order to enhance the use of mhss mental health promotion strategies including community outreach service campaigns and education programs should be targeted according to the characteristics of the population competing interests the authors declare that they have no competing interests authors contributions sjp initiated the collaborative project designed data collection tools collected data and monitored data collection wrote the statistical analysis plan cleaned analysed and interpreted the data and drafted the paper hjj monitored data collection analysed and interpreted the data and critically revised the draft paper jyk collected data and monitored data collection analysed and interpreted the data and critically revised the draft paper sk collected data and monitored data collection and critically revised the draft paper sr initiated the collaborative project monitored data collection interpreted the data and drafted and revised the paper all authors read and approved the final manuscript

the aims of this study were to determine the utilization of mental health services mhss by adults with a depressive mood and to identify the influencing sociodemographic factors using a nationwide representative korean sample methods the study included 2735 subjects aged 19 years or older who had experienced a depressive mood continuously for over 2 weeks within the previous year using the data from the knhanes iv fourth korea national health and nutrition examination survey which was performed between 2007 and 2009 and involved a nationally representative sample of the korean community population who were visited at home a multivariate logistic regression analysis was used to estimate the adjusted odd ratios ors and 95 confidence intervals cis for the use of mhss which was defined as using healthcare institutions consulting services and inpatient or outpatient treatments due to mental health problems results mhss had been used by 96 of the subjects with a depressive mood the use of the mhss was significantly associated with age education level and employment status after adjusting for sociodemographic and healthrelated factors specifically the or for the nonuse of mhss by the elderly ≥65 years relative to subjects aged 1934 years was 255 95 ci 113576 subjects with a lower education level were less likely to use mhss compared to those with a higher education level 79 years or 235 95 ci 119464 1012 years or 166 95 ci 107256 ≥13 years reference and the or of unemployed relative to employed was 047 95 ci 032067 conclusions among korean adults with a depressive mood the elderly those with a lower education level and the employed are less likely to use mhss these findings suggest that mental health policies should be made based on the characteristics of the population in order to reduce untreated patients with depression greater resources and attention to identifying and treating depression in older less educated and employed adults are warranted

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is a wellestablished predictor of health however subjective social status has emerged as an appealing alternative measure because it captures cumulative influences of social position by accounting for past experiences and perceptions of future accomplishments sss is a particularly valuable measure in populations who do not have their own ses for example adolescents or when ses indicators change as in retirement or unemployment like lower ses lower subjective status is associated with negative mental and physical health outcomes sss assesses ones perceived position relative to others in the social hierarchy the most common measures are the macarthur scales which ask individuals to rate where they feel they stand relative to the nation and their community by marking the rung on a picture of a ladder where they feel they stand compared to the given reference group ses and sss are usually highly correlated and ses factors specifically income and occupational position seem to be the most powerful predictors of sss the way subjective status is assessed may directly cause this effect the national ladder is anchored with objective ses markers describing individuals at the bottom as having the least money education and least respected job or no job national sss may represent a more proximal influence on health compared to objective ses while perceived status in the community may represent influences that are closer still than national sss however fewer studies have used the community ladder and the links between community status and health outcomes are inconsistent this may be due to a lack of understanding of exactly what the community ladder measures qualitative data from the macarthur network suggests variation in the way individuals define community with responses falling generally into two categories individuals close in physical proximity and close social contacts these two categories may differ in the relevance of objective ses comparing oneself to close social contacts may evoke more personal information than sesrelated information thus inconsistencies in definitions of community may contribute to the variation in health associations study aims to better understand the sss relative to close social networks this study aimed to separate the effects of more physical versus more social proximity by assessing their individual impact on chronic stress a central underlying process for many negative health outcomes we assessed selfreported psychological stress and basal cortisol functioning specifically the cortisol awakening response employed and unemployed individuals were evaluated to investigate the effects of lacking ses indicators most strongly predictive of sss method participants participants were 18 employed and 18 unemployed age and gendermatched german individuals unemployed participants were unemployed for at least 12 months in addition to looking for work and needing to generate income procedure the study was approved by the ethics board at the technical university of dresden unemployed participants were recruited through online and print advertisements in regional newspapers and employed participants through flyers and advertisements in the technical university of dresden and surrounding community the experimenter visited participants homes to obtain informed consent and provide questionnaires participants collected four saliva samples on each of two consecutive weekdays using the salivette device and stored them in the freezer until the experimenter returned measures participants provided demographic information sss was measured using two 10rung ladder measures adapted from the macarthur sociodemographic questionnaire participants rated their standing on the ladders with higher rungs indicating higher status the instructions mimicked the original community ladder please place a large x on the rung where you think you stand at this time in your life relative to other people in your neighborhoodrelative to family members and friends perceived stress was assessed with the 14item german translation of the perceived stress scale saliva samples were stored at 30°c and after completion of the study thawed centrifuged and assayed in duplicates using a cortisol chemiluminescence kit values from the two corresponding samples were averaged and two indices were computed the maximum car increase was computed by subtracting the wakeup value from the individuals peak value the car recovery was computed by subtracting the 60minute value from the individuals maximum value results the employment groups did not differ in age education chronic diseases medication use smoking or body mass index unemployed participants were more likely to be unmarried reported poorer mental health had lower monthly household income and felt less secure in their current financial situation of note controlling for any of these socioeconomic or health indicators did not change the pattern of results and thus findings are present without including them as covariates however for conceptual reasons all subsequent analyses controlled for age and sex employment status differences in sss the sss ladders were positively correlated with a trend for higher ratings relative to friendsfamily than neighborhood 180 p 08 friendsfamily 731 ± 174 neighborhood 669 ± 210 analyses of covariance revealed that the unemployed reported lower neighborhood status 605 p 02 η p 2 16 and no difference in friends and family status 153 p 23 η p 2 05 see figure 1 employment status differences in stress measures unemployed individuals reported more perceived stress than employed 1021 p 003 η p 2 24 both groups further showed a lack of significant changes in cortisol across the four samples 102 p 35 group f 002 p 87 groupbytime f 182 p 18 and for car increase 64 p 43 η p 2 02 however unemployment was associated with a lack of car recovery 692 p 01 η p 2 18 see figure 1 associations between sss and stress measures a series of hierarchical regression models were tested with age and sex entered first as control variables followed by employment status and subjective status ladder rating and finally an interaction term for employment statusbysubjective status rating these models were tested with selfreported perceived stress car increase and car recovery as outcome variables regression analyses revealed that lower perceived status among friends and family was associated with higher perceived stress regardless of employment status neighborhood status was not linked to perceived stress neither of the cortisol indices were associated with sss ratings discussion our findings suggest that the impact of employment status on sss may differ depending on who participants compare themselves to neighborhood status but not friend and family status was lower among the unemployed interestingly it was specifically friend and family status that predicted chronic stress however these statusstress relationships were the same for employed and unemployed individuals suggesting that sss compared to more proximal groups specifically family and friends may offer an important extension to the study of sss as a health predictor although not statistically significant overall friends and family status trended toward being higher than status among neighborhood however unemployed individuals reported lower neighborhood status a group close in physical proximity but not necessarily made up of close social contacts unemployed individuals may find that lack of income and job title are relevant factors in considering neighborhood standing although objective ses indicators have been identified as major sss predictors it appears that unemployed may not focus on ses indicators in determining status among friends and family suggesting that future studies may benefit from assessing close social contacts as a distinct facet of sss regardless of employment status lower ratings among friends and family but not neighborhood were associated with more perceived stress this study shows that even without explicitly describing the top of the ladder as those with the highest objective ses subjective perception of having lower status than surrounding individuals is associated with elevated chronic stress this link between stress and status among a previously untested group emphasizes the potential health impact of social standing among ones family and friends and demonstrates the value of a measure of very proximal sss that captures influences of the closest people surrounding an individual unemployed and employed individuals had comparable cars however for unemployed individuals this was followed by a lack of car recovery this observation is consistent with previous studies linking flatter cortisol slopes across the day and higher daily cortisol output with higher chronic stress similar to acute stress findings lack of cortisol recovery in a basal context may lead to elevated cortisol exposure and health risks consistent with exposure to chronic stress associated with unemployment limitations a skewed gender distribution and differences in availability of government unemployment services reduce generalizability of the findings furthermore associations between neighborhood status and perceived stress as well as subjective status and car recovery were not significant despite having medium effect sizes thus it is too early to dismiss neighborhood sss as a healthrelevant domain of status finally post hoc power analyses confirmed adequate power to detect large effects however the sample size does not allow for the detection of weaker relationships despite these limitations the current findings provide promising first evidence that sss differs in unemployed individuals and that it matters whom participants compare themselves to summary and outlook the current findings emphasize the health relevance of sss among individuals in closer proximityspecifically friends and family while unemployed individuals reported lower neighborhood status there was no difference in status relative to family and friends suggesting that lack of income and employment level may not be factors on which this type of status is based although ses plays some role in sss ratings these findings indicate that ses may not impact all domains of sss equally past research has demonstrated a gradient relationship between health and perceptions of ones standing in broadly defined social hierarchies for example united states by assessing status among a large generalized social group this measure may not have adequate resolution to detect which domains of status are most health relevant identifying specific components of sss and their distinct associations with stress will enable future research to target the most healthrelevant facets of sss for different populations employment status differences in subjective social status ratings and cortisol awakening responses means ± standard deviations for subjective social status ratings for friends and family employed 767 ± 137 unemployed 694 ± 201 for neighborhood employed 739 ± 179 unemployed 600 ± 220

inconsistent associations between health and measures of subjective social status compared to ones community suggest that how people define community may matter this study broke down community into status among neighborhood and friendsfamily to assess the impact of each domain on chronic stress in individuals differing in socioeconomic status 18 employed and 18 unemployed individuals the findings suggest that for ratings of subjective social status the social and physical proximity of the reference group matters specifically neighborhood status was affected by unemployment while friendsfamily status was associated with perceived stress emphasizing the importance of the comparison group in assessing subjective status

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general scientific summary using a large international dataset this study finds that sexual minority mens risk of depression and suicidality is associated with the legal protections and social attitudes toward sexual minorities in the countries in which they live among sexual minority men who still live in their country of birth structural stigma is related to depression and suicidality via two psychosocial risk factors internalized homonegativity and social isolation sexual minority men who moved from higherto lowerstigma countries and who had longer exposure to these lowstigma contexts experienced significantly less depression and suicidality as well as lower levels of psychosocial risk factors for psychopathology structural stigma and sexual minority mens depression and suicidality a multilevel examination of mechanisms and mobility across 48 countries sexual minority men represent one of the highestrisk groups for depression and suicidality with metaanalytic evidence consistently indicating that they are between 154 times more likely to experience internalizing psychopathology and associated comorbidity compared to heterosexuals recent evidence suggests that depression and suicide may have even surpassed hiv as a burden to sexual minority mens health in north america stigmawhich occurs when labeling stereotyping status loss and discrimination exist within a context of unequal powercompromises the mental health of disenfranchised groups worldwide including sexual minorities although stigma manifests at structural interpersonal and individual levels most research documents the mental health effects of interpersonal and individual stigma for instance interpersonal stigma such as discrimination and other forms of statusbased rejection are consistently associated with poor mental health among sexual minority populations individual stigma manifests as the internalization of negative societal attitudes and chronic anxious expectations of rejection sexual minorities who report more selfstigma and expectations of rejection have higher levels of adverse mental health outcomes the dearth of research on the mental health consequences of structural stigmadefined as societallevel conditions cultural norms and institutional policies and practices that constrain the lives of the stigmatized is partly due to methodological challenges in particular few datasets contain sufficient variation in structural stigma across geographical units from which to predict mental health despite these challenges researchers have begun evaluating associations between structural stigma and mental health this research has focused on sexual minorities which represent one of the few stigmatized groups for whom structural stigma is heterogeneous and rapidly changing across geographies this work has shown for example that lesbian gay and bisexual populations have lower life satisfaction an indicator of mental health if they live in european countries with high levels of structural stigma measured as lgbspecific discriminatory countrylevel policies and population attitudes studies in the us have similarly found that the sexual orientation disparity in psychiatric morbidity is significantly larger in highstructural stigma states defined as states whose hate crime laws and employment nondiscrimination acts lack protections based on sexual orientation these observational studies have been complemented by quasiexperimental evidence showing that lgb populations rates of psychological distress increase following increases in structural stigma and decrease following decreases in structural stigma this research has provided important insights but a number of important questions remain first because most populationbased mental health surveys do not measure respondents geographic mobility previous research has not been able to account for the possibility of differential mobility by mental health status whereby people with better mental health are more likely to move in general or more likely to move to certain types of structural stigma environments particularly to lowerstigma contexts differential mobility would confound associations between structural stigma and mental health however limiting analyses to nonmovers would rule out this confound and thereby strengthen evidence for the association between structural stigma and mental health second with the exception of some quasiexperimental studies most research treats exposure to structural stigma as a static experience thus there is limited data on whether changes in structural stigma affect mental health one way to approach this question is through studying stigmatized individuals who move to a different structuralstigma context such an opportunity would allow researchers to examine whether changes in exposure to environments diverse in terms of structural stigma are related to mental health a particularly relevant question in light of widespread global geographic mobility however examining whether this change in the structural stigma context is associated with mental health requires a novel data structure that includes 1 a large sample of respondents who have moved 2 linkage to objective indicators of structural stigma in countries of origin and receiving countries and 3 data on length of exposure to the receiving country and on mental health until recently the lack of such data has precluded researchers from leveraging mobility patterns to examine lifecourse variations in structural stigma exposure as a predictor of mental health third despite growing evidence that structural stigma is a risk indicator for adverse mental health outcomes few studies have identified mediating pathways given the relative lack of datasets spanning structurally diverse contexts that also include measures of potential psychosocial mechanisms minority stress theory and existing research on structural stigma suggest that several stigmarelated psychosocial processes might explain the association between structural stigma and sexual minority mental health sexual orientation concealment represents one potential mechanism linking structural stigma to poor mental health in fact psychological theories of identity concealment suggest that concealment is contextdependent and largely a function of ones environment with some environments being particularly threatening and thereby strongly motivating concealment however most research into environmental determinants of concealment has focused on interpersonal stigma within the immediate social environment such as from family rather than on structural stigma nonetheless a few studies have shown that individuals are more likely to conceal their stigmatized identities in more structurally stigmatizing environments yet whether sexual orientation concealment mediates the association between structural stigma and poor mental health remains unknown internalized homonegativity refers to the incorporation of heteronormative societal bias into ones self concept and represents a second potential mechanism linking structural stigma to poor mental health inherent to the definition of internalized homonegativity is its primary source in structural stigma including the assumption that internalized homonegativity stem s from negative stereotypes and myths about homosexuality that permeate mainstream society and are absorbed from ones culture still most research has examined internalized homonegativity as a function of interpersonal factors such as daily discrimination similar to the state of research on structural stigma and concealment a few studies have found associations between structural stigma and internalized homonegativity but none have examined whether internalized homonegativity mediates the association between structural stigma and poor mental health social isolation represents a final plausible mediator of the association between structural stigma and poor mental health sexual minorities experience more social isolation than heterosexuals across the lifespan in turn social isolation is associated with poor mental health outcomes among sexual minorities although stigma in the form of interpersonal discrimination is particularly likely to result in social isolation among sexual minorities even more so than among racialethnic minorities we are aware of only one study that has examined whether another source of social isolation among sexual minorities might lie in structural stigma in that study sexual minorities in australia reported worse life satisfaction as well as poorer mental health in high structural stigma communities which were defined as constituencies where the residents were more likely to have voted against samesex marriage in a national plebiscite on proposed samesex marriage legislation a lack of perceived social support mediated the association between structural stigma and mental health like concealment and internalized homonegativity social isolation represents a plausible mediator of the link between structural stigma and mental health because it captures the ways in which societal norms and attitudes become enacted by the individual to shape their daytoday cognitive affective and behavioral experience finding support for these three psychosocial mediators linking structural stigma and mental health would not only strengthen causal inference regarding this association but also suggest potential intervention targets for reducing negative mental health sequelae of structural stigma to address these outstanding questions in the emerging literature on structural stigma we take advantage of a unique dataset called the european menwhohavesexwithmen internet survey which includes a large number of sexual minority men living in 48 european and nearby countries emis2017 permits several strong tests of our research questions first from its inception it has sought to capture the diverse structural contexts surrounding sexual minorities across europe and includes valid mental health assessments because countrylevel structural stigma can be assessed objectively via laws policies and community attitudes associations with mental health are not likely to be biased by selfreported stigma exposure second emis2017 includes measures of several plausible mechanisms linking structural stigma to mental health third emis2017 includes participants born in 179 countries 11831 of these participants had moved from highertolower stigma contexts thereby providing a unique opportunity to examine whether changes in exposure to structural stigma is associated with risk of poor mental health finally emis2017s assessment of movement away from ones country of birth allows us to rule out any influence of differential mobility by mental health by performing separate analyses for nonmovers and movers the present study takes advantage of these methodological strengths to test the following four hypotheses first based on evidence from prior studies within a single country we hypothesize that greater countrylevel structural stigma toward sexual minorities will be associated with depression and suicidality among sexual minority men who continue to live in their country of birth second we hypothesize that sexual orientation concealment internalized homonegativity and social isolation will mediate the association between structural stigma and depression and suicidality among nonmovers third among sexual minority men who have moved from highertolower structural stigma countries we predict that the association between countryoforigin structural stigma and mental health will be weaker with longer exposure to the lowerstructural stigma receiving country operationalized as greater number of years living in the receiving country fourth among movers we hypothesize that the indirect effect of countryoforigin structural stigma on depression and suicidality will be significantly smaller among those with longer exposure to the lowerstructural stigma environments of their receiving countries method measures countrylevel structural stigma consistent with prior research structural stigma was measured via an indicator of 15 laws and policies related to sexual orientation combined with countrylevel attitudes towards sexual minorities among each countrys residents using this approach we created a measure of structural stigma for the 48 current countries of residence represented in emis2017 and the 178 countries of origin used in analyses restricted to movers the measure of laws and policies included three areas of legislation legal discrimination and criminalization recognition and protection to create the index negative scores were assigned for each form of protection and positive scores for each form of discrimination the range across the 48 emis2017 countries was 6 to 13 and across the 178 countries of origin 13 to 13 the measure of population attitudes towards homosexuality was obtained from the global acceptance index which provides a countryaggregated score based on 5236837 responses to 67 questions about acceptance of lgbt people contained in 11 international surveys from the years 20142017 for the 11 smallpopulation countries not contained in the gai we imputed the score from the two most similar countries score on the lawspolicies index the direction and magnitude of results remained the same when these countries were excluded because the index of laws and policies was highly correlated with the index of social attitudes we combined them into one index and weighted them equally consistent with prior work on this topic our combination of these two measures of structural stigma is further supported by existing research showing that legal policies and social attitudes often cooccur and recursively influence each other specifically we combined these two measures for each country by standardizing each summing them to create one index and linking the resulting index to the emis2017 dataset the zstandardized scores which ranged from 164 to 211 across the 48 emis2017 countries and from 222 to 191 across the 178 countries of origin were used in all analyses higher scores indicate higher levels of structural stigma supplementary table 3 lists the score and rank of each country supporting the construct validity of our measurement of structural stigma previous research has found this composite approach of combining laws and aggregated norms to be associated with sexual orientation concealment internalized homonegativity life satisfaction and hiv prevention behaviors in predicted directions among international samples of sexual minorities in addition to using these structural stigma indices as the primary study predictor we also used them to characterize the sample of movers specifically we classified movers from highertolower structural stigma countries as those who were born in a country of origin with a relatively higher structural stigma score than that of their current country by controlling for structural stigma in participants country of origin all analyses involving the sample of movers adjusted for the magnitude of the difference between structural stigma in participants country of origin and structural stigma in participants current country mental health outcomes depression was assessed with the 2item version of the patient health questionnaire for depression in which respondents indicate how often they had been bothered by depressed feelings and anhedonia during the past two weeks with response options ranging from not at all to nearly every day responses were summed for the primary analyses and were dichotomized at ≥3 to illustrate betweencountry differences in the proportion of respondents exceeding this valid cutoff a metaanalysis of 100 studies finds that the phq2s sensitivity and specificity are comparable to the sensitivity and specificity of administering the phq2 followed by the full phq9 making the phq2 suitable for use in studies such as the emis2017 that seek to reduce participant burden we use the term depression to refer to this outcome and are careful to note that the phq is not intended to diagnose major depressive disorder suicidality was measured by one item from the phq9 concerning the frequency of experiencing thoughts that you would be better off dead or of hurting yourself in some way during the past two weeks with response options ranging from not at all to nearly every day this variable was treated continuously and also dichotomized at not at all to illustrate betweencountry differences in the proportion of respondents exceeding this valid cutoff psychosocial mediators we examined three mediators of the association between structural stigma and mental health sexual orientation concealment internalized homonegativity and social isolation sexual orientation concealment was measured with the question thinking about all the people who know you what proportion know that you are attracted to men to all or almost all respondents indicated their internalized homonegativity in response to seven statements about ones comfort with homosexuality assessed on a 7point scale respondents indicated their perceived lack of access to tangible help from others in times of need in response to the 4item reliable alliance subscale of the social provisions scale using a 4point scale all mediators were examined continuously moderators among movers we used number of years living in the receiving country as a continuous indicator of length of exposure to structural stigma to illustrate moderation we categorized this variable in terms of living in the receiving country for ≥15 vs 514 vs 04 years based on the distribution of this variable covariates we controlled for variables that could serve as confounders of the association between structural stigma and mental health andor that improved model precision at the individual level we controlled for age education employment status settlement size and hiv diagnosis because some of these variables could conceivably be influenced by structural stigma we additionally present results without control for these covariates in supplemental figure 2 the direction and magnitude remain similar in these supplemental analyses at the country level we controlled for each countrys gross domestic product per capita to adjust for covariation between structural stigma and each countrys living standard we also controlled for each countrys general mental health burden using each countrys dalys lost to mental disorders which was also associated with structural stigma statistical analysis analyses were performed using multilevel regression supported by the nesting of participants within countries and the intraclass correlations across countries on the main study variables depression suicidality identity concealment internalized homonegativity and social isolation all multilevel models included random countrylevel intercepts all predictors were modeled as fixed effects except when testing the moderating effect of time since moving among movers for the moderation analyses the associations between time since moving and the outcomes were allowed to vary by levels of structural stigma using random slopes we used the maximum likelihood parameter estimates with standard errors robust to nonnormality and nonindependence of observations analyses were performed in mplus using complete cases and unweighted data indirect effects were derived from bootstrapped estimates first among nonmovers we examined the association between countrylevel structural stigma and mental health second also among nonmovers we performed three multilevel mediation models to estimate the indirect effect of our proposed psychosocial mediators on the association between structural stigma and mental health these models were conducted separately because in emis2017 participants were randomly assigned to receive either the internalized homonegativity or social isolation scale in order to facilitate comparisons of effect sizes across levels of structural stigma and to illustrate countrylevel differences in the proportion of sexual minority men who reported elevated depression and suicidality we also reran these models using the phq2 cutoff as a sensitivity analysis we additionally reran these models removing all covariates that could be influenced by structural stigma in these models third among movers from highertolower structural stigma countries we ran multilevel moderation models to examine whether number of years living in the receiving country moderated the association between countryoforigin structural stigma and mental health finally among these movers we ran multilevel moderated mediation models to examine if the indirect effect of countryoforigin structural stigma on mental health through our proposed mediators would be significantly smaller among those with longer exposure to the structural stigma environments of their receiving countries results descriptive statistics table 1 presents sociodemographic characteristics by respondents history of moving from their birth country the majority of respondents were born in their current country of residence and identified as gay respondents with a history of moving were more likely to selfidentify as gay be single have a high level of education live in a large city and be diagnosed with hiv compared to nonmovers association between structural stigma and depression and suicidality among nonmovers we first analyzed the association between countrylevel structural stigma and mental health among nonmovers men who lived in countries with higher levels of structural stigma had significantly higher levels of depression and suicidality figure 1ab presents the adjusted countrylevel proportions of depression and suicidality by countylevel structural stigma psychosocial mechanisms linking structural stigma to depression and suicidality among nonmovers countrylevel structural stigma was strongly and positively associated with all three mediators in turn internalized homonegativity and social isolation were associated with depression all three mediators were associated with suicidality there were significant indirect effects of the association between structural stigma and both depression and suicidality through internalized homonegativity and social isolation and through sexual orientation concealment for suicidality when rerunning these analyses using the phq2 cutoff we found a nearidentical pattern of results as when using the continuous scores of the phq2 items as a sensitivity analysis we also reran analyses removing all covariates that could theoretically be associated with structural stigma we found a nearidentical pattern of results as with the fully adjusted analyses with the exception that the indirect effect through concealment became significant for depression but nonsignificant for suicidality further the direct effects for depression and suicidality remained significant in the context of social isolation association between structural stigma and depression and suicidality among movers moderation by length of exposure to lowerstructural stigma receiving countries among respondents who moved from highertolower structural stigma countries there was a significant association between countryoforigin structural stigma and risk of depression and suicidality however as hypothesized this main effect was significantly moderated by number of years living in the current country of residence this interaction demonstrated that those with longer exposure to lowerstructural stigma environments in their receiving countries have lower risk of depression and suicidality countryoforigin structural stigma was associated with depression and suicidality only for those who had recently moved from highertolower structural stigma countries there was no significant association between countryoforigin structural stigma and depression or suicidality among those who had lived in their lowerstructural stigma receiving country for five years or more and who thus had longer exposure to lower levels of structural stigma psychosocial mechanisms linking structural stigma to depression and suicidality among movers moderation by length of exposure to lowerstructural stigma receiving countries we found significant indirect effects of all three mediators of the association between countryoforigin structural stigma and both depression and suicidality however as hypothesized the indirect effects of the association between structural stigma and both depression and suicidality were moderated by number of years since arriving to the lowerstructural stigma receiving country thus stratified mediation analyses were conducted these analyses show that the indirect effects of the association between countryoforigin structural stigma and mental health through the psychosocial mediators were smaller among those who have lived in their receiving country the longest supplemental table 2 shows the associations between countryoforigin structural stigma and each mediator stratified by number of years since arriving to the lowerstructural stigma receiving country associations between countryoforigin structural stigma and each mediator were smaller with longer exposure to the lower structural stigma environment of their receiving country discussion stigma is increasingly recognized as a fundamental cause of poor mental health across stigmatized populations however psychological research into the association between stigma and mental health has tended to conceptualize stigma as residing within the individual or as limited to interpersonal discriminatory encounters between individuals as an alternative approach our study locates the ultimate source of stigma in societal structures that in turn generate downstream influences on mental health through psychosocial stigma processes including identity concealment internalized stigma and social isolation such an approach has potentially important theoretical implications for the etiology of psychopathology among stigmatized populations specifically although individual and interpersonal manifestations of stigma are related to mental health across stigmatized populations stigma is a multilevel phenomenon and failure to examine its broadest societal manifestations potentially obscures the identification of sociocultural risk factors for psychopathology among the stigmatized further in documenting interrelationships between structural and individual forms of stigma our study begins to link structural stigma theory to minority stress theory which have previously been examined in isolation this integrative approach provides psychologists with a more comprehensive conceptual framework for understanding the multilevel influences on the mental health of sexual minorities this study advances research on structural stigma and mental health in three important respects first a growing body of evidence has established that structural stigma increases risk for adverse mental health outcomes among stigmatized populations but few studies have been able to rule out differential mobility by mental health status which would confound this association while two studies have found limited evidence of such differential selection by health among sexual minorities and black individuals both were conducted at the us state level and used measures of selfrated health rather than specific mental health indicators we extend this literature by documenting associations between countrylevel structural stigma and depression as well as suicidality among nonmovers thereby ruling out differential selection by health as an explanation for this association second taking advantage of divergent geographic mobility patterns among emis2017 respondents this study explores whether changes in structural stigma exposures are related to mental health in ways that are consistent with structural stigma theory we show that among movers from highertolower structural stigma countries those with longer exposure to lowerstructural stigma environments in receiving countriesie those who moved at least five years agohave lower risk of depression and suicidality and of experiencing the psychosocial mechanisms through which structural stigma might compromise mental health compared to those who moved less than 5 years ago this is one of the first studies to our knowledge to find support for structural stigma theory using differential mobility patterns an approach that complements other methodological strategies employed to date including quasiexperiments the triangulation of evidence across different methods is an established procedure for causal inference notably although we found that length of exposure to destinationcountry structural stigma moderated the association between countryoforigin structural stigma and mental health for movers from highertolower stigma countries we did not find such an effect for movers from lowertohigher stigma countries as reported in the online supplement we suspect these divergent findings may be due in part to the fact that these two groups of movers differ in important respects that are likely related both to their timing of and reasons for moving specifically movers from lowertohigher structural stigma countries were more likely to have moved as adults and for opportunity rather than duress owing to lack of opportunity in their countryoforigin these findings call for additional research to understand the reasons that the influence of earlier exposure to lower stigma contexts might not wane with greater exposure to a higher stigma context particularly among those who spent longer periods of time in lowerstigma environments before moving to higherstigma contexts as was the case with our sample of movers this research might consider a developmental hypothesis whereby growing up in more protective structural environments buffers sexual minority men from mental health problems upon moving to more stigmatizing environments regardless of the length of time they spend in the new more stigmatizing environment this hypothesis would be consistent with research showing that protections at the interpersonal and individual levels can weaken the association between stigma exposure and mental health by prospectively locating similarly protective features in the early structural environment that may buffer against later structural stigma exposure this future research would begin to integrate structural stigma theory with developmental life course models of sexual minority mental health third we documented several theorydriven psychosocial mechanisms linking structural stigma and mental health including sexual orientation concealment internalized homonegativity and social isolation the identification of these mechanisms expands previous research that has primarily focused on the role of discrimination as a mechanism linking structural stigma to mental health otherwise very few studies have examined the ways in which structural stigma shapes the daily lives of sexual minorities the present findings specifically suggest that hiding ones sexual orientation from others internalizing negative societal messages about the inferiority of sexual minorities and being isolated from reliable sources of social support represent ways in which structural stigma might get under the skin to generate adverse mental health the percent reduction in the association between structural stigma and mental health was particularly strong in the context of internalized homonegativity and social isolation these two pathways therefore represent potentially promising targets to address in structurally competent mental health care and for consideration in culturally responsive adaptations of evidencebased psychotherapeutic interventions for this population in the absence of structural reform the identification of plausible pathways through which structural stigma influences mental health also improves causal inferences because it establishes empirical relationships that are consistent with theoretical predictions effect sizes for the examined associations were small in magnitude consistent with the fact that structural stigma represents a distal social factor that is expected to exert a smaller effect than more proximal factors such as interpersonal discrimination which have been the focus of most studies on sexual minority mental health however even small effects can be substantively meaningful especially when they are related to factors whose influence is hypothesized to exert impact over a large population for instance we found that the odds of exceeding valid depression and suicidality cutoffs were approximately twice as high for sexual minority men living in the higheststigma countries compared to the lowest which likely represents a substantially elevated population burden of morbidity and mortality that could reasonably be expected to be reduced in highstigma countries as the laws policies and national attitudes that inform our structural stigma index are improved our study had several methodological strengths including being the largest dataset of sexual minority men in the world and the only dataset capable of examining the association between countrylevel structural stigma and mental health we also note its limitations while we used a large diverse sample of sexual minority men the data come from a nonprobability sample potentially limiting generalizability especially to those who are older have lower education have fewer lgbt community attachments and are more likely to conceal their orientations yet our analyses assume that the distribution of variables in the emis2017 sample matches the distribution of these variables in the population further nonprobability sampling can also lead to higher estimates of mental health concerns among sexual minorities these concerns are somewhat attenuated given that the present study was not focused on establishing population estimates of mental health conditions but instead sought to examine associations among variables for which nonprobability sampling is more appropriate further probabilitybased studies typically include relatively small numbers of sexual minorities in one country only and thus would not have provided an adequate sample size across numerous countries with which to evaluate our research aims future efforts are needed to systematically assess sexual orientation in populationbased research across countries future inclusion of a heterosexual comparison sample would permit establishing specificity of the associations found here as has been observed in prior research on structural stigma and sexual minority mental health further the emis2017 dataset was not focused on mental health and thus used brief selfreport items to assess mental health although these items have established psychometric properties and are associated with major depression and risk of suicide future research should determine whether similar results are obtained with the use of diagnostic mental health assessments additionally the suicidality item imprecisely assesses thoughts of both death and selfharm given the disproportionate risk of both suicidality and selfharm among sexual minorities future research is needed to disentangle these distinct yet related constructs in addition the data are crosssectional because crosssectional datasets can introduce the possibility that the outcome causes the predictor we take two steps to rule out this possibility first we innovatively assess structural stigma exposure using an objective index of legal policies and aggregated countrylevel attitudes toward sexual minorities because it is not influenced by subjective perception an objective index cannot be caused by participants mental health status one condition under which participants mental health status would influence their structural context is if mentally unhealthier individuals differentially migrate to higher structural stigma countries therefore we take a second step to rule out the possibility of differential migration by only including those participants who were born in the country in which they currently reside this innovation in the structural stigma literature further removes the possibility that poorer mental health causes higher structural stigma together these two steps address two primary limitations of crosssectional data at the same time the present design cannot establish a causal direction between the mediators and outcomes or any recursive impact between them future research would benefit from the examination of our research question in a longitudinal cohort which would enable researchers to more systematically examine withinperson change over time including multiple moves to both higher and lower structural stigma contexts while controlling for premove characteristics despite these limitations our study has potentially important implications for both theory and intervention with respect to theory this study advances our understanding of the sociocultural determinants of sexual orientationrelated disparities in depression and suicidality among men by providing additional evidence that structural stigma is associated with the mental health of sexual minority men both through proximal experiences and as a function of length of exposure to structurally diverse contexts at least for those who move highertolower structural stigma contexts moreover findings suggest the importance of routinely assessing lifecourse structural influences on mental health and deploying interventions to address those influences in fact multilevel interventions show promise for improving mental health in highstructuralstigma contexts including through reducing stigma within institutions and improving personal coping through scalable behavioral treatments this study suggests that such interventions may have powerful capacity to interfere with the mental health toll of structural stigma and countryoforigin gdp and countryoforigin dalys lost due to mental disorders and current countryofresidence structural stigma towards sexual minorities at level 2 these models are conducted only among sexual minority men with a history of moving from highertolower structural stigma countries figure 1ab country proportion of selfreported depression and suicidality among nonmovers by structural stigma in country of residence includes microstates monaco san marino liechtenstein and andorra † the designation of kosovo is without prejudice to positions on status and is in line with unscr 12441999 and the international court of justice opinion on the kosovo declaration of independence supplemental table 2 multilevelmodel estimates of the association between countryoforigin structural stigma and sexual orientation concealment internalized homophobia and social isolation stratified by years since arriving to current country of residence among movers from highertolower structural stigma countries figure 2 direct and indirect effects of sexual orientation concealment internalized homonegativity and social isolation as mediators of the association between countrylevel structural stigma and mental health penal code morality code maximum sentence in months and years 1 month to 2 years 3 to 7 years 8 to 13 years 14 years to life death recognition equal rights included in constitution samesex civil relationship recognition samesex marriage joint adoption for samesex couples second parent adoption for samesex couples supplemental figure 1 direct and indirect effects of sexual orientation concealment internalized homonegativity and social isolation as mediators of the association between countrylevel structural stigma and depression and suicidality

sexual minority men are at greater risk of depression and suicidality than heterosexuals stigma the most frequently hypothesized risk factor for this disparity operates across socioecological levelsstructural eg laws interpersonal eg discrimination and individual eg selfstigma although the literature on stigma and mental health has focused on interpersonal and individual forms of stigma emerging research has shown that structural stigma is also associated with adverse mental health outcomes however there is limited data on whether changes in structural stigma such as when a stigmatized person moves to a lower stigma context affect mental health and on the mechanisms underlying this association to address these questions we use data from the 201718 european menwhohavesexwithmen internet survey n123428 which assessed mental health ie patient health questionnaire and psychosocial mediators ie sexual orientation concealment internalized homonegativity and social isolation we linked these data to an objective indicator of structural stigma related to sexual orientationincluding 15 laws and policies as well as aggregated social attitudesin respondents countries of origin n178 and receiving n48 countries among respondents who moved from highertolower structural stigma countries n11831 longer exposure to the lower structural stigma environments of their receiving countries was associated with a significantly 1 lower risk of depression and suicidality 2 lower odds of concealment internalized homonegativity and social isolation and 3 smaller indirect effect of structural stigma on mental health through these mediators this study provides additional evidence that stigma is a sociocultural determinant of mental health

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introduction this paper combines transitivity analysis with a social representations framework in order to examine the ways in which the issue of antimicrobial resistance is discussed in uk news publications a more specific aim of the paper is to determine which social actors are presented as having agency in tackling this global issue the concept of agency construction brings together the analysis of discourse through transitivity with social representations theory as a framework for understanding how a community comes to comprehend discuss and behave in relation to a social object in 2015 the issue of antibiotic resistance or more generally antimicrobial resistance was widely discussed in the media the year 2015 ended with reports that antibiotic resistant gonorrhoea is becoming untreatable and that scientists in china discovered a gene in ecoli that makes it resistant to a class of lastresort antibiotics and transfers resistance to other epidemic pathogens it has become increasingly evident that if we fail to find effective antibiotics and manufacture them at the scale needed ten million people a year across the world will die by 2050 both desilva et al and bohlin and höst found that the most commonly reported cause of increasing antibiotic resistance was the unnecessary prescription of antibiotics patient expectation is one of several factors that underlie primary care physicians decisionmaking regarding the prescription of antibiotics in their survey of patients with upper respiratory tract infections linder and singer found that physicians prescribed antibiotics to 46 of patients who requested them their multiple regression model demonstrated that patients asking for antibiotics was a significant independent predictor of physicians prescribing them nisbet and markowitz have pointed out in a recent report for the american association for the advancement of science that despite the pervasive use of antibiotics and growing problems research on public awareness knowledge and attitudes about antibiotic resistance is limited as is research on communication and engagement strategies mcculloch et als systematic review of public knowledge and beliefs about antibiotic resistance found that people believed that others were largely responsible for the development of antibiotic resistance they had a low personal risk from resistance their risk increased if they were hospitalised or used prolonged courses of antibiotics and causes of resistance included antibiotic use and overuse and not completing an antibiotic course most importantly mcculloch et al found that people believed that minimising antibiotic resistance was outside their control and therefore that strategies should be aimed at clinicians this is consistent with brooks et als work which found that patients generally viewed antibiotic resistance as a societal problem rather than as one that would affect them individually similarly wood found that most people do not feel they have a personal role in either the problem of amr or its solution nisbet and markowitz found that members of the public put trust in science to find new antibiotics thus distancing their own actions and responsibilities from this issue they concluded that this disconnect between science knowledge and patient expectations has led some scientists to argue that public health campaigns need to focus on bolstering public understanding of antibiotics gill et al show that both patients and medical professionals have high levels of knowledge concerning mrsa a particular hospital infection resistant to antibiotics for both patients and visitors general media constituted the most common source of information concerning mrsa which is consistent with other studies of public understanding of science and medicine it has been recognised that a s a forum for the discourses of others and a speaker in their own right the media have a key part in the production and transformation of meanings although forms of social and digital media offer alternative sources and means through which such information is accessed by members of the public research has shown that social media users rely just as much on local and national newspaper websites for information discussion of amr in the media given the prominence of the news media as a source of information concerning medicine science and technology it is important to explore existing research into media representations of antibiotic resistance across the globe the news media have been shown to have an impact on public understanding of health issues which contribute to the formation of social representations and in turn guide perceptions attitudes and behaviour desilva et al found that two key individual measures were not frequently reported in discussion of amr in north american news articles in the swedish press bohlin and höst found that reporting of these measures was even lower media coverage of antibiotic resistance goes back as far as 21 november 1969 when the new york times published an article on the socalled swann report on the use of antibiotics in animal husbandry and veterinary medicine the article focused on the british governments early efforts to restrict the use of antibiotics for farm livestock as this can lead to the emergence of antibioticresistant bacterial strains in humans antimicrobial resistance was discussed in the journal chemical week in 1984 in an article that focused on the use of antibiotics in animal feed and the dangers this poses to human health furthermore the esrc research brief states that in order to develop effective patient education and health promotion materials to reduce inappropriate antibiotic use we need to understand how people talk about and think about antibiotics and infection possible approaches might include a discourse analysis of media reports discourse analysis can be defined as the study of language above the level of a sentence of the way sentences combine to create meaning coherence and accomplish purposes however even a single sentence or utterance can be analysed as a communication or an action in this work we are concerned with how language constructs at the clausal level shape the broader news discourse around amr 20102015 at the macro level thereby creating the potential for the emergence of social representations about the issue and the role that individuals have in its development and possible mitigation theoretical and conceptual framework theoretically our study is grounded in social representations theory offering a framework for understanding and exploring how scientific knowledge diffuses in society and informs thought and action at both social and individual levels a social representation is defined as a system of values ideas and practices regarding a given social object as well as the elaboration of that object for the purpose of communicating and behaving in relation to it the theory posits that social representations emerge when novelty is anchored to existing stimuli that are known about in a given social context and when it is objectified through the invocation of metaphors and images that can describe it accordingly it can provide a shared social reality and common consciousness visàvis amr this study forms part of a growing tradition of srtinformed research into science technology and society social representations theory is combined with transitivity analysis as a means of offering an account of agency that is predicated on examining the choices that speakers make when constructing sentences and making meaning transitivity analysis has offered a systematic method for examining how discourses at the macro level are formulated by language constructs at the clausal level which has been influential in critical discourse analysis studies the approach considers the clause in terms of the process that is being described the participants involved in the process and the circumstances associated with the process is characterised as having agency with a particular focus on the degree of agency attributed to ordinary members of the public sample we searched the news database nexis® using the search terms antibiotic resistance or antimicrobial resistance as well as superbug given the discernible increase in the use of these terms we restricted our search to 20102015 nexis® allows users to search a database of uk national newspapers which comprises 16 fulltext national newspapers including their online publications although there are of course alternative news sources in online and digital media it has been shown that the credibility of national quality press is rated higher than news on the internet and this database offered a sufficiently large dataset for our analysis the distribution of the articles by publication and by year is shown in table 1 insert table 1 here at this point our aim was to get a general sense of the ways in which the various social actors implicated in discussions of amr are characterised before any breakdown of the dataset by publication type the ideological standpoint and readership of the newspaper will have significance for how the material is presented and exploration of this would be a natural extension of our work consistent with a critical discourse analysis approach it is noteworthy for example that the dataset is heavily dominated by articles published in the mail online however in order to separate out those distinct voices we must first obtain a sense of the overall picture that cuts across publications as such the entire 627 articles were taken as a single dataset although the analysis is presented yearonyear in order to facilitate discussion of any changes over time analysis the aim of the transitivity analysis was to identify the different social actors and their respective roles in the debate on amr focusing not only on their responses to the issue but also on their perspectives on its emergence as such we extracted all mentions of antibiotics from the data and systematically assessed the clause construction to identify who and what was discussed in relation to antibiotics as well as the process between them across the 627 articles this amounted to 2500 mentions of antibiotics distributed as follows 2010 103 2011 288 2012 274 2013 525 2014 384 2015 926 the data show that although there is an increase in the number of terms to refer to agents in the discussion of amr these terms generally relate to a small number of social actors thus we find antibiotics and the infections bugs strains that they are designed to treat across the dataset with doctorsgps and patients also at the heart of the discussion some nouns use however are more abstract and without a clear individual or group of individuals in the subject position this is one form of exclusion that obscures the identity of the social actor similarly it is not always clear to whom we and you refer these are explored in turn below antibiotics table 3 shows which are the most frequent verbs that are used when antibiotics is in the subject position the most frequent processes attributed to antibiotics are the relational process indicated by are which provide some form of identification or classification of antibiotics and the material process used to indicate how and where antibiotics function by positing antibiotics in the subject position the user is given an indirect role or omitted altogether in a passive construction this is observable in the following example antibiotics are used on farms on livestock under the prescription and care of a veterinary surgeon the relevance of the farming context is relegated to a prepositional phrase and the role of the veterinary surgeon is given less prominence due to their position in the sentence this is a common way of backgrounding social acts and actors it is antibiotics that appears at the beginning and in the subject position and so is the more obtrusive agent where prescribing is the process of antibiotics a passive construction is also often used foregrounding what it is that is prescribed but providing only an allusion to the agent doing the prescribing by relegating this to the prepositional phrase in gp surgeries as such gps are suppressed as social actors with their involvement only implicit the verbs losing and becoming indicate relational processes in the present continuous tense demonstrating that this is an ongoing process the use of losing is generally in reference to the effectiveness of antibiotics in treating bacterial infections similarly antibiotics are reported to be becoming less effective the material process of working works to the same effect in that references generally report that antibiotics are no longer working this is another series of examples where the factors causing the decreasing efficacy of antibiotics are not reported in a direct way rather antibiotics is reported to be the agent active in a process of losing or becoming insert we appears throughout and although lacking specificity contextual cues from the surrounding text suggest that it is generally used to refer to the general public this indicates a focus on our responsibility in the rise of amr this also allocates blame to us in making amr materially happen most notably in the material process of using antibiotics the mental process of expect ing and also the verbal processes of ask ing and demand ing antibiotic treatment subsequently we are depicted as agents who potentially have some active role in preserving existing antibiotics by reduc ing our use of them from 2013 this is formulated as a discussion of our need for antibiotics including some more instructive pieces offering advice as to when a patient might need antibiotics but equally when they might not the ambiguity afforded by this collectivisation means that there is no impetus on individual responsibility since there are no named individuals there are some changes in the use of we over time in 2010 we can find for example a statement of the problem that we all face not so long ago we imagined that antibiotics could cure all such infections superbugs infection bacteria and strain in the same way that antibiotics are instilled with agency in becoming less effective the infections they treat are also depicted as being agentive infections which had previously been defeated treated remedied destroyed beaten by antibiotics are now developing into forms that survive and evade antibiotic treatment representing the infections themselves as activeas agentivehelps to depict an opposing force an enemy that we as a society of patients doctors scientists etc might collectively resist however this does generate a sense that the blame for the symptoms of these illnesses lies with the bacteria themselves and thereby may detract from the sense of responsibility that we the public might assume gps doctor and hospitals in the corpus we find statistical reports that indicate for example that some 74 of antibiotics are prescribed by gps in the uk the medical domain is reported to be the disseminating source of antibiotics which in turn implies that doctors gps hospitals medics etc are the ones with the capacity to inhibit their use the distribution of antibiotics is reported in a handful of terms from simply using dishing out handing out doling out to the overwhelmingly most frequent prescribing in terms of transitivity the process of prescribing has evoked some debate as it seems to originate from a verbal process has been cited as a behavioural process but unarguably has more material consequences in terms of access to medications here prescribing is the process most frequently attributed to the various medical agents and is presented as a process central to the development of amr phrases such as doling out imply that there is little regard for the quantity of antibiotics being prescribed and that the prescribers ie doctors are blithely doing so substantiating this more critical view of medical professionals is the oftcited circumstance in which antibiotics are prescribed such as when they are not needed unnecessarily or for coughs and colds however this does not tell the full story in that there are instances where we find that gps are pressured to prescribe antibiotics thus although gps are the active agents in the prescribing of antibiotics there is another force applying pressure for them to do so what we can surmise from this type of construction is that the writers may want to allude to the demands of patients who are likely candidates for the source of this pressure but do not cite them directly as the instigators of this process it would be telling therefore to look more closely at the patientgp relationship as depicted in the data we are told for example that gps who refuse to give out antibiotics are less popular furthermore some texts directly instruct readers to avoid your gp to slow rise of superbugs this example does highlight one of the potential oversights of the focus on grammatical agency employed here where the imperative form omits the subject for the verbprocess and thereby the patient is subject to exclusion however van leeuwen cites the use of possessive pronouns in this way as a recognised strategy for indicating sociological agency and his expanded system network offers some guidance on how to account for such examples use the use and overuse of antibiotics is reported to lead to the issues associated with amr but once again the users undergo exclusion in this depiction there is some sense in this if we acknowledge that it is not patientsthe public themselves that is the issue but rather their use of antibiotics then it seems reasonable to foreground this aspect however what this construct avoids is implicating agents such as the public doctors and farmers in the overuse of antibiotics farmers as a group of social actors also experience exclusion when the discussion of the use of antibiotics is situated in the livestock domain for example the routine preventative use in farming of colistin and all antibiotics important in human medicine needs to be banned immediately excludes those providing the chickens with antibiotics the farming context itself is marginalised appearing in prepositional phrases such as in the meat industry or as medicated feedstuffs this practice then is not foregrounded as a focus of the discussion and thereby becomes incidental which has the effect of normalising it farmers and chicken where there are interventions or actions in this context for reducing the use of antibiotics this is enacted not by farmers but rather the companies who trade with farmers for their livestock for example mcdonalds has also pledged to eliminate chickens fed on human antibiotics this does however only constitute a verbal process rather than any real transitive action one of the contributing factors to the issue of amr is that in the last 40 years only two new classes of antibiotics have been developed 1 there were only 37 references 2010 4 2011 3 2012 6 2013 7 2014 5 2015 12 to social actors representing the industry of antibiotic production 2 who were characterised as having lost interest in developingnot working hard to producereluctant to invest in developing new biotics and as such actors in the negation of material process pertaining to antibiotics thus while largely subject to exclusion when mentioned drug companies are represented as being inactive furthermore the use of passive constructions to report that the manufacture of antibiotics is not seen as profitable offers another form of exclusion by omitting the actors who hold this profitoriented perspective similarly there are 44 references to the people and processes involved in the research behind antibiotics 3 where scientists are discussed in terms of their ability to developproducecome up with new antibiotics however this is presented in the context that microbes mutate faster than scientists can come up with new antibiotics demonstrating the inability to complete a material process quickly enough other processes are verbal trials promote findings reveal research offers and scientists blame and call for so their role in the fight against amr is not shown to be as impactful as transitive material processes would be discussion in may 2016 the uk economist jim oneill published a longawaited report on how to tackle amr which recommended inter alia that a massive global campaign should be launched to make the world more aware of the dangers of antimicrobial resistance moreover in september 2016 the general assembly of the united 1 2 identified by the terms drug companies pharmaceutical companies the pharmaceutical industry pharmaceutical firms big pharma and indirectly manufacture of antibiotics and the pipieline 3 identified by the terms research scientists microbiologists study trials and findings nations held a special highlevel meeting on amr and committed to addressing the challenges posed by amr to health food security and development 4 the growing problem of amr can be attributed not only to biological and pharmacological causes but also to human action public perceptions of amr play a fundamental role in how individuals engage with antibiotics and consequently in the progression of amr this ties in with existing research findings that patients may expect and even demand the prescription of antibiotics although they are not needed that there is a tendency to misuse antibiotics and that amr is frequently attributed to external causes such as to doctors dirty hospitals others who overuse antibiotics and society as a whole rather than to ones own individual actions an apparent disconnect between science knowledge and patient expectations has led scientists and commentators to argue for greater public understanding of amr we strongly believe that the news media constitute an important startingpoint for understanding the nature and structure of representations of amr which in turn inform thought and action visàvis amr attribution is a key component of social representations and it can be regarded as a subprocess of anchoring indeed problems need to be attributed to specific causes in order for them to be understood and discussed in the data there was no sense of individual responsibility but rather amr was attributed either to the bacteria themselves or to society as a whole this could plausibly encourage the social representation that amr is a biological and societal problem over which individuals have no control such as was found in reported studies patients tend to make external attributions and to perceive a lack of control over the development of amr or its solutions chandler et al have observed similar blamegames in media and political discourse framing doctors as overprescribers and patients as misusers and overconsumers of antibiotics with selective andor limited attention intentional or not to contributions of socioeconomic inequalities and inequities demographics and differences in exposures to infectious diseases let alone the pharmaceutical industries role in the levels of antimicrobials sold this highlights that the response to overuse of antibiotics needs to come at multiple levels and the media might have a role to play in promoting individual action among members of the public but there are also political and economic structures that will continue to determine who has access to antibiotics boyce murray and holmes found that the british press often based antibiotic resistance reporting on governmental agency press releases rather than research reports which will have consequences for the linguistic construction of this media discussion of the issue if the content is appropriated from reports or other documents that are written for a different purpose in a different register potentially studies that adopt a systematic linguistic approach as we have presented here can inform media practices as to how to incite individual action if this is an accepted strategy for tackling amr given the centrality of human action to the development of amr it is key that we understand the underpinnings of the social reality and public consciousness around amr sources of societal information such as the media contribute to the development of social representations and yet the media can only possibly play a partial role in this developmental process since individuals groups and other channels of societal information function as coconstructors of social representations future research must explore how amr is portrayed not only in the traditional mainstream media but also in social media such as on websites blogs and in political rhetoric the wellcome trust for instance is doing an excellent job in disseminating information about amr on social media platforms such as twitter in order to enhance public understanding about it an important next step in research into amr would be to explore the impact of social media campaigns on the structure and quality of public understanding of amr machin and mayr have shown how transitivity analysis can be combined with a multimodal critical discourse analysis in their examination of the representation of criminals and crime fighters in the television show crimewatch which can offer some guidance as to how to extend this type of work into a multimediamultimodal domain in adopting a transitivity analysis we were able to identify those instances where the social actor was labelled in the process and thereby explore the more overt ways in which particular agents were implicated in the discussion of amr but as van leeuwen observes sociological agency is not always realised by linguistic agency by the grammatical role of agent therefore there may be other ways in which doctors patients drug companies etc can be implicated with less overt naming strategies such as the use of possessive pronouns it is necessary to consider what effect these have too extending this research in the ways that van leeuwen identifies in his system network could offer a more comprehensive picture our findings provide some indications of emerging social representations of amr bacteria superbugs and infections are positioned as the enemy which needs to be beaten but there appeared to be little focus on solutions or on the tools that might be utilised in the fight against amr adopting a solutions journalism approach has been shown to improve readers engagement with an issue as well as inspiring them to work towards a solution antibiotics are defined categorised but ultimately no longer responsive to bacterial infections the agricultural dimension of amr was largely marginalised despite the central role that this domain also plays in the development of amr thus amr was anchored principally to these entities bacteria superbugs and infections and the war metaphors employed in relation to these entities objectified amr as being driven by belligerent forces requiring action and mitigation research and manufacture of antibiotics were also subject to exclusion thus a stable social representation of amr in the news media concerns the anthropomorphic agency of bacteria antibiotics and infections which despite the use of war metaphors discursively attenuates the ability of human beings to engage successfully with the problem of amr it is easy to see how representations observed in the data might inhibit engagement with the problem of amr by disempowering individuals who indeed could take action against its progression indeed selfefficacy which this representation may well inhibit is a key predictor of behaviour change clearly those social representations that empower people to engage with amr should be encouraged and disseminated existing work on antibiotic resistance seems to suggest that there is a shortage of accurate and empowering information on the phenomenon in other words readers are not habitually exposed to representations that can inform them about the complexity of the problem or that can provide them with possible ways in which they as individuals may contribute to the prevention of antibiotic resistance the findings from our media analysis seem to support this assessment tables and figures

the increase of infections resistant to existing antimicrobial medicines has become a topic of concern for health professionals policy makers and publics across the globe however among the public there is a sense that this is an issue beyond their control research has shown that the news media can have a significant role to play in the publics understanding of science and medicine in this article we respond to a call by research councils in the uk to study antibiotic or antimicrobial resistance as a social phenomenon by providing a linguistic analysis of reporting on this issue in the uk press we combine transitivity analysis with a social representations framework in order to determine who and what the social actors are in discussions of antimicrobial resistance amr in the uk press 2010 2011 2012 2013 2014 2015 as well as which of those social actors are characterised as having agency in the processes around amr findings show that antibiotics and the infections they are designed to treat are instilled with agency that there is a tension between allocating responsibility to either doctorsasprescribers or patientsasusers and collectivisation of the general public as an unspecified we marginalising livestock farming and pharmaceutical industry responsibilities

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distinctiveness of aboriginal families as a population aboriginal men are arguably the most socially excluded in canada with higher unemployment homelessness injuries incarceration and suicide and lower education and life expectancies than all other canadians while some aboriginal families are typical of many nonaboriginal families population level findings indicate that many aboriginal families are unique in a variety of ways there is a higher rate of common law unions higher levels of mobility and more children younger than 14 years of age within aboriginal households compared with nonaboriginal households aboriginal men are less likely to be coresident with their children greater than onequarter of aboriginal children are living in lone mother headed households at the same time there are twice as many aboriginal fathers shouldering the responsibility of raising children alone compared with nonaboriginal fathers with a higher rate of aboriginal parents who live separately there are more aboriginal fathers who are the sole caregivers of their children when they take turns with their expartners in caring for children it is more common for aboriginal men to have children with several different partners and for fathers to live in households and be partly responsible for the care of children to whom they are variously related including children with different mothers their current partners children children who spend part of each week or part of each year living with them and so on as well continuing a culturally traditional pattern many aboriginal families do not conform to a typical eurowestern nuclear family structure children may be raised by their grandparents or by a number of different relatives in circles of care thus when practitioners want to engage a childs primary caregivers it is important to ask who is involved in the childs direct care over a given period of time and to ask a father about his varying roles in a way that conveys assumed responsibility in which a biological connection may not be so important it is also critical to be aware of the tremendous diversity among aboriginal families including the fact that some are thriving and some aboriginal fathers are role models of positive father involvement using a sociohistorical lens a recent inaugural study of first nations and métis fathers of young children in canada underscored the importance of understanding the historical conditions that account for challenges facing many aboriginal families and fathers among the 80 fathers who came forward to be interviewed about their fatherhood journeys virtually all pointed to the long series of colonial interventions illustrated commentary ©2012 pulsus group inc all rights reserved figure 1 evidencebased contributions of father involvement to child outcomes iq intelligence quotient in figure 2 which effectively disrupted aboriginal family and community life and traditional modes of subsistence child rearing and health promotion the indian residential schools delivered a final devastating blow to aboriginal peoples causing a disruption in the intergenerational transmission of indigenous cultural knowledge languages parenting and social care threequarters of the fathers in the research study reported having to address mental health and substance abuse challenges related to developmental trauma issues that interfered with their ability to remain in relationships with women with whom they have had children while fathers who volunteered to participate in the study were not necessarily representative of all first nations and métis fathers the healing process needed for many aboriginal fathers to become positively involved in family life has been documented by first nations scholars as part of the aboriginal health foundation program of research and the first nations regional health survey fathers in the recent study emphasized the need for health care practitioners social workers and teachers to learn about colonial history the indian act and social policies that continue to affect many aboriginal children and families and their access to services most fathers in the study described how they had no experience of a caring father figure in their lives many fathers who were involved with their children described having to pull out of thin air an image of what it means to love and care for a child and to sustain a positive relationship with their childs mother and other family members yet virtually all of the fathers including those who were very involved described their commitment to learn fatherhood as a lifelong journey of sustaining positive connections with their children and contributing to their wellbeing some fathers expressed their determination to find ways to be involved despite having few resources such as a comfortable home a vehicle discretionary funds or connections to social or recreational institutions it is important for practitioners to consider the potential practical barriers to some fathers participation in child health appointments hospital care and followup routines and to help fathers overcome these if possible for example by linking fathers with patient navigators or assisting fathers with procedures to obtain transportation vouchers social barriers may include fathers not knowing what is expected of them when entering a health care facility visiting hours meals possible costs for medications supplies and specialist visits and so on as well many aboriginal people in canada continue to experience racism and social discrimination some fathers in the study described feeling unwelcome in offreserve facilities such as wellbaby clinics child development centres libraries and even playgrounds several fathers reported having been asked by practitioners whether they were related to the child they were with as if their legitimate accompaniment of the child was in question significantly aboriginal children are more likely than nonaboriginal children not to have their biological father identified on their birth record and aboriginal child welfare records are more likely not to include the fathers name many aboriginal fathers in the recent study perceived a mothercentric approach in mainstream health social education and child protection service systems they identified a need for practitioners to be more vigilant in ensuring that fathers identity and contact information is included in childrens health school and child welfare records so that fathers can be notified about critical incidents informed about care regimens and included in health care decision making even if this requires extra figure 2 common impacts of colonial interventions figure 3 key strategies for supporting aboriginal fathers involvement effort on the parts of health care providers because fathers may not be coresident with their children and their childrens mother we could be the turnaround generation this expression of hope was expressed by approximately 40 of the fathers in the research study and also by fathers who participated in a recent national event focused on aboriginal fathers overall the research study pointed to five avenues for supporting aboriginal fathers to become the turnaround generation illustrated in figure 3 conclusion after so many decades of living in the shadows of canadas colonial legacies aboriginal fathers are calling for more concerted efforts to include them in prenatal programs decisions about their childrens health care and education and parenting education and support programs yet support for father involvement falls between the cracks of government ministries at the federal provincial and territorial levels with no dedicated funding there are few examples around the country of programs to support aboriginal mens transition to fatherhood and to provide ongoing father education encouragement and inclusion however more aboriginal organizations such as friendship centres and first nations communities are recognizing the need to promote fathers involvement and there is increasing interest in creating father support and education programs many fathers in the study noted however that fathers may be looking for different kinds of support than those that appeal to mothers rather than starting with peer support groups involving sharing personal stories a majority of fathers identified the need for concrete information provided in plain language information handouts that could be available in clinic waiting rooms or handed to them by practitioners topics they suggested included information about child development milestones oral health how to make healthy affordable meals and snacks how to get children ready to learn in school what to expect as children mature how to support boys and girls through puberty and where to take children for affordable recreation that can be accessed by public transit fathers emphasized that learning fatherhood takes time and therefore health care and other practitioners need to be persistent patient and creative in their efforts to involve aboriginal fathers practitioners need to recognize that some aboriginal fathers are well prepared to become partners with professionals in supporting their childrens optimal health and development while others may be affected by sociohistorically conditioned socioeconomic educational and personal limitations yet the resilience in the face of adversity demonstrated by aboriginal peoples as a whole combined with aboriginal fathers desire to become the turnaround generation by recreating positive roles for aboriginal men in raising children are assets that need to be capitalized on in policies and practices aimed at improving aboriginal childrens health and development outcomes

l inks between childrens wellbeing and their mothers health literacy and behaviours are widely understood and accepted canada similar to many other countries has made longstanding investments in maternal and child health programs yet both research evidence and conceptualization of the social determinants of health provide a solid rationale for securing fathers involvement in their childrens health and development research shows that although children can thrive without a fathers involvement regular contact with a positively involved father is strongly associated with good developmental and health outcomes 1 as shown in figure 1 practitioners may agree with the idea of involving fathers in prenatal education and childrens health development and education however there has been little policy support public health program investment or practitioner preparation to support fathers transition to parenthood or their positive involvement lack of effort or success is especially unfortunate in regard to aboriginal fathers there is evidence of poorer health outcomes among aboriginal children compared with nonaboriginal children on almost every health indicator 2 and poorer overall quality of life 3 as grand chief of the british columbia first nations summit edward john has said fathers and grandfathers may be the greatest untapped resource in the lives of aboriginal children and youth 4 the present article urges practitioners to recognize the contributions that fathers can make to childrens wellbeing and to tap into aboriginal fathers potential as contributors to the care and development of aboriginal children at the same time the sociohistorically conditioned challenges facing many aboriginal fathers must be recognized so that efforts to harness their potential are understood as part of a longterm multigenerational process of healing and strengthening aboriginal families

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introduction the modern world is dominated by digitization in several aspects from developing countries to developed countries this binary coding process contributes to the development of a variety of fields when it comes to digital anthropology a field of study that emerged during the latter part of the 19 th century focuses on understanding the behavior of mankind in the digital environment digital anthropology is a discipline that fits into the division of cultural anthropology considering cultural anthropology religion plays one of the prominent roles buddhism is not only a religion but a unique cultural aspect in sri lankan social context this paper is based on these two prominent factors and seeks to understand the evolutionary process in modernday popular buddhism utilizing the characteristics of the era of 40 the main objective of this study is to introduce a new model for digital religious studies by utilizing digital anthropological knowledge to understand the digital behavior of sri lankan religious contexts how to propose a model utilizing digital anthropological knowledge to understand the changes in popular buddhism is the existing problem of this research to fulfill these objectives within a framework the researcher applied one of the prominent factors in modern popular buddhism the propagation of dhamma to examine the characteristics of the modern evolutionary process of buddhism gananath obeyesekere and richard gombrich play one of the leading roles when considering the early works which attended to understand the changes in sri lankan buddhism their controversial ideas on protestant buddhism built novel dimensions in religious studies in sri lanka and their theoretical aspects are still utilized by scholars for their academic addresses obeyesekere and gombrich pointed out the change in cosmology and the creation of new religious roles which interconnected matters based on gods and other figures although they argued that strictly buddhist ideas roles and institutions have not remained unaffected by the new trends according to that period anyhow their proposed concept called protestant buddhism caused novelty in the practices of buddhism and prepared the field for a new term called applied buddhism sri lanka has been conventionally considered a fort of theravada buddhism according to tilakaratne the organizational aspect of modern buddhism the sasana comprising the four groups of bhikkus bhikkunis and upasakas and upasikas has changed pondering the new trends in buddhism he highlighted concepts like transyanic buddhism american buddhism and eco buddhism amunugama underscored the contribution of anagarika dharmapala piyadasa sirisena and john de silva on the new trends of sinhala buddhism as well as the impact of the theosophical society of olcott taking into consideration the main subject emphasized in this paper dhamma sermons played one of a significant roles in buddhism he who acts according to the dhamma is protected by the dhamma itself is a popular quote found in the buddhist teachings of buddha dhamma affects the transcendental life as well as the secular life of a person according to thalpavila shilavansha thero there are seven types of dhamma sermons such as wedding sermons funeral sermons title sermons custom topic sermons memorable sermons demonsbased sermons nearby sermons other than these types he proposed more types of dhamma sermons sermons to monks personal sermons general sermons sermons for girls sermons to young people sermons for the elderly sermons to men sermons to women sermons to the learned sermons to the ignorant sermons to the urban people sermons to the villagers sermons to worshipers marriage sermons sermons to warlords sermons to prisoners sermons to patients sermons on paganism sermons to free thinkers sermons to separatists and missionary sermons he proposed several factors for becoming a popular monk in dhamma propagation such as ignoring party affiliation ignoring highs and lows ignoring selfinterest ignoring provincial divisions general knowledge abandonment of sectarianism abandonment of caste and compassion when asserting the historical significance of buddhist dhamma sermons walpola rahula thero stated the importance of choosing chullahaththipadopama sutta by mihindu thero as the first propagation of dhamma to king devanampiyatissa to explain the basis of buddhist philosophy and religious background in digital anthropology there are six principles proposed by daniel miller and heather horst that underline the characteristics of the concept called digital dialectic nature of digital culture human is not one iota commitment to holism cultural relativism and global nature authenticity of ambivalence and materiality of digital culture are the respective principles presented by them as they stated the development of binary code radically simplified information and communication considering the development of the digitalization era 40 or the fourth industrial revolution is a prominent notion proposed by the works of the german government or on the other hand it is the ongoing automation of traditional manufacturing and industrial practices using modern smart technology various components come under industry 40 such as cyber security augmented reality big data cloud computing internet of things etc digitalization is one of the key factors which effected the 4 th industrial revolution because when it comes to modern day innovation has come to have an impact on the way of life of individuals of all ages from children to working individuals to more experienced individuals campbell and evolvi illustrate the theoretical background and the methodological aspect based on digital religion they critically emphasize the how digital religion studies seek to investigates the spirituality religiosity in digital space sara pink heather horst and others proposing seven key concepts that can utilized to understand and conduct research on digital environment such as through experiences practices things relationships social worlds localities and events considering the existing gap of this desk research in sri lankan social context various studies on buddhism were based according to vary of perspectives although various studies were conducted on buddhism and digital era in various other countries there is a huge lack of sri lankan academics in this field of study especially in digital anthropology this study aims to fill this gap based on a digital anthropological perspective and buddhist practice known as dhamma sermons and focuses on preparing a primary model to theoretically describe the modern evolutionary process of popular buddhism from the real world to the virtual world utilizing propagation of dhamma in the fourth industrial revolution the researcher of this study mainly focused on the changes and progression caused in traditional dhamma sermons due to the development of digital technology in the fourth industrial revolution the results of this study could be applied to other disciplines like sociology digital studies and media studies for their examinations on the mentioned aspects as a theoretical analysis based on existing literature the proposed model can applied to their studies too while understanding a characteristic of a particular religion in an existing culture materials and methods this research was based on one of the key principles in digital anthropology authenticity of ambivalence proposed by daniel miller and heather horst in 2012 in their paper titled the digital and the human a prospectus for digital anthropology to examine the validity of this theoretical aspect this paper applies two cases regarding presentday dhamma sermons based on digital platforms especially social media which underlines the characteristics of popular buddhism these three cases were based on the sermons of attaragama pragyalankara thero also known as kotuwe podi hamuduruwo both posts were publicly uploaded by different facebook pages and they have been selected purposively to accomplish the objectives of the research the main justification for applying this page was the widespread audience and the content of its posts also they have a vast number of comments and reactions the method used in this research was descriptive qualitative and to align with the research objectives the researcher did not consider the comments of the public on these posts focus was regarded with the statements of the thero and critically analyzed with the literature that was utilized for the research and compared the differentiations in these sermons and traditional dhamma sermons after collecting the underlined sayings of the respective monk the researcher theoretically examined the validity of the previously mentioned principle of digital anthropology and attended to highlight the evolutionary changes caused by traditional dhamma sermons in the sri lankan popular buddhism context qualitative data obtained from secondary sources were applied for this research results and discussion it is quite complicated to state precisely when and where the concept of popular buddhism was established in sri lankan academic context this concept can be assumed to be a residual concept that emerged from popular culture though there is hardly any other religion in the sri lankan social structure that is as time and space shaped as buddhism martin wickramasinghe had mentioned about this cultural formation as that the independence and spirituality of sinhala culture was preserved due to buddhism according to daya amarasekara contemporary sinhala buddhism shows that it affects the coexistence as well as the conflict between social and worldly tendencies socially that complex religious face can be identified only by popular buddhism walpopla rahula thero once stated from the time buddhism became the state religion it began to change and his statement indicated that since of that politicization buddhism achieved the perfect establishment for long period in sri lankan social context there is no doubt to state that digitization is affecting every aspect of the world including the cultural factors like religion the study of preliterature was a confirmation of the extent to which cultural diffusion has influenced the existing sri lankan cultural context this study does not examine whether that sociocultural change is good or not although focuses on the impact of the diffuse influence of digital culture on buddhism in the socalled era 40 which known as 4 th industrial revolution post 01 fight like wwf to solve family problems this video has 55 minutes of duration and more than thousands of audiences were engaged with it in order to prove the trustworthiness of this post on existing research the statements can be considered to the comparison of traditional dhamma sermons and modern ones following table contains the statements which underlines the different aspects of modern dhamma sermons and the way digitalization affected relevant time in the video for these sayings is also mentioned here considering his propagation of dhamma through a particular digital platform the researcher underlined the significant features that describe the current objective of the study popular buddhism dhamma sermons impact of digital culture can be identified considerably through the following statements collected from the first post contemplating the selected sayings of him researcher underline the different nature in dhamma sermons comparing to early periods not only with his language according to the content too there is a significant diversity comparing with the existing literature a monk should not be considered about his selfinterest when it comes to the abovementioned statements there is a quite different pattern in the sermon language is one of the prominent factors in traditional dhamma sermons due to various changes in present society language also shifted to various aspects according to shilavansha thero a monk must advise his people on the importance of dhamma sermons instead of conquering his own advantages this phenomenon can be identified in 527time duration there is a huge variation displayed comparing to early doctrines of dhamma sermons when pondering the impact of digitalization to these types of dhamma sermons various terms and occasions can be recognized lankan political parties this also a prominent shift compared to traditional buddhist sermons from digital anthropological perspective this event can be examined applying the 5 th principle named authenticity of ambivalence or ambivalence and the principle of openness and closure it emphasize the contradictions of openness and closure arise in digital domains considering internet there is a novel openness for the public as well as a limited freedom this phenomenon can be identified in political as well as the religious context digital concept or the digital culture underlines the capacity of production through the openness and accessibility on the other hand there is a solid closure and restriction emerged as a tension in digital due to these characteristics more than idealized communities there are crosscutting affiliations of groups utilizing the internet to think through new opportunities this new openness was significantly utilized by popular buddhism and the falseness or the idealized thinking are not considered as important conceptions due to these new groups which highlight different perspectives and ideas or opportunities of buddhism as highlighted early table particular monks novel statements sayings are some of the characteristics that emphasize the tension of this socalled openness of digital these sayings can be defined as unsuitable or inappropriate statements for a buddhist monk according to someones point of view although these types of things widely spread due to the support of digitalization and the considerable influence for this trend is the openness of the internet post 02 people become couples at dhamma sermons this video consisted with 14 minutes of duration and was found from a facebook page which shares different types of posts and not considered as a religious page pondering the engagement of the audience clearly identify thousands of reactions and comments as the first post selected earlier following are the statements and sayings regarding this post align with the research dhamma sermons taking five percepts as example is a prominent custom considering the relevant monks sayings there is a huge difference of explaining this third percept to buddhist laymen one of the significant characteristics identified in his sayings are the taking digital cultural terms and concepts as he states about the mobile package of hutch a sri lankan telecommunication service provider and the countrys third largest mobile network operator during his dhamma sermons while explaining five percepts it clearly highlights the possible impact of digital culture likewise the way he argues about a suicide case connected with facebook it comprehensively determines the effects of digital platforms to traditional buddhist dhamma sermons in the principle of openness and closure of digital concept underlines the capability and the capacity of the production in digital platforms since digitalization affects buddhism changes and evolutionary features arise and there is no limitation for new ideologies on the other hand closure and restriction too discussed through the 5 th principle when it comes to buddhism in digital media there is clear negative and positive feedback from different audiences this phenomenon is quite similar to the first principle of digital anthropology the dialectic nature of digital culture wijayarathna abhayasundere and jayaweera stated this principle by utilizing the significant characteristics of siri sadaham ashramaya and its teachings the way people react to those sayings highlights the closure and restriction of digital conclusion and recommendations sri siriwattano pa phrakrukittipatananuyut phrakrupaladnattaphon walker t the method and process for establishing a centre for the production of buddhist digital communication era 40 through the cooperation of a group network in chiang rai province proceedings of the

along with era 40 digitalization involves several aspects of modern social context and religion is one of the prominent when it comes to sri lankan popular buddhism numerous changes can be identified through digital platforms like social media this research attends to understand the evolutionary patterns of buddhist dhamma sermons by applying two cases selected from facebook attaragama pragyalankara thero also known as kotuwe podi hamuduruwo is a key figure which emphasizes the characteristics of modern popular buddhism two posts regarding his propagation of dhamma browsed through random facebook pages applied to understand the characteristics of the modern evolutionary process of buddhism the main objective of this study is to introduce a newfound model for digital religious studies by utilizing digital anthropological knowledge to understand the digital behavior of sri lankan religious contexts for the analysis of this phenomenon the researcher applied the 5th principle of digital anthropology named ambivalence and the principle of openness and closure proposed by daniel miller and heather horst in 2012 through their work titled digital anthropology different patterns in language as well as variations compared to traditional dhamma sermons identified through literature were identified from the data collected from the relevant posts as an examination based on qualitative data this research considered various literature to fulfill the research gap one of the key conclusions that arise from the research is that digital anthropological knowledge is a way to understand modern popular buddhism comparing traditional customs with modernday and analyzing them utilizing digital anthropological principles emphasize the evolutionary patterns of contemporary dhamma sermons

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impact of covid19 on individuals with eating disorders the novel coronavirus pandemic has farreaching effects on both physical and mental health many aspects of the pandemic are already adversely influencing mental healththe disease itself restrictive policies aimed at reducing the spread of covid19 economic consequences and more a third of americans were showing signs of clinical anxiety or depression by late may 2020 addressing mental health needs is an integral part of the covid19 response factors related to covid19 will affect mental health in the general community but may have greater adverse effects on individuals with preexisting mental illnesses reports from china suggest that those with psychiatric illnesses before covid19 experienced a worsening in depression anxiety and posttraumatic stress symptoms during the peak of the outbreak individuals with eating disorders may face unique risks secondary to the pandemic public health measures designed to flatten the curve and the impact of covid19 on food availability may directly and adversely affect the core symptoms of eating disorders including dietary restriction binge eating and compensatory behaviors interviews with patients highlight issues such as intense urges to binge in those with bingeeating disorder when highrisk foods are being stockpiled to guard against disruptions to the food supply anxiety about food availability for those with anorexia nervosa or avoidantrestrictive food intake disorder and changes in the availability of treatment and social supports isolation and economic factors interfering with treatment progress or precipitating relapse specialist clinicians have highlighted the importance of attending to the unique needs of patients with eating disorders during this time and introduced potential adaptations to existing evidencebased interventions in inpatient and outpatient levels of care however the need for datadriven information from individuals with lived experience is urgent to guide clinicians in how best to deliver needed services one study surveyed 32 patients with eating disorders in spain about the impact of physical distancing measures during the first 2 weeks of confinement they also reported qualitative data from a multifamily chat group in the united kingdom consisting of eight patients with an and their carers patients in both groups reported exacerbation of their eating disorder symptoms increased anxiety and challenges associated with reduced contact with their treatment teams suggesting that patients with eating disorders may be at risk for symptom exacerbation andor difficulty maintaining treatment progress during the global pandemic the objective of this study was to characterize the impact of covid19 on patients with selfreported eating disorders and to describe their treatment needs resultant data will inform best practices for clinicians and caregivers and provide a roadmap for eating disorders care during the evolving pandemic as well as other catastrophic events that could interrupt direct service delivery methods participants and procedure participants from the united states and the netherlands were invited to take part in an online study us participants were recruited via social media or via emails to participants who consented to recontact from ongoing studies nl participants were also recruited via social media and involving human subjects act did not apply to this study and official approval of this study by the metc was not required measures the online survey addressed concerns and challenges participants are facing with regard to their eating disorder and general mental health during the covid19 global pandemic the survey was developed in english and translated to dutch the survey was administered using qualtrics in the us and surveymonkey in nl in the us the qualtrics survey options limiting responses to one per ip address and preventing indexing were enabled sociodemographics and illness status participants reported their age sex gender identity and geographic location lifetime eating disorder diagnoses and current illness status were selfreported covid19 exposure and situational circumstances several questions captured covid19 exposure and level of lockdown such as quarantine physical distancing voluntary or mandatory isolation working from home and shelterinplacestayathome orders impact of covid19 on eating disorders questions about covid19related concerns on eating disorders captured the previous 2week timeframe a 4point likertscale asked participants to rate their level of concern about access to and affordability of food and treatment and worsening of eating disorder symptoms due to a lack of structure changes in the social support environment and time spent living in a triggering environment the survey also assessed the impact of covid19 on specific eating disorder symptoms these items were combined to create a mean impact score freetext items queried details on additional eating disorderrelated concerns and any positive changes in their eating disorder or symptoms associated with the pandemic impact of covid19 on general physical and mental wellbeing a 7point likert scale addressed the extent to which participants were worried about exposure to andor contracting covid19 relevant domains included worry about self or others worry about physical andor mental health and changes in overall anxiety levels since the start of the pandemic principal components analysis suggested these items loaded onto one component so a total worry score was calculated the generalized anxiety disorder 7item scale assessed anxiety symptoms and has demonstrated excellent psychometric properties a score ≥10 is a positive screen for gad the survey also assessed whether participants had experienced a change in their levels of anxiety since the end of 2019 whether this change was due to covid19 and any positive changes in their lives related to covid19 circumstances impact of covid19 on eating disorder treatment we assessed covid19related changes to eating disorder treatment modality and for those currently receiving treatment the frequency of sessionscontacts and perception of the quality of treatment one freetext item inquired about the participants perceived greatest treatment needs statistical analysis data from the us and nl were analyzed separately we first report descriptives of the demographics clinical characteristics and covid19 exposure and situational circumstances we assessed the different sections by a descriptive analysis of the quantitative survey items we then conducted oneway analyses of covariance to explore differences between groups on continuous items from the various questionnaire sections controlling for biological sex age and day of study enrollment logistic regression was used for nominal variables we used the following category definitions for group comparisons although individuals could indicate as many eating disorders as they have experienced in their life in currently ill participants for the purposes of analysis we created hierarchical lifetime diagnostic categories ie a person was only included in one category in the order of an bn bed other eating disorders as the a priori goals of the study were to conduct a broad analysis of areas of concern of patients with eating disorders in order to inform providers globally about healthcare service needs we intentionally did not correct for multiple comparisons the us and dutch free text responses were coded independently all responses to each free text question were reviewed counted and grouped into categories which were then grouped in themes themes were then ranked based on the number of individuals providing comments in that theme given our goal of providing strictly descriptive results we did not undertake formal efforts at establishing a coding scheme results quantitative results sociodemographic and illness characteristics table 1 presents demographic information for the us and nl samples which were very similar the mean age was young adult ranging from 16 to over 60 and participants were predominantly female and currently ill or symptomatic us participants were welldistributed from across the country in both countries the majority of participants reported a diagnosis of an the next most common lifetime diagnoses were bn bed atypical an and other specified feeding or eating disordereating disorder not otherwise specified with different distributions between countries less common were arfid purging disorder and nighteating syndrome a full 56 of us and 34 of nl participants reported multiple lifetime eating disorder diagnoses consistent with the known diagnostic fluctuation of these disorders slightly over half of participants in both samples reported being in treatment when covid19 struck we excluded sex as a covariate for nl analyses because of the small number male participants covid19 exposure table 2 presents information on extent of exposure to covid19 in the us virtually all participants had been impacted by covid19 with 99 reported practicing physical distancing only 1 reported having a covid19 diagnosis but many more reported some degree of selfisolation quarantine or working from home seven percent of respondents reported family members who had been infected and 25 reported a family member having lost employment due to covid19 the dutch sample showed a similar pattern98 reported practicing physical distancing and between one third and half of the participants reported voluntary selfisolation or working from home in nl 2 of the respondents reported having a covid19 diagnosis 13 reported family members who had become physically ill and 6 reported a family member having lost employment covid19related impact on eating disorder illness we describe the results for the whole sample combining those who endorsed somewhat or very concerned on items about eating disorder concerns and frequently or daily or more on items about eating disorder illness behaviors the most prevalent concerns were parallel in both countries foremost 79 and 66 of respondents were concerned about worsening of the eating disorder due to lack of structure furthermore respondents were concerned about worsening of the eating disorder due to being in a triggering environment or lack of social support and being unable to access food consistent with their meal plan concerns about having access to enough food or not being able to afford food or treatment were less commonly endorsed in both countries t a b l e 1 descriptive data showed that the greatest impact of covid19 on eating disorder behaviors for us participants was in the domain of feeling anxious about not being able to exercise this question was not asked of nl participants over one third of participants in both countries reported worsening of dietary restriction and compensatory behaviors regular binge eating on stockpiled food was reported by 23 of respondents in the us and 14 in nl individuals with past eating disorders also expressed concerns these comparisons in lifetime diagnostic subgroups in both countries many group differences emerged on the eating disorder concern and illness behavior questions that were generally consistent with diagnostic characteristics for example the an group reported significantly greater concerns about accessing foods consistent with their meal plan and a greater worsening of dietary restriction the bed and bn groups reported more frequent binge eating of stockpiled food the results on the individual items are shown in tables s2 ands3 comparisons by treatment status participants selfreported their treatment status and results are shown in table 6 in the us participants who reported difficulty accessing their treatment provider reported higher mean eating disorder impacts compared to those who reported that they had received facetoface or onlinetelehealth treatment f 694 p 01 in nl there were no differences between these groups f 012 p 91 notably 47 of patients in the us and 74 in nl rated their treatment in the last 2 weeks as somewhat or much worse than usual other comparisons comparisons of eating disorder symptomatology by illness status and level of lockdown can be found in the supporting information were 1261 and 1183 respectively the majority of participants reported an increase in anxiety levels since the end of 2019 and only 02 and 3 of this group reported that this change in anxiety was not at all due to covid19 covid19related impact on general physical and mental wellbeing covid19related impact on eating disorder treatment table 6 presents treatment status over the past 2 weeks most respondents had transitioned to onlinetelehealth care with smaller numbers still receiving facetoface care or not having been able to engage with their provider at all consistent with the literature high numbers of respondents were not receiving any eating disorders treatment comparisons of the impact of covid19 on eating disorder treatment by diagnostic subgroup and level of lockdown can be found in the supporting information comparisons in currently ill versus past ill individuals in both countries participants reporting a current eating disorder us n comparisons by treatment status among those who were receiving treatment there were no significant differences in mean worry score between those who reported that they had not been able to engage with their treatment provider at all note percentages on available data are given us missing data on the first item in the table was 14 the next two items were applicable to only those in treatment and were answered by 240 and 238 participants respectively nl missing data on the first item in the table was 43 and the next two items were both answered by 235 participants abbreviations nl netherlands us united states t a b l e 7 summary of themes obtained from qualitative data united states in the past 2 weeks have you experienced any positive changes in your eating disorder symptoms in comparisons of the impact of covid19 on general physical and mental wellbeing by lifetime diagnostic subgroups and level of lockdown can be found in supporting information qualitative results a series of openended survey questions asked participants to 7 and8 a positive consequence of the changes due to covid19 reported by respondents was a perceived increase in social support that helped challenge their eating disorder behaviors and increase motivation to recover their greatest treatment need was for more discussion we describe the early impact of covid19 and treatment needs in patients with selfreported eating disorders in the us and nl at the time of the study launch the us had been in some degree of lockdown for approximately 3 to 5 weeks in nl restrictions had been underway for approximately 1 month although fairly few participants were directly affected by covid19 the overwhelming majority were indirectly affected anxiety levels were elevated and concerns were high regarding the impact of covid19related factors on their eating disorder and on their mental health in general consequences of the lockdown measuresa lack of structure increased time spent in a triggering environment lack of social supportwere common concerns additionally worsening of eating disorder behaviors was broadly consistent with respondents selfreported eating disorder diagnosis us participants were particularly anxious about not being able to exercise of note even those who were not currently symptomatic endorsed some degree of concern indicating a heightened vulnerability for relapse our results align with other studies showing worsening anxiety during covid19 mean gad7 scores were substantially higher than typical in the general population during nonpandemic circumstances but on par with scores in both general psychiatric disorder and eating disorder samples to our knowledge gad7 has not been assessed in the general population in the us or nl during the covid19 pandemic for comparison encouragingly more than onethird of participants identified that covid19 had led to positive changes in their life many reported a sense of connection with family and friends an ability to focus on recoveryoriented goals and engagement in adaptive coping skills that respondents were able to name positive effects of this pandemic in addition to acknowledging the deleterious effects it has had on their eating disorder highlights the complex nature of individuals experiences we were particularly interested in ascertaining participants perceptions of treatment during covid19 unfortunately nearly half of both samples reported not currently receiving treatment for their eating disorder this is consistent with many previous reports indicating that eating disorders are often underdetected and undertreated for those who were in care most had transitioned to telehealth services at a similar frequency to previous facetoface sessions however the transition was not without challenges in our sample 47 of us respondents and 74 of nl respondents reported that the quality of their treatment had been somewhat or much worse than usual it is not clear what influenced this perception and we underscore that the survey was deployed at a time when many clinicians were just making the transition to remote care followup surveys will allow us to address whether quality of remote care continues to be a concern to our knowledge this is the first largescale study to capture concerns of individuals with eating disorders during covid19 our rapid deployment had limitations first eating disorder diagnoses were selfreported as interviews were not feasible in the timeframe second despite many striking similarities differences between the us and nl emerged in terms of sample composition as well as the countries approach to pandemic controlwith the nl strategy being more comprehensive and uniform and the us being more fragmented moreover differences in these strategies and stage of the pandemic at deployment could affect responses our use of convenience sampling could introduce bias as individuals who were most worriedconcerned might be more inclined to participate some of our questions may have used language that could be interpreted in multiple ways such as triggering environment and lack of structure we also mistakenly omitted the question on raceethnicity which we will critically include in subsequent waves especially given the disparity in covid19 outcomes across racial and ethnic groups finally our use of predetermined questions did not allow for an unbiased survey of respondents concerns however we hope that the inclusion of free text questions encouraged sharing of both negative and positive experiences although outside of the scope of the present study given that many individuals with eating disorders returned to their families of origin during lockdown it would be of value to document the impact of covid19 on carers and family members experiences particularly with relation to stress burnout mealtimes and healthcare provider support in summary individuals with eating disorders may be experiencing a worsening of symptoms and those with past eating disorders may be vulnerable for relapse during covid19 although these data are primarily descriptive we aim to provide preliminary guidance to healthcare providers about ways in which data availability statement data availability data will be made available at the end of the 12month followup period via the open science framework conflict of interest c m b reports shire idorsia pearson c m p reports sunovion supporting information additional supporting information may be found online in the supporting information section at the end of this article

objective we evaluated the early impact of covid19 on people with selfreported eating disorders method participants in the united states us n 511 and the netherlands nl n 510 recruited through ongoing studies and social media completed an online survey that included both quantitative measures and freetext responses assessing the impact of covid19 on situational circumstances eating disorder symptoms eating disorder treatment and general wellbeing results results revealed strong and wideranging effects on eating disorder concerns and illness behaviors that were consistent with eating disorder type participants with anorexia nervosa us 62 of sample nl 69 reported increased restriction and fears about being able to find foods consistent with their meal plan individuals with bulimia nervosa and bingeeating disorder us 30 of sample nl 15 reported increases in their bingeeating episodes and urges to binge respondents noted marked increases in anxiety since 2019 and reported greater concerns about the impact of covid19 on their mental health than physical health although many participants acknowledged and appreciated the transition to telehealth limitations of this treatment modality for this population were raised individuals with past histories of eating disorders noted concerns about relapse related to covid19 circumstances encouragingly respondents also noted positive effects including greater connection with family more time for selfcare and motivation to recover discussions covid19 is associated with increased anxiety and poses specific disorderrelated challenges for individuals with eating disorders that require attention by healthcare professionals and carers

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introduction technological innovations have changed domestic work dramatically since the beginning of the twentieth century in every country and context where these modern shifts applied these have happened in tandem with changes in the position of women in society affecting relationships between women of different social classes and between women and men these concerns are topical in view of discussions about migration movement of women informing current globalization debates these movements have been partly fuelled by the employment by better off households in richer countries of women domestic workers from poorer countries in brazil wealthy homes have always had large amounts of cheap domestic labour available to import from poorer areas how is this practice configured in relations of inequality in the country what effects does it have on household technologies consumption how are deeply entrenched social differences in the home lived with on a daily basis and justified the exploration of these issues in this paper aims to contribute to further reflection about the global woman debate bridget andersons study of the politics of domestic labour in contemporary europe shows the predominance of racialized groups in paid work in the home and calls attention to the pernicious effects this employment has on relations between middleclass women and men who thus avoid both conflicts and challenges to their entrenched gendered positions of inequality andersons perceptive study points to the gender and generational conflicts implicated in the employment of a person to do domestic tasks she argues that the employment of paid work in the home creates particular sorts of relationships developing personhood not just as a worker but also as an employer and entailing particular sets of gender relations central to the construction of personhood is the consumption of care in the buying and selling relation anderson argues following arlie hochschild that as women flee from home into outside employment no one is left to care the new domestic workers thus fill this gap yet while the argument for the centrality of the need of buying love in the new domestic labour contracts is doubtless important the material dimensions of this work which remains arduous and lengthy need to be kept in focus there are many reasons for considering the emotional and the material dimensions together one relates to how they both link with unequal relationships predicated on positions of class gender and race another refers to cultural needs of material and emotional care demanded within particular moral environments justifying particular patterns of relationships in domestic life one other salient reason refers to concrete material conditions related to demands of contemporary lifestyles in this paper i focus specifically on the reasons i call ordinary morality and on how housework technologies are deployed as part of the materiality of ways of living these are explored within the specific configuration of relationships of class gender and race prevailing in brazil i argue that a major implication of the widespread use of paid domestic work is to hinder technological developments for housework this crucial political outcome has been neglected in feminist debates about domestic labour women and homes remain marginal to technological innovation concerns the cost of womens domestic labour is central to these developments while technological modernization in machines for housework is uneven at a global scale different levels of availability of domestic workers play a significant role in the differentiated patterns of innovation across regions yet domestic labour availability is not simply a numerical concern the ways in which the social relations implicated in its deployment are justified constitute the moral context enabling its use as resource for the social position of those able to pay the material and the moral are interlinked on the basis of participant observation secondary data and a case study in the south of brazil i discuss maids machines and moralities in households the ethnographic study was carried out in 1997 in the southeast of brazil in the affluent region of greater campinas in the state of são paulo the study centres on the differences between poor and middleclass homes regarding womens work and the gendered domestic divisions of labour with a particular concern with how paid domestic work affects the division of labour in households and the consumption of household technologies there was no intention to produce a representative sample of the population in statistical terms but i wished to capture the relationships of women and men with domestic labour and i wanted to include a wide range of social experiences of this kind families were selected according to their significance for theory ideas and concepts i carried out participant observation and 55 semistructured interviews in 30 families all families had dependent children 22 of them included children of school age women defined themselves as housewives in 9 households 21 families selfclassified as white the brazilian case has some parallels with those in more developed countries for instance in britain the growth of female employment particularly that of married women has like in brazil been sharp since the 1970s in a longer historical trend uk consumption of technologies for the home grew enormously in the 1930 when domestic servants were fast disappearing but does the brazilian trend reflect a process towards greater equality between women and men and among women broadly similar to those in developed countries how have womens jobs outside the home affected the patterns of domestic living what has happened in brazilian homes when women have in growing numbers taken on outside employment as paid domestic labour becomes an increasingly significant feature of middleclass home life in contemporary europe and north america through processes of the displacement of the poorer women across the globe an exploration of the brazilian case is illuminating contradictions of economic development within brazil have resulted in great disparities of wealth which somewhat mirror the patterns of inequality in the context of home life of the international contexts involved in the domestic work world exchanges on a global scale brazilian specificities also remain maids in rio de janeiro in the southeast of brazil maria the maid stepped out of the kitchen at 1pm bringing food to the table ronaldo anita and their children fernando and manuela sat around it so did i as a friend of anita we had a salad for starter four hot dishes to choose from two desserts and cold and hot drinks it was a normal weekday when the meal was finished everyone moved on to their personal affairs and the table was left for maria to clear maria lived in a small bedroom in a secluded part of the house adjacent to the kitchen this was the service area where laundry ironing and cooking was done hidden away maria was only seen when she served water coffee at meal times or while she quietly and unobtrusively made the beds mopped the floors and cleaned the bathrooms in the morning maria was up before 7am to serve breakfast and she was still up at 9pm clearing the table after dinner maria came from the northeast and had been working for anita for about 10 years anita relied on maria for all the housework anita was an academic like me she worked on poverty and land reform in the northeast she would never consider her everyday life without a maria she did not engage with my attempts to converse about servants and their social inequalities anita was brazilian all the people in this scenario are white in recife in the northeast of brazil vanya went shopping with janice her cook janice pushed the trolley picked up the goods and placed bags in the car vanya told janice what to buy paid and drove the car at home janice removed bags from the car and put the goods away the livingin nanny teresa looked after 5 year old julian keeping him out of the way so that cida the cleaner could get on with her jobs i was a friend of vanya staying for a few days i could not even make myself a cup of tea or get a glass of water from the kitchen whenever i stepped in through the door a servant offered to attend to my needs vanya was an academic like me working on sexuality and race she could not imagine a life of looking after children doing housework relating to a partner and researching in culture without a janice a teresa and a cida vanya was english everyone in this scenario is black except for my friend and i these are two stories of people with widely varying cultures and social positions all were immersed in a world of deep social inequality anita alone earned ten times more than she paid maria maria worked very long hours had no pension house or security they were the same age vanya paid her three servants together in recife as much as anita paid maria alone in rio this was why northeastern maria was grateful to have her rio job both anita and vanya had husbands who earned quite a lot more than they did the income of each one of the families was about 40 times higher than their servants wages the husbands were seen by anita and vanya as sensitive men good providers and supporters they did no housework or childcare but then… even i could not get myself a glass of water without having it offered to me on a tray why was it so easy for my welloff friends to live a comfortable life with such social inequalities crying out from within their homes the ease of access to the labour of others obviously derived from economic inequalities but the moral issues also appeared significant how was this seen as a proper way of running homes what political consequences did it have for wider economic and social contexts moreover how could these practices coexist with contemporary transformations of womens position in the labour market and in society one of the most significant changes in brazil since the 1970s has been the increasing participation of women in the labour market this is linked to economic necessities and employment demands but also to demographic and cultural changes like a reduced fertility rate and increased education already in 1995 40 per cent of the brazilian workforce was female this rate was 45 per cent in the more developed são paulo metropolitan region in 2001 in 2005 there were 53 per cent of women in the economically active population the increase has been greater in urban areas and in the most developed regions married cohabiting and separated women have played a bigger part in the employment rise than single women the proportion of married women working has been more than half since 1993 ethnicity has strongly shaped the place of women in the employment structure a recent study by the international labour organization based on data from brazilian national statistics shows that the difference between black and white women employed as domestics is large 24 per cent of blacks against 14 per cent of whites yet the proportion of all women employed in domestic labour has decreased particularly in the more developed urban areas where this kind of employment has been more prominent in a related development the consumption of technologies for housework has grown since the 1960s the consumption of these technologies relates to increased purchasing power lower prices of goods changes towards smaller family units and also to different ways of dealing with housework demands in terms of levels of wealth colour of skin and employment of domestic labour the households in my study show a striking picture of inequality and subordination in the home skin colour grows whiter as the income level increases the employment of paid domestic help increases with income and the whiteness of the skin figure 1 indicates that the place of individuals in society and their access to the labour of others appears firmly based on income class the proportion of families in each level of income in this study is far from being statistically representative there is a deliberate larger intake of higher incomes because of a concern with the effects of paid domestic service on the gender division of labour and on inequalities in the home for brazil as a whole at the time of my study more than 50 per cent of the population earned below 2 minimum wages with just 5 per cent earning more than 10 minimum wages the region investigated is one of the most affluent in brazil with a population affording much higher incomes than for the country as a whole thus it is to be expected that a statistical representation of these variables would show a staggering disparity of what is here qualitatively represented i indicate five income categories to grasp the gradient of very high wealth disparity all the paid domestic help were females figure 1 the majority of women in these households had employment outside of the home seven had no earnings and two earned only very small amounts one from childminding and another from architectural design all of them were mothers of small children and five of them were lonemothers they mostly had busy daily schedules women contributed half or more of the household income in over onethird of the families there were only four women who were sole household earners and they were all in the lowincome group three of the women in the lowincome group worked as maids in wealthier households these were the only three maids included in their home contexts in this study 1 womens income was absolutely significant for the economy of their households when in the lowincome group but it was also important in the middlehigh and upperlow income households despite this the womans income did not change her status in the home in any significant way this is confirmed by cynthia sartis study of poor families in são paulo who argues that the distribution of authority in the family was based on the different and traditional roles of men and women however in the families i studied it was often the womans income that objectively positioned the household in a higher income category it was only in the middle income households where women who did not earn any income were found in the middlelow income group a more conservative household strategy of having a sole earner was stronger although women earned fairly well in the upperhigh income group their income did not make a great difference to the wealth of their homes men earned sufficiently high incomes by themselves in this group overall the significant participation of women in the labour market did not reflect an equally important contribution to the financial resources of the household womens earnings were most important when hardship was greatest but it made no significant impact on overall wealth levels within the best off group the everyday routines of the women in the wealthier households that employ domestic labour appeared fairly disengaged from their childrens routines welloff mums childcare activities involved taking to and picking up from school feeding in the evening and putting into bed getting children out of bed and feeding them breakfast and lunch was predominantly done by maids or nannies in one of the homes the maid had to spoonfeed a pampered 4year old but the mother did not count this among the household caring activities children in upperlow and upperhigh households ordered maids to do things for them and expected their whims to be fully attended to or they would tell off the maid for a group of privileged children a culture of expectation of being serviced by a lower class person has been part of their growing up there are basically three ways in which women who do household work without pay can attempt to diminish their burden one is by employing someone else to do the work or some of it another is by putting pressure on the state for the provision of some public services to lessen this work a third way is by deploying household technologies to facilitate the work these three strategies can be combined this paper considers the first and third as the research found no evidence of housework burden issues being pressed upon governments either at a local or national level however i reflect about government intervention in domestic service in the conclusions machines ownership of household technologies has increased sharply in brazil all the families i studied had cooker fridge and washing machine or equivalent however there were estimates that in the mid1990s only 75 per cent of brazilian homes had both fridges and cookers these are universal household goods in countries such as great britain and the united states the washing machine owned by 16 of the families was of the most basic kind called tanquinho this is a 4kg capacity washtub which fills automatically with water has a bleaching agent compartment but no soap dispenser and switches off automatically it does not spin dry five of the six poorest families owned a tanquinho while four more tanquinhos were owned by middlelow income households and another four by those of middlehigh income however the two later groups also owned older washing machines which were used to spin dry clothes washed in the tanquinhos only the two upperincome groups did not own any tanquinho because they had access to better quality washing machines clearly the job of doing the laundry is more difficult with lower quality equipment wringing clothes by hand or transferring from tanquinho to spin increases labour considerably but ownership of good quality technology did not necessarily mean ease the household tasks of all concerned figure 2 in two homes two cookers were in use in the montes household the newer cooker had been a present from the mans mother it was installed opposite the old cooker which was used for frying and for making dirtier or longer cooking foods at the oliveiras two kitchens were installed a new fully fitted kitchen had been built and the old one had been transferred to an area of the service house where the maid cooked but the fridge had not yet been installed and the maid needed to walk about 10 meters between the cooker where she cooked in the service house and the fridge in the new kitchen inside the house this had been her daily routine for six months after washing up manually in the service house the maid transported plates pots and cutlery to the new kitchen where they were kept the new kitchen was used only on weekends by the woman of the house while this use of two kitchens is exceptional it has a curious historical counterpart in colonial times when slavery prevailed in the betteroff homes it was common to have two kitchens the clean kitchen was located inside the house the dirty kitchen outside in the dirty one laborious sweets and desserts were cooked and the heaviest and less hygienic tasks were carried out one explanation for this spatial division of cooking activities has emphasized that contrary to europe where the heat of the hearth provided cosiness the brazilian climate made the range an object that was undesirable in the domestic space however there are references that even in the very cold south proper cooking was done in small tents built in the back yards of houses an explanation that may suggest that external kitchens aimed to provide a spatial separation that reflected the social divisions between masters and slaves which echoes maids and employers relations nowadays as rita oliveira says i have built an outside kitchen for the maids to use because i got tired of having my kitchen scratched… they the maids wrecked it all the ways in which the performance of everyday domestic tasks is made easy or difficult reflect unequal social divisions for instance it was accepted that electricity should not be used if it could be substituted by the labour of maids and also it was widely perceived that maids could damage household technologies if they were allowed to use them many stories of damage or of protective strategies by the mistresses were told from a sociological and economical point of view the rationality of such practices rests on both the low labour cost of maids and the relatively high cost of electricity and technologies underlying these reasons there were also the lack of skills to operate machines due to low literacy and the absence of training in the operation of technologies for those very persons who should in fact be their main users the maids the women employed to do housework in homes with everything were unable to make use of the equipment designed to make housework easier better more efficient this technology was predominantly used on weekends when access to the labour of servants was not available the current use of labour is careless and wasteful because it is cheap and abundant training is not provided tasks are not made easier these practices are informed by the social morality prevailing in the country morality how are people involved in and how do they justify their practices when they seem to be stuck in places of deep social differentiation i explored the ordinary morality of domestic labour through the application of a vignette to participants in my study my concern was with a particular morality or ethics of care as defined by tronto this refers to moral sentiments not to reason it is a morality of the daily experiences and moral problems of real people in their everyday lives in practical terms my method involved reading a vignette story to an interviewee and asking their opinion about what the characters in the story should do i applied four vignettes in this study the moral reasoning portrayed by the one i present in this paper is mirrored in the other three even though each of them addresses different dilemmas of everyday home life i talked to each adult separately the vignette explored here is a long one about a familys relationship with a maid i used a method of building in a temporal dimension and altering the circumstances of the characters at a latter stage respondents were invited to make a choice about what ought to happen in the first second and third stages this increased the complexity of my story the vignette story usually triggered the telling of further related stories about the respondents their friends and families the assumption built into this method is that meanings are social and that the choice of a particular action brings out both the personal and the public morality of relationships the story is a hypothetical situation based on real life occurrences the context is typical of brazil and the language reflects relationships and takenforgranted assumptions about the roles of individuals for instance to address a maid by dona before her name is often a sign of respect indicating that she is older but it can also carry an idea of affection or mark a social distance a man who looks after his son with the assistance of a fulltime livingin maid is clearly not doing it on his own when the story says he does do so it colludes with the invisibility of the maids job respondents can either remark on this or agree with it isabel and sérgio had a 7year old son pedro they lived in a big and comfortable house they both had fulltime jobs and a maid dona margarida had been employed for 4 years dona margarida looked after the house and pedro sending him daily to school and she was an excellent cook she lived in the house and had saturdays and sundays off isabel died suddenly and sérgio had to look after pedro on his own dona margarida worked as before sérgio and pedro never cleared the table washed up or made beds they took a shower in the mornings and left their damp towels on the bathroom floor… it was always dona margarida who looked after everything and now she looked after some of the things that isabel used to do her work increased and she was tired do you think that dona margarida should • ask sérgio for a wage increase • ask sérgio to hire a helper for her • leave the job • ask sérgio and pedro to do some of the tasks that isabel used to do before respondents who were poor tended to identify with the maid but feared that she should not leave the job since jobs were difficult to find and the orphan boy was attached to her because she was clearly important to the family she should hint at a need for compensation for her increased effort as a priority she should mention the need for a helper but she should take what the boss would choose to give her either help or wage betteroff respondents tended to emphasize the emotional attachment more than half of the respondents suggested that the maid should ask father and boy to do the tasks the late mother used to do while nearly half of them did not remark on the fact that sérgio and pedro created some new tasks for dona margarida however the welloff were more likely to suggest that father and son should do some of the tasks while most lowincome women said dona margarida should have a helper perhaps these women believed that the practical help the maid could get from sérgio and pedro was not going to be very effective only one person a man said the maid should leave the job independently of the respondents choice i carried on with the vignette unfolding the story dona margarida asked for nothing and carried on doing her job and getting tired one year later sérgio got a girlfriend cléia who came to live in the house dona margaridas work increased because cléia did the same as sérgio and pedro and cléia and dona margarida did not get on well what do you think dona margarida should do • ask sérgio for a wage increase • ask sérgio to hire a helper for her • leave the job • ask sérgio pedro and cléia to collaborate by doing some tasks in this second episode i presented the situation unfolded one year later this contradicted some respondents previous opinions i deliberately portrayed a maid of submissive character in order to test the morality of the command submission relationship since my key concern was with how relations of inequality were perceived and dealt with in the home this does not imply that servants in brazilian homes are all submissive like dona margarida appears in this vignette indeed many practices of resistance are also found described by jurema brites as subtle tactics of insubordination which include borrowing without permission clothes from employers and stealing food or objects in the vignette the maid carried on as before never making any demands or letting her boss know that she felt overburdened the new girlfriend living in the house acted just like father and boy the maids work increased i invited respondents to say what dona margarida should do repeating the same alternatives as before the gender dimension became relevant this time the most common reply now mostly by women was that the maid should leave the job this was because a potential substitute mother had emerged changing the situation and creating conflict dona margarida was then freer of the inputed emotional ties interestingly unlike in the first situation now those with higher income predominantly said that dona margarida should leave the job underlining the gender dimension of care in which the girlfriend could substitute for the emotional labour of the maid and confirming the caution of poorer respondents about losing a job i then carried the story further to a final episode where the maid chose not to ask for anything but one year later lost her job due to growing conflict with the girlfriend however dona margarida found another job at a neighbouring house six months later sérgio got in touch asking her to return he had broken up with his girlfriend i did not offer any alternatives as answers but asked again what do you think dona margarida should do some respondents thought she should now remain where she was but more than half in similar proportions by gender thought she should return to the old job because of the emotional ties with the boy and his father she cannot abandon the child because she loves him she should go back because of the boy hes like a son… but ask for a helper she should go back because there was a friendship and this counts a lot in reality she helped bring up the child she already had intimacy with the home return in a reversal of the pattern in the previous round the suggestions that dona margarida should return to the old job predominated among those with higher income while those with lower income tended to agree that the maid should not return to the old job resistance by the poor to being played off by the wealthy now surfaced the fear of job loss no longer existed but the richer felt the loss of care and the emotional attachment by the maid was claimed back both submissive acceptance and resistance as well as affective ties are apparent in the reactions to this vignette indicating a complex relationship between poverty and obedience money and affect with the important exception of this last moment in the story when the poorer would choose the maid not to return to the old job this vignette shows that respondents choices were consistent with a prevailing morality prescribing the dedication of the dispossessed to the welloff this reflects what teresa sales in her study of northeast brazil referred to as the political culture of the gift it implies passivity and gratitude of the receiver in face of the giver and relates to a history in which slaves were dispensable depending on the gift of their superiors for their very survival from this context as remarked various analysts evolved a culture of social and political submission here the maid was not simply a worker but a devoted carer however the respondents acceptance of mens detachment from housework and care did not equally apply to women the late mother used to do some tasks like cleaning the table washingup in the evening or making beds and picking up damp towels from the bathroom this shows that welloff women can effectively have hands on light housework despite the colonial ideal portrayed in contemporary soap operas of madams avoidance of all physical work the girlfriend too was expected to do these household tasks and not to behave like the father and the boy did as illustrated by reginas comments she should return… after so many years… what prevented her was the girlfriend resistance was mainly from the poor some remarked that dona margarida had been mistreated and that leaving damp towels on the floor was unacceptable some criticized sérgio for treating her as a change of clothes in and out depending on having a girlfriend it was clear for some that dona margarida deserved much better treatment also she was the ideal caring maid of many peoples dreams as shows dércio if there is affection for the family she should go back i would like my maid to have an emotional link with the family or at least with naomi naomi was his 3year old daughter and dércio had complained of his maids lack of emotional attachment to her the pattern of gender relations in which most brazilian domestic life is centred around the needs of men where the woman services and the man provides is socially pervasive and it is the ideologically dominant pattern even where the woman is also a provider in the vignette or in accounts of real everyday life triggered by the story of the vignette it was not surprising that men did not do anything in the home a particular sort of patriarchy supports these gender relations sustained by highly unequal relations of class which affect intergender dynamics more specifically deep social differences based on class and race appear to contribute to a reduction of domestic conflict in relationships between women and men in welloff homes julia souza was one of the first to point out the paradox that some brazilian womens liberation came at the cost of the subordination of inferior women she focused on the economic implications of this labour relationship for capitalist development and also reflected on the inconsistencies of brazilian feminism following on from this suely kofes sandra azeredo and others have also argued that professional women may be able to progress in their careers because they can make use of the services of other women for domestic service moreover danielle ardaillon has argued that the maid is the big problem of the professional woman central to domestic life their absence or disruption deeply affects the routine of the family and celma vieira has emphasized the easier progress of white women in general at the expenses of black maids vieira has also observed how the living areas of maids in modern houses resemble the structure of colonial architecture which separated manor house and slave quarters although only a few families employ live in maids the little bedroom and bathroom designed for maids are revealing of the status of domestic servants either employed everyday of occasional daily cleaners as donna goldstein describes the toilet normally has no seat the shower has no curtain and water damps the whole room the bedroom with a tiny bed is used to store all sorts of unwanted and desused items in the household at the end of the twentieth century i still found evidence that the widespread use of domestic servants by the upperand middleclasses had taken the edge off many conflicts about gendered domestic divisions of labour since more menial domestic labour was given to poorer women as reactions to the vignette showed orders from middleclass men to lowerclass women were perceived more strongly as a right than the ordering to do that goes between women this study has focused on the wealthier southeast of brazil but the social divisions between servants and betteroff household members are even sharper in the north and northeast regions the value of domestic labour is lower and the demands for care from the wealthy are greater where poverty is higher the price of brazilian domestic labour increases considerably as one moves south and is highest in the big urban areas but even in the economically affluent region of greater campinas maids in middleclass households are rarely allowed to use all available household technologies this is a consequence of the cheapness of domestic labour and it affects the patterns of development of household technologies the good quality cookers and washing machines are very expensive or imported while the cheaper ones still demand considerable amounts of labour input for their operation although prices of technology have dropped overtime the cost of domestic labour has not increased sufficiently to make it attractive to replace maids with machines the earnings by the poorer have not been sufficiently high to generate new waves of demand for technology in the home in certain respects this fits into the model of brazilian society that some economists have called excluding modernity it has been based on income concentration and sophisticated consumption for a minority of the population and exacerbates social differences the fact that some better off women find that they need to have washing machines in order to keep their maids may be a small indicator of a trend towards less inequality conclusions reminiscing about the feminist debates in the 1970s in the united states barbara ehrenreich writes that t he radical new idea was that housework was not only a relationship between a woman and a dusty bunny or an unmade bed it also defined a relationship between human beings typically husbands and wives she goes on to say that talking about housework was to talk about power the degradation of housework was not derived from it being manual labour but from the fact of the person who is cleaned up after being consistently male while the person who cleans up is consistently female rendering housework as a symbolic enactment of gender relations analysing the contemporary servant economy ehrenreich remarks that i ncreasingly often the house cleaner is a woman of color and a recent arrival from the third world bringing about the challenge of making this work visible again if as she argues t he growing servant economy… is largely a result of mens continuing abdication from their domestic responsibilities housework is not however the same sort of work that it was the current context in developed countries is permeated by an array of machines services and nearly ready products as part of a new technological nexus enabling a lifestyle less dependent on long domestic labour hours care of children and of other needed persons and some household tasks do remain essential for quality daily living but the context is different from that of the 1970s in brazil however continuities are stronger of course a lot of feminist ideas have been debated in brazil and many have been productive in bettering womens social stand however not much has yet affected domestic relations though womens paid two different scenarios demand reflection from the case explored in this paper in one brazilian domestic service dwindles like it did in the uk in the 1930s and in the us after the second world war would greater equality in the home and increasing modernization of household technology ensue in the other current increasing use of immigrant womens domestic labour in europe and the usa may come to affect the machines for housework and morality of everyday living in the home slowing the pace of changes in gender relations the challenges for feminist thinking posed by both scenarios are pressing

this paper engages with debates about the increasing use of paid domestic labour in europe and the usa contributing with a reflection about the case of brazil relations of gender class and race are considered in the deployment of maids for housework the patterns of consumption of household technologies and the moral reasoning of daily living with hierarchical divisions within the home the paper considers some parallels between the brazilian context and that of more developed countries and also the specificity of brazil based on participant observation secondary data and an ethnographic study rich empirical data are weaved through to discuss material and moral dimensions of domestic labour and care how does the availability of cheap domestic labour configure relations of inequality how are social differences in the home lived with and justified the exploration of the brazilian case illuminates some of the problems contradictions and possible consequences of wealthier households benefitting from the displacement of poor women that is currently happening through international migration the paper argues that in brazil the deflecting of tensions in gender divisions of labour in households onto a subordinate person has affected relations of equality between women and men and also the patterns of technological innovation to facilitate housework these are outcomes to be guarded against in europe and the united states in face of the current trends in global woman relations

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introduction perceived risk is related to judgments about susceptibility to disease as well as the probability of benefit from preventive actions and interventions 1 the literature regarding risk perception in low income and underserved populations is still relatively undeveloped for several cancers including cervical cancer where there is a clear relatively defined set of risk factors and preventive actions in the us disparities exist whereby hispanicslatinas have the highest incidence of cervical cancer and african americans have the highest mortality 2 this pattern may be explained in part by differences in screening utilization 34 lower screening rates may be attributed to low perceived risk of cancer and limited knowledge of cervical cancer risk factors 5 6 7 8 which may mediate the relationship between risk perception and screening rates 910 women who smoke are exposed to secondhand smoke 1112 and who have been infected with particular hpv serotypes are at greater risk of cervical cancer 13 examining whether women who possess one or more of these known risk factors actually perceive greater disease risk remains an important question similarly perceived test accuracy has also been found to be an influential factor on perceived risk of cervical cancer as many women have shown concern regarding the overall accuracy of their pap test 1415 the objective of this study was to examine perceived risk of cervical cancer among a low income diverse population of women by comparing selfassessed risk of cervical cancer perceived prevalence of abnormal test results for others and perceived pap test accuracy by sociodemographic variables and known risk factors methods and materials study design and sample selection this investigation was part of a larger study that recruited women undergoing pap testing at one of two university of texas medical branch regional maternal child health outpatient clinics between october 25 2002 and june 1 2003 women were eligible for participation if they were between 18 and 55 years of age and selfidentified as hispanic latina white or african american written informed consent was obtained from all women prior to participation participation involved completing a selfadministered questionnaire in english or spanish the study was approved by the utmb institutional review board measures a short questionaire was used to gather data on age raceethnicity marital status education household income employment status smoking status and history of genital warts hpv infection and other sexually transmitted infections perceived risk of cervical cancer was assessed by asking what do you think is your risk of ever getting cervical cancer in your life time from 0 to 100 where 100 meant you definitely would get cervical cancer and 0 meant that you definitely would not the questionnaire included the openended question please write why you think this is your risk perceived prevalence of an abnormal result was measured by asking if you had to guess what percent of women who come to the utmb clinics have ever had an abnormal pap smear using the same 0 to 100 metric estimates of pap test accuracy were assessed by asking out of 100 pap test results how many do you think are incorrect in addition we measured the expectancy of obtaining an inaccurate pap test result with a likelihood statement if i came back for followup of an abnormal pap smear i might find out that the first result was wrong and an evaluation statementfinding out my abnormal result was wrong and my pap smear is normal would be the best thing i can imagine hearing from the clinic a 6point likerttype scale ranging from strongly agree to strongly disagree was provided for each statement for analysis responses were recoded into agree and disagree analysis quantitative analyses were conducted using ibm spss statistics analysis of variance was used to examine participants estimates of their own lifetime risk of cervical cancer prevalance estimates of abnormal results and pap test accuracy by participant characteristics bonferroni adjusted p values were examined for pairwise comparisons pearson correlation coefficients were computed to evaluate associations between continuous variables a twotailed alpha level of 005 was considered statistically significant the openended responses were content analyzed and categorized results a total of 429 women met eligibility criteria of these 356 initially agreed to participate women who refused differed from those who initially agreed with respect to raceethnicity χ 2 4380 p 0001 and insurance status χ 2 748 p 001 disproportionately more latinas refused the study relative to white and africanamerican women while women insured through medicaid or indigent care had higher refusal rates than privately insured women of the 356 who initially agreed to participate 338 women completed the survey while 18 women did not a greater proportion of women who had accepted the survey but did not complete it were hispaniclatina relative to white or african american χ 2 1756 p 0001 the mean age of the sample was 299 ±86 years additional participant characteristics are shown in table 1 one participant was excluded from further analyses due to inappropriate responses on focal survey questions leaving a sample size of 337 perceived risk of cervical cancer womens assessments of their own lifetime risk of cervical cancer ranged from 0 100 with a mean of 592 ±295 risk estimates were positively correlated with perceived prevalence of abnormal results r024 p 0001 and perceptions regarding the accuracy of the pap test r013 p 005 perceived risk was not significantly associated with age race ethnicity education income smoking status expectancies regarding an inaccurate pap test result or selfreported history of an abnormal pap test result hpv genital warts or stis the openended responses regarding risk estimate justification are shown in table 3 of twelve 2 cervical cancer risk factors recognized by the american cancer society women in this study recognized eight risk factors hpv infection sexual behavior smoking stis family history contraceptives multiple pregnancies and des exposure women who reported having a family history of cervical cancer or other kinds of cancers and having a history of an abnormal pap test primarily used the upper end of the rating scale to reflect their own risk most women who indicated lower percentages expressed that they do not have a family history of cancer have regular check ups or have had a hysterectomy it is important to note that while the lifetime risk of cervical cancer for the average woman is likely much lower than many of the risk estimates provided in this study there were wide variations in the percentages offered for the same recognized risk factor for instance while a total of 10 women included smoking in their risk estimate justification two current smokers reported highly discrepant lifetime risk estimates estimated prevalence of abnormal pap test results for others on average women estimated that nearly half of all women who receive pap testing at the clinic have ever had an abnormal result these estimates were positively correlated with pap test accuracy r032 p 0001 furthermore the perceived prevalence of abnormal results for other women differed by raceethnicity of the respondent f489 p 001 specifically africanamerican women estimated a higher percentage of other women who have abnormal pap test results compared to hispaniclatina and white women women who experienced an abnormal pap test result reported higher proportions of other women experiencing an abnormal result t 367 p 001 pap test accuracy estimates of pap test accuracy ranged from 0 to 100 women who agreed with the statement if i came back for followup of an abnormal pap smear i might find out that the first result was wrong reported higher estimates of pap test inaccuracy than women who disagreed with this statement t26 p 005 estimates of pap test inaccuracy were unassociated with participant age raceethnicity education income smoking status expectancy of an inaccurate pap test result or selfreported history of an abnormal pap test result hpv genital warts or stis conclusions and discussion this study contributes to womens health by focusing on quantitative and qualitative perceptions of risk perceptions regarding how common an abnormal pap test result is among women attending routine screening and beliefs regarding the accuracy of the pap test no differences were observed in risk estimates based upon factors that would suggest higher risk such as older age smoking status prior history of an abnormal pap test result or hpv infection it is possible women do not recognize these factors as placing them at higher risk of cervical cancer indeed a lack of knowledge about risk factors for cervical cancer is an explanation that is congruent with other findings 5 6 7 8 however qualitative data obtained in the present study suggest that women are not unaware of these risk factors other explanations exist beyond lack of knowledge including optimistic bias illusion of invulnerability or wishful thinking importantly if the current study stopped at examining quantitative risk estimates a critical part of the story would have been missed the qualitative data reflecting womens rationale behind their risk estimate are unique to this study and suggest that women do in fact recognize several key behavioral risk factors for cervical cancer in the current study women recognized eight out of twelve risks factors acknowledged by the american cancer society 2 in several cases womens answers were not technically correct but they provided explanations that indicated an appreciation for risk and protective factors such as having an abnormal pap result in the past skipping exams and delaying treatment of an abnormal result in this study africanamerican women reported higher proportions of other women experiencing an abnormal pap test result relative to hispaniclatina and white women it is possible that awareness of the higher death rate of cervical cancer among african americans may contribute to this finding although further work is needed to support this explanation historically lower participation rates in cervical cancer screening programs among african americans may also provide insight into this finding 1617 but the relationship is unclear cognitive constructs such as risk perception are not necessarily interpreted in the same way in different cultures 18 thus further research is needed to explore cultural nuances recognizing that the racialethnic groups examined in this study are not monolithic this study included a convenience sample of women within the southern region of the us latinas and women with public insurance were more likely to decline participation in the study therefore the conclusions that can be drawn are limited by these factors with regard to generalizability nevertheless the geographic location is important for targeted education efforts as texas has one of the highest incidence rates for cervical cancer 2 similarly this study included women already attending a clinic appointment for pap testing thus the findings may be biased toward those who have a greater awareness of cervical cancer and its prevention however our data suggest that education remains essential so that women who attend screening are fully informed about the limitations of pap testing our results emphasize the importance of educating patients regarding cervical cancer screening particularly given recent changes in recommended intervals screening intervals are now spaced out to 35 years the change from annual or biannual screening to less frequent testing may be alarming to women who perceive an inflated personal risk of developing cervical cancer clearly communicating that the individual risk is low and that cervical cancer develops slowly from precursor lesions may help reduce patient anxiety while increasing acceptance of and adherence to the new testing intervals findings from this study provide further understanding of the perceived risk for cervical cancer among a diverse population of relative socioeconomic disadvantage and underscore the general inaccuracy of womens perceived risk or personal susceptibility regarding cervical cancer and the importance of addressing this issue in clinical practice the findings elucidate the complexities surrounding how women perceive their own numerical risk of cervical cancer and how they rationalize this estimate which pose a challenge for health professionals it seems particularly important for health care professionals to appropriately calibrate womens perceptions regarding their lifetime risk of cervical cancer as well as inform patients of the limitations and importance of the pap test with or without hpv testing in light of currently changing screening guidelines précis this study advances our understanding of how women qualitatively view their risk of cervical cancer thus highlighting areas for practitioners to enhance patient education efforts themes representative quotes

backgroundrisk perception is an important predictor of cancer prevention behaviors we examined perceived risk of cervical cancer among an ethnically diverse population of women of lower socioeconomic status materials and methodsfemales attending a womens health clinic were recruited for a study addressing cervical cancer prevention survey questions evaluated lifetime perceived risk of cervical cancer 0 to 100 beliefs about the accuracy of the pap test and estimated incidence of abnormal pap test results risk estimates for oneself were followed with an item seeking a brief qualitative explanation of the risk estimate resultssurveys were completed by 338 women the mean m ±sd age of respondents was 299 ±86 years women selfidentified as hispaniclatina 32 n107 white 34 n116 and african american 34 n115 estimated perceived lifetime risk of getting cervical cancer ranged from 0 to 100 m592 ±295 risk estimates were associated with perceived prevalence of abnormal results r024 p 0001 and perceptions regarding the accuracy of the pap test r013 p 005 on average women estimated that nearly half of all women have ever had an abnormal result 492 ± 269 n335 range 0 100 with africanamerican women estimating a higher percentage compared to hispaniclatina and white women women who themselves experienced an abnormal pap test result reported higher proportions of other women experiencing an abnormal result t 333 367 p 001 conclusionsthis study advances our understanding of misperception of risk and how women qualitatively view their risk of cervical cancer the findings underscore areas for practitioners to enhance patient education efforts

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introduction drug use is often associated with higher crime rates 12 in france studies estimate that 20 of inmates were convicted for crimes concerning illicit drug possession use or sale 34 furthermore between 60 and 80 of inmates report using drugs in the weeks prior to incarceration 4 5 6 even in prison there are possibilities for substance use disorder treatment in 1994 france inscribed in its laws that inmates should have access to the same standard of care as any other patient and shifted responsibility for prisoners health from the justice ministry to the health ministry since then usual care is performed by sanitary units in penitentiary settings those units are mostly composed of nursing and medical staff but in order to deal with drug use care help is enlisted from psychiatric hospitals and specialized institutions 7 doctors specialized in addictology and educators are then tasked to help ensure that prisoners benefit from the same standard of care as they would outside of prison since 2015 an alternative has been offered to inmates wanting to work on their social skills and drug use during incarceration this socioeducational program inspired by spanish prisons is called respect module this program puts an emphasis on rehabilitation through work inmates sign a contract describing their objectives and their commitment to achieving them by doing so they agree to follow a welldefined code of conduct that also grants them more leeway during their personal time they are then tasked to choose a personal activity plan and to respect a specific schedule throughout the day 8 finally in 2017 a third type of care was introduced as an experimentation unit the rehabilitation unit for drug users was created to try and apply the therapeutic community approach to drug use care in prison the tc model consists of mediumto longterm accommodation structures that do not solely focus on addiction pathology but aim to rehabilitate patients so they can behave and live accordingly with social rules to that end patients are held accountable and are expected to become positive and reliable actors of the community this community as a method approach 9 values ones personal involvement in the group dynamic in order to change oneself this way the individual will improve himself by appealing to the groups resources through the development of his own social skills 10 staff mainly play a role in promoting interactions among peers through educational activities and monitoring residents and groups statuses 11 tcs effectiveness is already well described overseas in regular settings for its effect on drug use both during tc and after discharge 1213 these effects mainly consist of a reduction in drug episodes that can be reduced by 77 3 months after discharge and sustained for a longer period prisonbased tc programs also have an effect on drug use notably on relapse 1415 which can decrease by 15 this effect on relapse can in turn diminish the likelihood of recidivism from 17 up to 39 mainly by reducing drugrelated offenses 15 16 17 prisonbased tc was also shown to be effective in reducing rearrests 16 even if it has only been described as a small to moderate effect when aftercare is not involved after release in rudu prisoners days are organized with multiple group activities focused on resolving issues using communication skills learning how to express their feelings when speaking with their peers or using arts and creations to do so expression groups help redefine their relation with the products of their addiction as well as their central role in the prisoners problems this unit was implanted in the neuvic detention center thanks to the collaboration of penitentiary associative and medical actors rudu is mostly composed of specialized educators as well as social workers an addictologist a psychologist probation officers and even prison guards rudu staff often have interviews with prisoners to assess their progress review recently encountered problems or talk about their nearterm prospects the tc model differs vastly from classic care in french prisons the tc model focuses and relies on social rehabilitation to improve the overall state of the inmate while classic care solely aims to work on the addiction pathology through medical interviews the tc model gives structure to the inmates stay in prison by encouraging them to participate in regular group activities and discussions it is also important to note that the tc model allows for closer monitoring with regular interviews than classic care this pilot study aimed to evaluate care based on the tc model in french prisons through the rudu experimental unit and compare its effectiveness with other types of care available in french prisons such as classic care and socioeducational programs to that end a questionnaire was purposely built based on the fifth version of the addiction severity index 1819 the primary objective was to evaluate the evolution of the overall addictive disorder focused on the primary substance used or to be given up by the resident the secondary objectives were to evaluate and compare effects on other factors linked with delinquency and addiction such as social interactions selfesteem and reincarceration methods study design this retrospective study was conducted by the esquirol hospital center of limoges this study was funded by the regional health agency of the nouvelleaquitaine region of france and was registered in the health data hub a letter was sent to the known addresses of all inmates whose files were to be included to inform them about the study and give them the opportunity to voice their opposition towards the use of their data file selection the study took place in two prisons in the nouvelleaquitaine region of france the first one offering the three different types of care was the neuvic detention center the second one was the montdemarsan penitentiary center which offers both classic and socioeducational care for drug users socioeducational files were only selected in montdemarsan tc files were only selected in neuvic classic care files were selected in both centers files were selected if the inmate had spent at least 3 months in the studied units care and were meeting rudu s admission criteria listed as follows drug user seeking help and treatment use of multiple substances and absence of heavy psychiatric comorbidities that would prevent group therapy some additional pairing criteria were required for the selection of files from other types of care in order to ensure comparability and prevent bias the files were paired according to the duration of care primary substance of the addiction pathology age group and psychiatric comorbidities study procedures the study started by including all adequate tc files from the 103 files available for the 2017 to 2020 period only 39 tc files were adequate and therefore included these 39 files were used to build the pairing grid based on the criteria described above classic care and socioeducational files were then selected according to the pairing grid for those the end of treatment was arbitrarily defined to be similar to the original tc files they were to be paired with in total 23 classic care files and 13 socioeducational care files were included for a total of 75 files a total of 16 of the 23 classic care files were from the neuvic detention center while 7 were from the montdemarsan detention center after all the files were selected a questionnaire based on the 5th version of the addiction severity index 18 19 20 was filled out using the files as sources of information the asi is a heteroquestionnaire that takes interest in two periods the lifetime and the last 30 days it could not be used directly since it requires a dialogue with the patient to fill in the data corresponding to the last 30day period therefore our questionnaire was built by removing the family history domain from the asi and replacing the two periods of interest for severity grades with the initiation of care studied and the end of said care the questions relating to the last 30 days and selfevaluation were also removed from all the remaining domains severity grades were given to all the domains evaluated by our questionnaire namely medical status employment and support primary addiction status legal status socialfamilial status and psychiatric status grades were not reflective of a single questionnaire item but rather represented the global status of an explored domain for example primary addiction status incorporated items regarding abstinence reduction in consumption ability to feel measure and voice craving ability to ask for help ability to refuse when the substance was offered by another inmate compliance with treatment etc similarly psychiatric status was composed of psychiatric history diagnosis treatment for psychiatric or emotional problems etc finally along the same lines employment and support status incorporated items regarding previous employment education level and diploma or lack thereof main source of income training during incarceration etc grades ranged from 0 to 9 with 0 being the lowest and describing the absence of problem while 9 was the highest and described an extreme problem needing emergency care and treatment grades were given jointly after a full examination of all the files of each inmate by both investigators one was a medical doctor specialized in addiction medicine and psychiatry who focused on medical status primary addiction status and psychiatric status domains of our questionnaire and the other was graduate in addiction medicine with a masters degree in biology who focused on employment and support legal status and socialfamilial status of our questionnaire this second investigator also selected and revised the files selfesteem scores presented in this study were selfreported and ranged from 1 to 5 with 5 being the highest in this study abstinence took into consideration the willingness aspect of undertaking a period without consumption as a step of recovery and not simply because the substance could not be procured the duration of abstinence was measured in days multiple periods of abstinence were not taken into account abstinence data were centered on the main substance of choice for each inmate the data were only taken into account if measured during inprison care reincarceration rates were measured 90 and 180 days after release from the detention during which the studied care occurred statistical analysis this study questionnaire provided both qualitative and quantitative data quantitative variables were described using means and standard deviation and qualitative variables were expressed in numbers and percentages to analyze this studys qualitative data chi 2 tests were used if the sample size was deemed too small fishers test was used when paired quantitative data were analyzed using wilcoxons test otherwise mannwhitneys test was used all statistical analyses were conducted on ibm spss statistics version 26 with a statistically significant threshold set at 005 results study population the study population age ranged from 20 years old to 59 years old 377 ± 91 years the mean duration of care was 1758 ± 537 days all inmates were male in total 795 of the tc population had benefited from care previously while only 391 from the classic care and 462 from the socioeducational care population had tc and classic care were compared in populations prior access to substance use care no significant difference was revealed when comparing tc and socioeducational care global effectiveness of care regarding addictive disorder evolutions of severity grades were used to compare the effectiveness of care admission scores corresponded to the severity grade awarded from the first interview with a professional involved in care similarly the latest score was given according to the files last interview usually within a week of release delta represents the progress made during care the higher the delta value is the more progress was made during care when looking at primary addiction status the comparability of the admission score ensured that the baseline was similar among the three types of care studied the baseline showed tremendous problems for all the files included the delta values indicated that progress was made across all types of care studied when comparing tcs and classic cares delta we found that tcs effect was significantly superior however the same could not be said when comparing tc and socioeducational care this indicated that the global progress in the addiction pathology is higher with tc than with classic care but not higher than with socioeducational care comparing care effectiveness in improvement of psychiatric status and financial situation for both psychiatric status and employmentsupport the baselines indicated important issues requiring care for all populations studied similarly to primary addiction status progress was achieved in both psychiatric status and employmentsupport across all three types of care studied no significant difference was detected when comparing tc to the two other types of care studied three files from classic care and two files from socioeducational care did not contain enough data to be graded possible factors of improvement promoted by the therapeutic community model both tc and socioeducational care shared the same rate of abstinence at 8462 the classic care abstinence rate was at 6957 and was not significantly different from tc tc had the longest mean duration of abstinence followed by classic care socioeducational care had the shortest mean duration of abstinence no differences were observed when comparing tcs duration of abstinence with the other populations selfreported selfesteem and socialfamilial status could only be found in tcs proprietary files so we only took interest in progress being made during tc when comparing admission scores to latest scores for both of these items the significant improvement made during tc was revealed effects on reincarceration rates finally the reincarceration rates at 90 and 180 days after release were analyzed the data could only be obtained for the former neuvic detention center prisoners while for both the reincarceration rates were lower at 90 days after release than 180 days after release and no significant difference was found between the two types of care studied discussion this study gives us the first data on the tc models effectiveness on drug use disorder in french prisons while this study did not allow us to establish profiles of prisoners most likely to respond to a particular type of care we can still identify disparities between their populations indeed our study showed that tcs population is more likely to have previously accessed professional help in substance use care than the population undergoing classic care this could indicate that prisoners that have already encountered classic care in addiction whether it was in prison or not tend to be motivated to take part in more intensive type of care such as the one the tc model provides 916 our results point towards the tc models superiority in its capacity to induce better improvement overall in addiction status when compared to classic care these findings are consistent with previous studies in europe and north america 21 this result can be explained by the more intensive nature of tc although it remains difficult to identify which components are the most beneficial 15 socioeducational care is also more intensive than classic care and relies on personal involvement which could explain why the overall improvement in addiction status is similar for socioeducational care and tc when comparing other aspects of care such as psychiatric status and employment support we were not able to detect differences between the three units the lack of significant improvement in psychiatric status is consistent with the limited effect on mental health in the tc literature 22 this means that the tc model could benefit from stronger psychotherapy components in order to broaden the range of its benefits to inmates the addiction pathology and its treatment are complex and involve multiple factors selfesteem is described as one of these factors as lower selfesteem is correlated to more substance use 2324 the tc model allows residents to work on this personality trait as it is also linked with group membership and belongingness 25 de leon suggests that group membership can constitute a replacement for the bond with the object of addiction 9 belongingness is also known to be a crucial part of tc used in order to promote change and in turn improve selfesteem 26 therefore tcs positive effects on selfesteem could be linked to belongingness and both of them might play an important role on the overall progress made by the inmates on their addictive disorder in that sense they could constitute a secondary index of this criteria of effectiveness familialsocial status is also an important factor in addiction status improvement that is worked on with the tc model used in rudu 27 in this unit prisoners learn to improve their communication skills in expression groups with the help of other residents care professionals and even prison guards our findings indicate no significant differences neither in terms of promoting attempts of abstinence nor in the duration of such endeavors our results were unexpected as tcs positive effects on relapse have been described 14 and could be expected to translate into a positive effect on abstinence however abstinence is not the main purpose of the tc model because the recovery process and goals are not solely based on the addictive disorder but instead on a whole person approach which could explain the absence of a significant effect on this criterion 9 still it could be a meaningful indicator for some prisoners progress with their addictive disorder that should not be dismissed it also means that future studies should strongly consider other criteria to measure addiction status such as craving frequency and intensity or reductions in drugs consumed both in nature and quantity in addition to abstinence reincarceration rates were of particular interest as prisonbased tc has shown effectiveness in reducing reincarceration 14 and recidivism 2829 we were not able to detect any significant differences in our study probably due to the low number of files containing data on this subject indeed data could only be obtained for 39 tc files and 16 files for classic care the short time period with uptodate information could also have played a role in those results studying reincarceration rates for a longer period after release could allow a significant difference to emerge other items could also be studied such as recidivism which was considered by o mitchell and colleagues as the most reliable and comparable outcome criterion 1517 finally rudu allows for care professionals to systematically search for adequate aftercare in the couple of weeks leading to release it is well described that aftercare is one of the most important components for substance use treatment success and for preventing relapse recidivism 11617 and reincarceration 143031 similarly the study period being focused on inprison care and therefore not allowing us to measure the progress retained after could have deprived us of meaningful indicators of effectiveness 32 hence the tc model represented by rudu might offer much more societal advantages and rehabilitation capabilities than our study is able to reveal limitations this retrospective study encountered two main limitations while comparing the different options of addiction care in french prisons firstly the files content is highly dependent not only on the detention center but also on the specific type of care received by the prisoner this disparity in files content and the lack of standardized tools for evaluation could have hindered the comparison by misrepresenting both the progress and the difficulties encountered by prisoners and fields teams alike secondly a robust cost analysis of the three types of care studied is also missing from this study although we originally aimed to include a costeffectiveness analysis we were prevented from producing such an analysis by the lack of available data and the poor comparability of those obtained despite these shortcomings the economic data retrieved could help design a more robust analysis that could be used in a future prospective study such a prospective study should be focused on inmates fates after release from the three different programs studied here followup would be crucial to assess how much of the progress both in the addiction pathology and in social rehabilitation made in prison is retained when inmates are no longer in a secure environment particular attention should be given to aftercare and whether or not inmates return to a known problematic social environment or rather choose to start anew to avoid the repetition of criminal behavior finally the longterm economic impact should be assessed to help policy makers decide how to help develop and fund such care programs conclusions this study represents a first look into the tc model in french prisons through the special unit that is rudu although tcs effectiveness has already been demonstrated in reducing substance use and criminality in conventional settings and in prisons overseas such data are lacking in france 21 this study points towards stronger improvement in the addiction pathology granted by the tc model than by classic care in prison it also shows that the tc model is not solely focused on the addiction pathology but rather on social rehabilitation and can significantly improve other characteristics such as socialfamilial status and selfesteem more studies are required on the subject particularly when it comes to follow up and the fates of inmates after release to that end it is important to implement standardized tools to monitor evaluate and improve such treatments as tcs more intensive care can be more beneficial for some inmates than the classic procedure available the clear identification of the most efficient components of the tc model and the profiles of prisoners most likely to stay in care and take advantage of it is crucial to ensure its efficiency 915212528 it could also be interesting to evaluate the benefits of rudu and the tc model on an economic scale to see if it is compatible with healthcare and the justice system in france to that end costbenefit analyses relying on standardized tools such as asi or the drug abuse treatment cost analysis program 3334 could provide interesting insights to both field teams and policy makers data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available because it is derived from a sensitive and protected sample of the population author contributions tv validation investigation formal analysis and writingoriginal draft al methodology and writingreview and editing tg methodology validation and writingreview and editing pn conceptualization validation investigation and writingreview and editing all authors have read and agreed to the published version of the manuscript funding this work was supported by the regional health agency of the nouvelleaquitaine region of france the ars had no role in study design data collection and analysis decision to publish or preparation of the manuscript informed consent statement patient consent was waived due to the study not involving human directly but focusing on the data recorded in their files however they were informed of the intended use of their data and could voice their opposition towards the use of their data

background in france addiction care in prison usually consists of nurses interventions medical care and socioeducational programs but new alternatives have arisen namely the therapeutic community tc model this pilot study aims to evaluate the effectiveness of this prisonbased tc in comparison with classic and socioeducational care offered in french prisons methods to compare these three types of prisonbased care two detention centers files were screened for use of multiple drugs willingness to participate and absence of psychiatric comorbidities incompatible with group therapy a custom questionnaire was built based on the fifth version of the addiction severity index it investigates medical status employment and support primary addiction status legal status socialfamilial status and psychiatric status through various items results our sample only consisted of male repeat offenders with a mean age of 377 ± 91 years primary addiction status improvement was observed for all care studied but was more important in tc than in classic care selfesteem and socialfamilial status saw significant improvement throughout tc care conclusions the tc model represents an alternative to classic and socioeducational care in french prisons more studies are needed to assess the extent of the benefits provided on both the medical side and economic side

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introduction onchocerciasis is a neglected tropical disease caused by the nematode onchocerca volvulus onchocerca volvulus is transmitted through the bites of blackflies of the genus similium that breed near rivers and streams in regions with constantly moving water 1 s damnosum complex and s neavei found in africa and the middle east and in parts of east africa respectively are the most important vectors however in america the most important vectors are s ochraceum s metallicum s oyapockense s guianense and s exiguum 2 although this disease occurs mostly in warm tropical settings its parasitic flies survive under environments favourable for their growth all year round 3 the disease is known to affect rural populations and is a major cause of blindness and onchocercal skin disease in endemic areas with severe socioeconomic outcomes 4 symptoms include severe itching disfiguring skin conditions and visual impairment 5 globally it is estimated that about 90 million people are at risk of being infected with onchocerca volvulus in endemic areas mostly in subsaharan africa and out of which about 37 million are infected and 300 000 are permanently blind as a result of onchocerciasis 1 however 1 to 5 percent of the population in onchocerciasisendemic areas who are exposed to a high rate of infection transmission do not exhibit any clinical signs of the disease and are thus considered putatively immune individuals 6 it is known that onchocerciasis is a chronic slowly progressive parasitic disease that has been regarded as the secondleading communicable cause of blindness globally with around 500000 persons blind yearly 7 a study by crump morel and omura 8 revealed that out of approximately 123 million persons who are at risk for infection in 38 endemic countries 257 million are infected and 1 million are blinded or have a serious visual impairment onchocerciasis is endemic in ssa countries causing partial or total loss of sight and extreme itching with skin conditions 9 as a result of high infection load 10 study shows that onchocerciasis is the second most common infectious cause of avoidable blindness 11 these have a significant impact on peoples social and economic lives which lead to poverty and impede their development 11 all because they become unproductive and those who are badly afflicted spend all of their time and money roughly 20 per year or 15 of their yearly income on their health and medical treatment 12 it was estimated in 2017 that 99 percent out of the estimated 208 million onchocerciasis cases came from the poorest and most vulnerable populations of ssa 13 out of the 218 million people about 25 million people are infected globally and 90 million people are highly at risk of the disease with more than 99 of the cases coming from 31 countries in the ssa 14 of those who are infected 146 million suffer from skin disease and 115 million population has been estimated to experience loss of sight while 220000 are confirmed to be completely blind which caused 1 136000 disability adjusted life years in 2015 14 15 16 17 and 123 million dalys in 17 the whos onchocerciasis control program has effectively reduced the prevalence of onchocerciasis by interrupting the transmission of the parasite and by mass population treatment in the regions at risk of the disease 7 the widespread use of ivermectin therapy is essential for managing and eradicating onchocerciasis as a public health issue which will help to stop the pandemic of neglected tropical diseases by 2030 15 from who report efforts to stop the spread of the disease have improved as of 2020 but six countries saw a 27 reduction in coverage as a result of their inability to carry out largescale treatment plans which was made worse when the covid pandemic first appeared 15 in response several studies contend that community involvement is essential for managing and eradicating onchocerciasis or even all ntds particularly in areas with limited resources 18 additionally the health system has implemented testandtreat procedures which are meant to identify patients who require therapy need to stop receiving it due to side effects or do not require it 19 ivermectin mass drug administration remains the primary method for controlling with effort of eradicating onchocerciasis in ghana 20 despite several years of mda with ivermectin infection with onchocerciasis and the commonly associated clinical manifestations of the disease still persist in many regions and districts across ghana 20 despite the significant reduction in the prevalence of onchocerciasis in ghana there are still communities with positive microfilaria prevalence above 1 21 for instance a study carried out in three communities in ghana showed that the prevalence of microfilaria in the communities were 132 24 and 29 respectively 20 adolescents are among the schoolgoing children that are targeted by the ghana health service for mda program and other interventions that are targeted toward the elimination of onchocerciasis in ghana because adolescents are among the highest group at risk of onchocerciasis in the nkwanta north district of oti region despite these efforts recent observations within the district show that more and more adolescents are diagnosed and treated for plos neglected tropical diseases onchocerciasis there are limited scientific studies documenting adolescentsperceptions regarding the management of onchocerciasis and the support that is available to them in this view this study sought to explore the adolescents perception regarding the management of onchocerciasis community and health system support in nkwanta north district of ghana methods ethical approval and consent to participate this study was approved by the university of health and allied sciences review committee consent to participate in the study was also obtained through written informed consent forms and parental assent forms from the participants and their parents all methods were carried out following relevant guidelines and regulations the reporting of this study is guided by the consolidated criteria for reporting qualitative research 20 setting the study was conducted in nkwanta north district of the oti region ghana the district is located in the northeastern part of ghana the district is located between latitude 7˚30n and 8˚45n and longitude 0˚10w and 045e 22 the district capital kpassa is located 270 km to the south of ho the population of nkwanta north district according to the 2010 population and housing census is 64553 representing 30 percent of the regions total population 22 the nkwanta north district is one of the districts in the oti region with the highest level of onchocerciasis prevalence and adolescents are most at risk of the infection 23 design this study adopted a qualitative phenomenological design and exploratory descriptive qualitative approach this design and approach were adopted in this stusy to facilitate an indepth exploration of adolescents illness experiences of onchocerciasis the phenomenological design was used in this study because we sought to hear adolescents affected by onchocerciasis tell their experiences about living with onchocerciasis this gave us an indepth understanding of their perceptions of the condition and its management using both routine mda and tnt procedures 24 using indepth interviews study population the main target population for the study was adolescents between 10 and 19 years old who were affected by onchocerciasis in the nkwanta north district at the time of data collection for the study sampling the purposive and snowball sampling strategies were used in selecting participants for this study the adolescents were selected based on whether they still have the disease and are on treatment or have just completed treatment the adolescents who have completed their treatment within one year of the time of this study were selected because they can provide rich information on the issues being studied they were chosen on the basis that they represent a specific perspective on the phenomenon rather than a population 25 gatekeepers and key informants such as chiefs queen mothers assembly members nurses and public health officers were used as a means of gaining access to the adolescents sample size we sampled 16 adolescents for the conduct of this study our sample size was based on data saturation data collection data were collected using indepth interviews in collecting data from the participants through facetoface interactions data for this study were collected using an indepth interview guide a structured data collection tool was used to collect data on the sociodemographic characteristics of the participants the interviews were conducted in the homes of the participants the interviews were conducted in english and ghanaian languages the choice of local language for the conduct of the interviews was to ensure that we have indepth information without any language barrier challenges to ensure that the use of the local languages did not affect the quality of data collected the researchers who could not speak the local language were assisted by interpreters that speak the local language fluently all interviews were recorded using a digital audio recording device permission was obtained from all participants to record each interview handwritten notes were taken during the interview process to record responses given by the participants the purpose of using both the audio recorder and handwritten notes is to ensure that the interview process is not halted should any of the equipment breakdowns during the interview process to ensure the trustworthiness of the instrument interview guides were given to experts in qualitative research to peruse the appropriateness of the questions before we used them ethical considerations ethical clearance was obtained from the university of health and allied sciences review committee and permission was sought from the district assembly and district health directorate before data was collected provision was made for the translation and interpretation of the instrument into ewe and other local languages that are mostly understood and spoken by a large proportion of people in the study setting written informed consent was obtained from participants who were above 18 years however for participants who were below 18 years and were still minors during the time of the data collection both individual from the adolescents and parental consents were sought before adolescents were interviewed this had been done by giving them informed consent and parental ascent form forms to sign indicating their willingness to participate in the study for those adolescents whose parents were not available during the data collection we obtained their consent and ascent of their respective guardians before their participation in the study participation was purely voluntary and they were informed of their right to withdraw from the study at any time this had been done by giving them written informed consent and parental assent forms to the parents or guardians to sign indicating their willingness to participate in the study the purpose of the study was also explained to the parentsguardians and also to the adolescents themselves before interviewing them they were informed of their right to stop at any point in time of the interview process when they feel so and also assured that any statement or comments including that of privacy will remain protected after the data collection participants and their parentsguardians were identified and approached with the help of key informants since the interviews were carried out in the home of the participants their parents were informed about the study by visiting them in their homes all the parents and the participants voluntarily agreed to participate in the study the confidentiality of the participants was adhered to by ensuring that no information from participants was disclosed to any third party the respondents were identified by codes and numbers instead of their real names all the interviews were conducted by qualitative researchers with the support of research assistants who were welltrained in qualitative data collection the computer which was used for the transcription of interviews was protected with passwords data analysis all recorded interviews were transcribed verbatim into a word document in english before codes and themes were developed thematically using atlasti v75 transcripts were analysed thematically 25 familiarization with the data was done to take note of key ideas and recurrent themes coding was done based on the research objectives as well as themes that emerged from the data itself quotes from the participants were used in presenting the data to substantiate issues discussed by participants the initial themes that were developed were reviewed and refined into final themes taking into consideration internal homogeneity and external heterogeneity 26 the themes were defined and named and a detailed analysis was conducted and written based on how they fit into the broader story of the data a frequency table was however used to present the sociodemographic characteristics of the participants results participants profile table 1 presents the profile of the participants we noted that 12 of the participants were aged 1518 years old regarding the educational status of the participants we noted that most of them 6 were still in junior high school while 4 were in senior high school approximately 6 of the participants had lived with the condition for 15 years and 610 years respectively however 4 of them had lived with the condition for more than 10 years thematic results adolescents perceptions of mode of transmission and risk factors of onchocerciasis and its management table 2 presents the themes derived from the interviews conducted among onchocerciasis adolescents on the meaning created by onchocerciasis four main themes were realized these were community perception of the mode of transmission and risk factors of onchocerciasis adolescents perception of the mode of transmission and risk factors of onchocerciasis adolescents perceptions of ivermectin treatment of onchocerciasis and adolescents experience regarding ivermectin treatment regarding perception of the mode of transmission and risk factors of onchocerciasis most of the participants indicated that the community members have diverse perceptions regarding onchocerciasis according to the adolescents the community members believe that onchocerciasis is a serious disease that can cause blindness adolescents further stated that most of the community members believe that it is caused by the bite of insects while some of them also believe that it is caused by the consumption of some types of food products or stressful work the following quotes summarised some of the responses from the participants people say the condition can lead to eye blindness and there will be some worms on your eyes when you have such a condition the condition mostly affects the eyes female participant 18 years plos neglected tropical diseases some people say that there are types of food which are not supposed to be eaten and once eaten you will get the disease concerning the adolescents perception of the mode of transmission and risk factors of onchocerciasis most of the adolescents believed that onchocerciasis is caused by insect bites blood infection genetic infection poor environmental hygiene and sun also others noted the disease could have been inherited from parents the following quotes summarise some of the views of the adolescents i know the disease is hidden in some foods so once we eat that food we get infected food like maize has to be milled and mixed with another food item to prepare food so the infection can be hidden in such foods and once eaten you get the disease also when you go to the farm insects like mosquitos and millipede and centipede can bite you and give you the disease male male participant 18 years what i know is that the disease affects the eyes and i can become blind and i also believe when you stay under the sun for long female participant 18 years when i was growing up i realized that there was something like a ball on my fathers body also i have seen that something on my body as well i think the condition is something in the blood because my father was also having it male participant 18 years visàvis of the adolescents perception of the ivermectin treatment as part of the management of the condition most of the adolescents specified in their interviews that the ivermectin treatment has led to positive change in the condition by helping relieve the symptoms they were previously experiencing the following quotes represented the views of some of the adolescents the drug has helped me a lot the pains i used to feel in my body and joints are no more after i took that drug it has helped me because all the challenges i have by then were all resolved after i took the drug concerning the adolescents experiences regarding ivermectin use all the participants indicated that after the use of ivermectin they experienced mild to severe side effects including fever headache body itching rushes swollen body and blurred vision the following quotes summarise some of the views of the adolescents when i took the medicine the whole of my body became swollen and my body itches but that only lasted for some time the pains i felt became normal and i can now see well as compared to the previous time male participant 18 years community and health system support table 3 presents the themes derived from the interviews conducted among adolescents affected by onchocerciasis on community and health system support available for them during the management of their condition two themes emerged from the interviews communitybased support and health system support regarding the communitybased support available for adolescents we noted that the community support available for the management of their condition mostly comes from family and relatives and the churches most of the adolescents also noted that they get support from church members such as regular visits encouragement and prayers this support serves as a moral boost and a coping mechanism for soothing adolescents from the pain they might have been going through at a particular moment the following quotes represent the views of some of the adolescents yes my church members from the church where i and my parents worship came to check up on me on my return from the health facility female participant 16 years yes i had support from my church people some gave me money and other things and some also pray for me when they came to our house to visit me male participant 15 years the family support available for the adolescents as described in their interviews includes financial and social support my mother was helping me with water and other things i needed my pastor and church members also prayed for me and some of my friends also came to visit me male participant 19 years my father helping me with everything and my sister also has been giving me money to be managing myself and to take me to school when i came back from the hospital female participant 15 years concerning the health systembased supports we noted the main supports that were available to the adolescents in the management of their condition included financial support free treatment a home visit counseling and education regarding the financial support the participants indicated that the facilities that took care of them gave them money to take care of themselves when they get home financial support for the adolescents could be a way to encourage other infected people who have not reported to health facilities for treatment to seek care the following are some of their views i was given money to use to support ourselves for the time we have spent at the hospital for example they gave me some amount of money to use to support myself when i get back home and for my time spent at the health facility leaving things i could have been doing when home male participant 15 years female participant 19 years they transported us to the health facility and they gave us some money to use to support our farm work for the time we have spent there leaving our farm male participant 18 years concerning the free treatment the adolescents reported in their interviews that all the cost for the treatment of their condition was borne by the health facility without them paying any fees they always go around and dress our operated wounds for us explaining things to us about how to care for ourselves when we get back home they did all these for free i did not pay any money for my treatment male participant 18 years when we went to the hospital the doctors did not take any money from us and the drugs and operation were free of any charge which was very helpful to us female participant 15 years furthermore the adolescents indicated that when they were at the facility there were health professionals that specifically counseled and educated them on what to do or not to do so to get better faster and become healthier the doctor was going around and dressed our operated wound for us educated us and counsel us not to do any hard work till the wound is healed and also not to take drugs unnecessarily female participant 17 years yes they educated us and asked us not to buy any medicine on our own when we are not feeling well but we should rather go to the hospital with the small card they gave us so that they will take care of us instead in other to prevent any complications male participant 19 years the interviews also showed that home visit was one strong part of the health system support which is available for adolescents affected by onchocerciasis some of the participants have these to say when i got home after the operation the doctor was still coming to my house to help dress my wounds till it got healed female participant 16 years i was not given any medicines again but there was a doctor who normally comes around to dress my wounds in my house if he will not come himself there is a nurse that will come to do it for me in the house female participant 19 years when i came back from the hospital one of the nurses has been coming from time to time in my house to treat the wound and also make me take medicine male participant 19 years discussion in our study we explored the management of onchocerciasis among adolescents perception community and health system support in nkwanta north district of ghana we noted in this current study that community members have diverse perceptions of the mode of transmission and the risk factors of onchocerciasis some community members believe that onchocerciasis is a serious disease that can cause blindness and some believe that it is caused by the consumption of some types of food products or stressful work adolescents themselves believed that onchocerciasis was caused by insect bite blood infection poor environmental hygiene sun or could have been inherited from parents these findings are consistent with previous studies 27 28 29 30 31 the findings from our study where the adolescents reported that the community members believed that onchocerciasis is caused by consumption of food products or stressful work at the farm poor environmental hygiene sun or is inherited from parents at birth could be attributed to inadequate health education and information about ntds among the general populaces especial those in the remote areas of the district where the mode of communication and information are limited 32 33 34 these findings imply that more health education campaigns including using community communication systems on onchocerciasis and other ntds is imperative to correct the misunderstandings or misperceptions of communities of the mode of transmission and the risk factors of onchocerciasis this is very important because people s correct understanding of how diseases like onchocerciasis os transmitted could be crucial in their effort to take measures to prevent it concerning ivermectin treatment the adolescents reported in this study that it had a great positive impact on their condition as it had helped relieve symptoms they were experiencing before the initiation of the treatment these findings are unswerving from the reports by the previous studies 35 36 37 however some of the adolescents also indicated that they had experienced some side effects including fever headache body itching rushes swollen body and blurred vision from the drug these findings are consistent with the reports of the previous studies 38 39 40 41 these experience of side effects could discourage some adolescents from taking the ivermectin treatment or participating in the mda programme that is one of the major strategies to eradicating onchocerciasis in ghana therefore it is important health workers educate or inform the communities about the possible side effects of the ivermectin treatment so that the community members who have received the treatment are not surprised by these side effects if they experience them we found that the community support available for the management of onchocerciasis among adolescents was financial and emotional support and these supports mostly come from family and relatives and church members these supports were considered by the patients to have been very crucial during the treatment of their condition and recovery afterwards prayers encouragement and counselling from family and church members were reported by adolescents to have helped them emotionally and strengthened them to go through whatever pain they might have been experiencing as a result of the condition and also the anxiety and depression as a result of stigmatisation 18 42 43 44 45 46 this point to the protective factor of social support to people affected by onchocerciasis ntds hence it is important more steps are taken by programme planners and implimentaters to include education on social support into the interventions that are targeted at elimating or eradicating ntds to educate communties on the importance of social support to the patients living with any of ntds this if well done could help maximise the level of community support among the communities and also help reduce the stigmatization in this current study we found that financial support free treatment home visit counseling and education were health system supports available to adolescents who suffered from onchocerciasis these supports especially the financial and free treatment from the health system which were widely reported and appreciated by the adolescents could be ascribed to the fact that onchocerciasis as one of the major ntds is known to disproportionately affect the most disadvantaged the rural poor with reduced access to health care services therefore free treatment was very important for the management of their condition and also fight the elimination of onchocerciasis 5 47 48 49 50 51 strength and weakness the current study was a communitybased study conducted in nkwanta north district using an indepth understanding of the lived experiences and the perceptions of adolescents of the mode of transmission of onchocerciasis and its management this has helped to explore the welldetailed scope of how patients infected with onchocerciasis live with their condition and how they effectively cope with daily life experiences despite the strength of this study it also has some limitations the use of indepth interviews for the data collection in this research project could have introduced response bias on the part of the participants the use of purposive as well as snowball sampling introduced the possibility of selection bias on the part of the data collectors there might also be recall bias from the participants and social desirability bias on the requested data the use of different languages and also the use of interpreters to collect the data could have distorted the presentation of the questions to the participants conclusion we found from the study that community members have diverse perceptions about onchocerciasis adolescents believed that onchocerciasis was caused by insect bites poor environmental hygiene or could have been inherited from parents we noted in this study that adolescents believe that the ivermectin treatment could have had a great positive impact on the condition as it has helped relieve the symptoms they were experiencing before the initiation of the treatment our research recognises that community and health system supports is very important in the effective management of onchocerciasis contributing to the attainment of sustainable development goal 33 which is targeted at ending the epidemic of ntds like onchocerciasis by 2030 these findings call for more communitybased education by health authorities to educate the communities on ntds and how they are transmitted as it could help address the diverse and erroneous perceptions the adolescents and the communities have of the onchocerciasis mode of transmission also further measures need to be taken by ghana health service to include educational programmes on social support in the interventions that are targeted at eliminating or eradicating ntds to educate communities on the importance of social support to the patients affected by any of ntds all relevant data are within the manuscript

onchocerciasis affects the quality of life to a greater extent among affected individuals the world health organization who s onchocerciasis control program ocp has effectively reduced the prevalence of onchocerciasis by interrupting the transmission of the parasite and by mass population treatment in the regions at risk of the disease despite the successful reduction of the prevalence of onchocerciasis by who the socioeconomic burden resulting from the disabilities caused by onchocerciasis are still immense this study sought to explore the adolescents perception regarding the management of onchocerciasis community and health system support in nkwanta north district of ghanathis study adopted a qualitative phenomenological design and exploratory descriptive qualitative approach an indepth interview guide was developed to collect data for the study oneonone interview was conducted data collected from 16 onchocerciasis adolescent patients were analysed thematically using atlasti v757 quotes from the participants were presented verbatim to substantiate the themes realisedmost of the 12 participants 750 were aged 1518 years old it was noted that 6 3750 of participants were in junior high school jhs while 4 250 were in senior high school shs it was noted that community members have diverse understandings and perceptions of onchocerciasis including beliefs that onchocerciasis is a serious disease that can cause blindness it is caused by the consumption of some types of food products or stressful work adolescents believed that onchocerciasis was caused by insect bite blood infection poor plos neglected tropical diseases

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introduction skilled attendant at delivery is one of the key indicators used in assessing progress towards the millennium development goal of improving maternal health this is when a qualified health worker manages labour effectively promptly identifies and manages complications and adequately supports with effective referral systems for specialised care when needed the global target is for at least 90 of births to be supervised by skilled birth attendants worldwide by 2015 however for developing countries the international confederation of midwives and international federation of gynaecology and obstetrics in 2002 proposed a target of one skilled birth attendant for every 5000 populations this means that a skilled attendant can be expected to attend 200 births every year vol 27 empirical evidences have shown that early and regular attendance of antenatal care by pregnant women and delivery under supervision of a skilled attendant are associated with improved reproductive health outcomes with resultant decrease in maternal and perinatal deaths studies have shown that sba presence at delivery could prevent around 16 to 33 of maternal deaths in fact countries where sba are utilized at delivery have reduced maternal mortality rate to as low as 50 per 100000 live births subsaharan africa currently contributes to 57 of the 358000 global maternal deaths the life time risk of a woman dying during pregnancy childbirth or in the early postnatal period is also very high in this subregion 1 in 31 compared to 1 in 4300 in developed regions regrettably greater than onethird of the approximately 265 million stillbirths and 33 million neonatal deaths globally occur in ssa generally the proportion of sba supervised births in developing regions increased from 53 in 1990 to 61 in 2007 yet in south asia and sub sahara africa this figure remained less than 50 moreover a substantial proportion of antenatal care users do not deliver with skilled attendants and a significant proportion of mothers in developing countries still deliver at home unattended by sba in nigeria the national demographic and health survey 2013 reports an overall coverage of 38 for sba at delivery which partly explains the high maternal mortality ratio of 576 maternal deaths per 100000 live births in the country this grave scenario requires more researches to help in identifying factors that are associated with utilization of skilled care at births among pregnant women this study has the potential of providing useful information for evidencebased decision making for policy makers working in the field of maternal and child health the study design was descriptive crosssectional survey aminimum sample size of 369 was calculated using the lesliekish formula for estimating single proportion according to the 2013 ndhs 38 of deliveries were supervised by skilled birth attendants with the margin of error set at 5 the sample size was increased to 409 using a nonresponse rate of 10 all consenting women in the reproductive age group of 1549 years with history of childbirths within 12 months preceding the survey were interviewed women who were too ill to give required information were exempted from the study methods study site the respondents were selected using multistage sampling technique in the first stage one ward was selected by balloting from the 12 electoral wards in ilorin west lga in the second stage one enumeration area was selected by balloting from all the enumeration areas in the selected ward in the third stage all households in the selected enumeration area were recruited into the study in the fourth stage all eligible women were approached in the selected households to recruit them till the sample size was achieved data collection method and instruments data were collected using semistructured interviewerguided questionnaire based on findings from previous studies the questionnaire was written in english language but translated into yoruba which is the major language spoken by the study population and back translated into english language the instrument was used to collect information on respondents sociodemographic characteristics antenatal and delivery care practices data analysis the data were fieldedited daily and statistical package for social sciences version 21 was used for analysis data were analysed using descriptive and inferential statistics bivariate chisquare test and multivariate logistic analyses were performed on respondents characteristics and factors that significantly predict availability of sba at delivery adjusted odd ratio and 95 ci were presented and used as measures of the strength of association a p value 005 was accepted as significant respondents socioeconomic status using oyedejis classification of social class respondents socioeconomic status was classified into three low middle and high this classification used a composite score of respondents educational levels and occupational types of their spouses both were scored the score ranged from 1 to 5 for respondents educational level and spousal occupational types respectively respondentsscores from each of the occupational and educational categories were added together and rated out of 10 those who scored less than 5 points were grouped into lower social class scores from 5 to 7 points were grouped into middle social class while those who scored between 810 points were grouped into high social class ethical consideration approval to conduct the study was obtained from the bowen university ethical review committee and permission received from the department of primary health care ilorin central lga written consent was obtained from study participants before they were allowed to participate in the study participation was entirely voluntary and confidentiality was ensured study participants detected not to have used skilled birth attendants in the last delivery were adequately counselled against such practices in their subsequent deliveries results a total of 400 copies of the questionnaire were considered satisfactorily completed by the respondents and were analysed out of the 420 that were administered the mean age of the respondents was 303±60 years seventyfive percent of the respondents were married while 583 had tertiary education most belonged to the middle socioeconomic class the majority had their first pregnancies when they were ≥ 20 years of age while 580 had two to four children 4 shows that the proportion of women who delivered with sba was significantly higher among women within the 3039 age group those with tertiary education high socioeconomic status and whose age at first pregnancy was ≥20 years higher proportion of respondents who delivered with sba belonged to those who had anc visits received anc in private hospitals and those living within 1030 minutes walking distance to places of deliveries discussion this study assessed the factors associated with the use of skilled delivery care among women in ilorin northcentral nigeria it reported that most women received anc in their last pregnancies during which discussions on major danger signs in pregnancy labour and puerperium were done this agrees with the 2013 ndhs report for nigeria which shows that 67 of the women in northgentral nigeria received anc from skilled personnel however studies elsewhere reported differing figures such as 31 in nepal and 34 in ethiopia good anc practice has been proven to correlate positively with availability of sba at births husbands were the main decision makers with regard to where to receive anc service in most respondents most communities in nigeria practice patrimonial family system where most decisions are taken by men who are often the heads of the families families with supportive husbands in reproductive matters are more likely to utilize maternal health services compared to families where women take reproductive actions independent of their husbands aoradjusted odds ratio ciconfidence interval significant at p 005 almost threequarter of the respondents in the current study had their deliveries supervised by sba according to the nigerian ndhs report for 2013 465 of the women in the northcentral geopolitical zone had sba present during their deliveries which was the fourth highest figure among the six geopolitical zones in nigeria the reason for the increased figure reported in the current study could have been due to socioeconomic class and urban location of our respondents these could have impacted positively on their knowledgebase subsequently creating a positive healthseeking behaviour with regard to delivery care utilization which is mostly present in the urban communities in the current study having sba at births was significantly associated with age ≥20 years and having higher education age and education status have been reported as important sociodemographic variables determining maternal healthcare services utilization our finding could have been due to the fact that pregnant adolescents in developing countries tend to have inadequate knowledge about reproductive health matters and are usually in poor financial status hence they are less likely to have access to high quality obstetric services provided by sba this study reported that respondents who attended at least one anc visit were more likely to have sba at delivery this could be because these respondents have received appropriate health information during their anc visits regarding benefits of sba utilization moreover our study revealed that respondents who had one child had significantly increased odds of sba uptake compared to those with five or more children besides respondents whose homes were within walking distances from tend to deliver with sbathese findings are in keeping with previous research long distances could discourage sba utilization among pregnant women particularly in developing countries with poor road networks and high level of insecurity since the survey relied on information voluntarily provided by the respondents the study may not be totally free from information bias as all the answers given may not be a true representation of actual utilization of sba effort was made to minimize this bias by explaining in details how their response wound assist policy makers in designing costeffective safe delivery programmes for pregnant women in nigeria in conclusion although most women in the northcentral geopolitical zone of nigeria utilized sba as revealed by the current study it is below the global target of ≥90 of deliveries being supervised by sba thus more efforts are required to ensure sba at each delivery in achieving this goal stakeholders must guarantee enough health facilities offering basic and comprehensive obstetric care services to stem the tide of maternal deaths in nigeria and other african countries thereby making the sustainable development goals a reality

1094 95 ci 3603326 having only one child aor 433 95 ci 1181582 having at least 4 anc attendance aor 1884 95 ci 8955582 and residing near delivery sites aor 1149 95 ci 2435556 conclusion the proportion of births supervised by sba needs improvement in northcentral nigeria full implementation of reproductive health policies will enhance skilled births in nigeria

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introduction foreignborn residents or immigrants comprise an increasingly significant proportion of the united states population but have been underserved in public health promotion 1 acculturation to us cultural practices by immigrants is associated with greater likelihood of having chronic health conditions 2 however the estimated health impact of acculturation depends on how acculturation is measured 34 acculturation was initially conceptualized as a unidirectional process where immigrants acquired the values practices and beliefs of their new homeland while simultaneously discarding those from their cultural heritage 5 more recent views of acculturation acknowledge that immigrants frequently maintain features of their original culture in their personal lives and adapt to their host culture in their public lives 6 7 8 nonetheless unidirectional measures of acculturation are still widely used 349 language preference country of nativity and duration of residence in the us are used as proxy measures of acculturation in latino and asian immigrant health studies 34 however language use may not be an adequate proxy for asian indians because many were exposed to english language from an early age in elementary school classes taught in india 10 duration of residence in the host country has also been criticized as a proxy measure because the indian diaspora led to many asian indians living in other developed countries where they were exposed to western cultural values prior to immigrating to the us 11 measures that assess several domains of acculturation such as social relationships cultural activities and linguistic preference are thought to be more valid than proxy measures 1213 however many scales lack a conceptual framework of acculturation and are rarely used in studies evaluating health behaviors or outcomes because of respondent burden and costs 3 given that proxy measures are often the only available indicators of acculturation in many of the data sets routinely used to study the health of asian americans it is important to know how valid they are as measures of acculturation the california asian indian tobacco survey provides an opportunity to evaluate temporal measures of acculturation such as duration of residence in the us caits was a multilingual populationbased assessment of asian indians that contains several measures of acculturation our objective was to examine the association of temporal measures with selfreported measures of acculturation among asian indians one of the fastest growing ethnic groups in the us 14 in addition given that no commonly accepted acculturation scale exists for asian indians we created an acculturation scale using existing survey items and report the properties of the scale methods data source caits was a 27min multilingual telephone tobacco use and health survey administered to 3228 adults of asian indian background and resident in california in 2004 15 surnames for caits were compiled from names from social security 16 and through the vital statistic office for the california department of health services from 19982002 using a stratified random sample caits had a household response rate of 67 and randomly selected interviewee response rate of 81 15 we received irb exemption from the university of california los angeles for these analyses measures three temporal measures of acculturation were examined as dependent variables duration of residence in the us percentage of lifetime in the us and age at immigration duration of residence in years was calculated by subtracting the survey year from the year the respondent entered the us percentage of lifetime was calculated from duration of residence in the us divided by respondents current age and age at immigration was calculated from year entered the us minus the respondents birth year these measures were only answered by foreignborn respondents acculturation measures were 11 questions that represented six aspects of acculturation language use media behavior social customs social contacts cultural identity and generational status these items have been included in existing scales of acculturation 91213 table 1 provides a description of the core items and possible responses language of the interview was dichotomized into english or asian indian language how open would you be to your son marrying outside of cultural group and how open would you be to your daughter marrying outside of cultural group correlated at r 095 to deal with local dependency we generated a new variable how open would you be to your child marrying outside of cultural group using the average of the two responses of note respondents were not given a definition or characteristics of a cultural group prior to their response nativity and generational status correlated at r 075 and responses from both questions were averaged together as a single item analysis plan first we examined the mean number of years lived in the us mean percentage of lifetime in the us and mean age at immigration by responses to the acculturation items responses to the acculturation items were analyzed both in their original categories and after dichotomization but we only report the former because the results were similar we also conducted standard contingency table analysis to identify meaningful temporal measure cutoff points that differed between more american acculturated responses and less acculturated responses 17 the reference category was a dichotomized acculturation item and the classification category was the temporal measure 17 acculturation items were dichotomized as 0 for less acculturated or 1 for more acculturated to american culture for example responses for how often do you keep in contact with family and friends in india were dichotomized into those who responded very often somewhat often or neither often or rarely versus those who responded somewhat rarely or very rarely we used a specificity cut point ≥070 second we conducted exploratory factor analyses to evaluate the dimensionality of the items in the overall acculturation scale 18 several factor criteria were examined to help determine the number of factors oblique factor rotations were then run for the plausible number of underlying factors confirmatory factor analysis was conducted to evaluate the fit of alternative models for the data the goodnessoffit of the confirmatory factor analysis models was evaluated using the chi square statistic the comparative fit index and the root mean squared error of approximation models with a cfi of 090 and rmsea ≤006 may be considered acceptable 1819 third we transformed linearly the recoded 11 acculturation scale items to a 0100 possible range for example the item how often do you speak your native language at home had five response categories labeled 1 through 5 that were recoded to 0 25 50 75 100 the 11 items were then averaged together to produce the scale score item descriptives itemscale correlations internal consistency reliability and pearson productmoment correlations of the scale with the temporal measures were estimated poststratification weights were used in the analyses to correct for noncoverage and differential nonresponse the poststratification adjustments were stratified by gender and age grouping and counties were grouped by 12 california regions used in previous tobacco control research 15 the analyses were conducted using stata 112 results sample demographics the average age of the sample was 37 years most respondents were male and welleducated foreignborn respondents had a mean duration of residence in the us of 13 years or onethird of their lifetime spent in the us the median age at immigration to the us was 25 years old construct validity of temporal measures in general greater duration of residence in the us greater percentage of lifetime in the us and younger age at immigration were associated with endorsing items indicative of increased acculturation specifically with increasing duration of residence in the us asian indian immigrants were more likely to prefer english as their primary language and as their preferred language used in the interview asian indian immigrants who had lived for a greater duration in the us were less likely to speak their native language at home read indian media observe traditional cultural or religious holidays and stay in contact with family and friends in india living more years in the us was significantly associated with second or greater generational status and with respondent birth in a developed country there was a nonlinear relationship between frequency of indian food consumption or openness to respondents child marrying outside the cultural group and duration of residence in the us small sample sizes in some response categories may explain the lack of a linear relationship inappropriate measures of acculturation for asian indians may be another explanation for example marriage outside of a cultural group may have been interpreted as marriage to someone of indian descent but of a different indian languageculturereligion as opposed to marriage to someone of a different raceethnicity contingency table analysis suggested a meaningful cutoff at 1216 years duration of residence in the us and 3440 for percentage of lifetime in the us between respondents who were more versus less acculturated to american culture productmoment correlations between selfreported acculturation items and duration of residence in the us ranged from r 005 for generational status to r 032 for ethnic identity correlations of percentage of lifetime in the us with acculturation items ranged from r 010 for marriage of child outside cultural group to r 054 for generational status age at immigration had a negative linear relationship with most acculturation items except native language spoken at home frequency of indian food consumption and contacts with family and friends in india correlations between acculturation items and age at immigration ranged from r 004 for contact with family and friends in india to r 042 for generational status age at immigration had a meaningful cutoff at 2931 years of age between the more versus less acculturated respondents we would expect measures that assess acculturation domains to be negatively correlated with age at immigration because acculturation varies depending on whether the immigrant arrived as an adult or as a child with the latter group more closely resembling the nativeborn population reportedly due to less exposure and ties to their country of origin 20 acculturation scale various factor criteria suggested that between 2 and 4 factors were sufficient to explain most of the shared variance simple structure was optimized for the twofactor promax obliquely rotated solution the estimated correlation between the two factors was 023 factor 1 appears to represent frequency of engaging in indian cultural behaviors and factor 2 corresponds to the influence of indian culture on social behaviors in the us to improve model fit we estimated five correlated errors suggested by lagrange multiple indices factor loadings were statistically significant and moderate to large in size the cfi for the twofactor model was 089 and the rmsea was 007 suggestive of an acceptable fit 1617 despite some evidence of two potential domains underlying the 11 acculturation items internal consistency reliability estimates were only 070 for engagement in indian cultural behaviors and 059 for influence of indian culture on social behaviors in the us scales internal consistency reliability for the 11item scale was 073 and itemscale correlations ranged from 028055 the 11item acculturation scale had a mean of 39 and a standard deviation of 17 skewness was 045 and kurtosis of 304 the cfi for the onefactor model was 065 and the rmsea was 010 indices suggesting suboptimal fit 1617 productmoment correlations of the scale with duration of residence in the us was r 037 with percentage of lifetime in the us was r 045 and with age at immigration was r 034 p 0001 for correlations there was a linear relationship between the acculturation scale score and duration of residence in the us discussion this study examined the associations of temporal measures with direct measures of acculturation among asian indians while temporal measures may only partially capture acculturation duration of residence or percentage of lifetime in the us may be better proxies for acculturation than english preference or country of nativity for this population studies of asians indians cannot rely on language use as a proxy for acculturation because large majorities of asian indian immigrants are proficient english speakers 1021 additionally asian indians who immigrate to the us may have spent significant time in a westernized country prior to immigration to the us although we were not able to quantify that percentage in our sample except for nativity in a developed country 11 our study had several limitations we developed a shorter acculturation scale than those used in the literature for asians with nonetheless acceptable reliability for group measurements but not for individual level measurement 22 our scale was predicated on a unidirectional process of acculturation or a linear relationship between moving from one cultural identity to the other over time 5 while the strength of this assimilation model of acculturation is its simplicity this model has been criticized for not allowing ethnic minorities to have bicultural identities despite the fact that many ethnic minorities describe themselves as such 7823 as previously mentioned temporal measures of acculturation have also been criticized however proxy measurement and unidirectional scales continue to be widely used in immigrant health research because of the practical and financial challenges of using more indepth psychometric scales and lack of a sound theoretical approach to acculturationrelated health research 2425 despite these limitations the 11item scale captured the breadth of acculturation the correlations of the scale were comparable to previously reported correlations of the 21item suinnlew asian selfidentity acculturation scale with duration of residence in the us and age at immigration 13 some have criticized the use of acculturation in health research given the conceptual and methodological difficulties with the construct as well as its limitation as a modifiable factor in health promotion 2627 given these concerns studies examining acculturation and healthcare should also account for modifiable access and utilization indicators such as health insurance coverage usual source of care patientprovider communication and socioeconomic status 27 specifically for asian indians who may be insular in their social activities and cultural practices a greater understanding of these variables may be useful in explaining health outcomes in this growing minority population mean acculturation score by duration of residence in the us among asian indian immigrants higher acculturation score correlates with greater acculturation to american culture table 1 acculturation scale core items lowerlevel domains and responses items responses language use for the 2factor model with correlated residuals the goodnessoffit df 29 chi square 39266 cfi 089 rmsea 07 indicating an acceptable fit the correlated residuals for factor 1 were home language preference and preference for indian food frequency of contact with familyfriends in india and generational statusnativity and preference for indian media and frequency of contact with family friends in india the correlated residuals for factor 2 were english fluency and respondent choice of language in the interview and interview language and openness of ones child marrying outside ones cultural group

there are few validated acculturation measures for asian indians in the us we used the 2004 california asian indian tobacco survey to examine the relationship between temporal measures and eleven selfreported measures of acculturation these items were combined to form an acculturation scale we performed psychometric analysis of scale properties greater duration of residence in the us greater percentage of lifetime in the us and younger age at immigration were associated with more acculturated responses to the items for asian indians itemscale correlations for the 11item acculturation scale ranged from 028055 and internal consistency reliability was 073 some support was found for a twofactor solution one factor corresponding to cultural activities α 070 and the other to social behaviors α 059 temporal measures only partially capture the full dimensions of acculturation our scale captured several domains and possibly two dimensions of acculturation

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i introduction a wall is more or less white than another wall we can see or imagine so our subjectivity with the wealth of comparisons it implants in us transforms us into tourists of ourselves visitors of the odd sights of everyday life it removes the dull sense that anything at all is obvious arlie russell hochschild 1 longterm care nursing and personal care homes provide specialized medical and social care to societys most vulnerable including younger but mostly older adults with multiple health ailments and disabilities these are complex organizations 2 providing ever more highly acute medical and social care owned by forprofit nonprofit and public entities and governed by intersecting regulations that structure tableside and bedside work the sectors complexity drives debate about its regulation as kieran walshe argues n ursing home regulation remains the constant subject of policy attention… 3 in the context of this complexity how states should regulate to best guarantee good living conditions and care for residents while maintaining good working conditions for staff are important considerations and the focus of this paper who does what work how it is organized and how many people are available to do it are arguably the most important factors affecting residents receipt of quality social and health care so it is particularly important to have the right staffing regulations 4 interestingly despite the similarity of residents needs and of ltc work tasks staffing is regulated and organized quite differently depending on country regional and organizational contexts this variety in the face of similarity invites us to explore the regulatory structures in ltc by investigating the nature and form of macro level staffing regulations which can be either highly prescriptive or more interpretive in connection with frontline work organization we define prescriptive regulation as a tendency to identify which staff should do what work and when and how they should do it interpretative regulation reflects a tendency to broadly define care but not which staff should do it nor when and how they should do it the variety also allows us to explore how frontline care workers react resist and respond to the tensions between the regulatory context and the needs of the situation that they encounter in their everyday work drawing on the conceptual framework afforded by gøsta espingandersens three worlds of welfare capitalism we examine care work regulation and frontline work organization with examples of music activities medication dispersal and dining in liberal conservative and social democratic regimes in canada germany and norway respectively 5 this paper seeks to answer three questions where do each jurisdictions staffing regulations fall on the prescription interpretation continuum what are frontline care workers strategies for accomplishing everyday social health and dining care tasks furthermore in what ways does a policylevel prescriptive or interpretive regulatory approach affect the potential for promising practices to emerge on the frontlines of care work following the literature review in section ii section iii outlines the studys methods in section iv we first describe the ltc regulatory context in each of ontario manitoba and british columbia ii literature review like peter jacobson we use regulation as a term inclusive of governmentlevel legislative and administrative oversight 6 specific to the ltc sector regulation has been described as interrelated policy approaches that control quality and guard against abuses standards to make care practices consistent and to match outcomes to targets and marketbased incentive schemes like performancebased measurement and internal competition 7 both definitions of the term focus on government roles but ignore social relations our notion is more expansive draws on feminist political economy 8 and includes the range of norms values and ethics that structure and frame who does what work under what conditions and with what consequences as a result we define care work regulation as the range of laws rules norms ethics values and systems that structure care work and workers actions and activities given our broader definition we draw on several literatures focused on institutional health and social care work at multiple levels of analysis we consider overarching gender norms and debates about ownership and profit in care conceptual frameworks addressing forms of government ltc regulation and additional layers of regulation emanating from professional ethics selfregulation and accreditation gender norms ltc houses a mostly female clientele in need of intimate social emotional and medical care and employs a mostly female workforce of healthcare professionals and nonprofessionals the ratio of professionals differs jurisdictionally in the literature care work is understood as complex but in practice it is treated as less skilled and less highly paid work compared with other sectors early feminist scholars were vocal about the gendered nature of care 9 its status as skilled work in both its paid and unpaid forms 10 and its position within formal production and informal reproduction systems 11 there is little debate that this workspace is structured by overarching gender norms and expectations about womens capacities and sense of duty to care with its feminized labour force there is the expectation that labour will be endlessly stretchable and fill care gaps to address residents needs in the face of austere systems and familial care 12 ltc is thus a highly gendered home space and workplace regulated by overarching gendered norms and expectations of women that are shared across places but with obligations to provide familial care that are place specific private in ltc regulation in the context of the ltc regulation private involves delivery payment quality and standards there are different levels of forprofit nonprofit and public sector delivery based on a jurisdictions historical context and social welfare approaches 13 even so there remains considerable debate about the impact of ownership on the quality of residents care at an aggregate level studies have shown that commercial provision of care can have negative quality implications on balance showing higher quality in nonprofit and public facilities on important quality measures for residents clinical outcomes 14 there remains a knowledge gap about the impact of ownership on the quality of ltc working conditions in contrast there is little current policy debate about user fees because governments in all countries differentiate between accommodations and care costs user fees can be dependent on the persons income level which is a general feature of institutional care jacobson draws our attention to another aspect of the ltc sectors regulatory complexity a continuum exists between regulations that facilitate market forces such as private accreditation and professional selfregulation and ones that displace or substitute for the market as with government regulation 15 private regulation can provide overarching regulatory frameworks for instance studies have shown how the quality of ltc is associated with higher numbers of professionals providing it 16 although any relationship between the nature of regulation and the ratio of professionals to nonprofessionals on the frontlines is underexplored private accreditation conducted by forprofit and nonprofit organizations sets standards for quality skills and qualifications and adds another regulatory layer while some studies have looked at the link between accreditation and resident outcomes 17 the role accreditation plays in structuring frontline ltc work is underexplored government regulation organization responses and frontline care work policymakers enact ltc sector regulations to set principles and roles to guard against abuse neglect and risks to residents and workers to control who does what work and to delineate who pays for what especially as this concerns allocations of public funds and outofpocket user payments according to walshe governments can choose three regulatory paradigms compliance deterrence and responsive regulation with new public management most closely resembling the deterrence paradigm 18 however walshes singular focus on governmental rules and organizational responses renders frontline workers agency invisible furthermore the focus on rule compliance assumes that care is a straightforward linear process devoid of complex social relations an assumption categorically challenged in feminist critiques as karen davies argues care work takes time and requires flexibility 19 thus attending to the needs of the situation may require noncompliance with some rules in order to provide good care this a point underscored by the application of complex adaptive systems theory to healthcare environments 20 even considering the intersecting layers of regulation such as gender norms governments professional ethics and accreditation shows how the tension between rule making and rule following is mired in obfuscation confronting this tension steven lopez highlights frontline work with his participant observations in a nonprofit nursing home in the united states by noting that workers managers and clients engage in mock routinization and institutionalized rulebreaking because of a mismatch between time and tasks the development of new skills with the institutionalization of rulebreaking negative effects on quality the collaboration of shoplevel supervision and workers experience of managerial irrationality 21 his study reveals how complex and tensionprone is the space between regulations and frontline work and further challenges us to better understand how this space functions in different jurisdictional and ownership arrangements following presentation of the method we document several government regulatory approaches visàvis frontline ltc work iii method there are limits to using crossnational and even crossregional statistical staffing data because of the way data are collected and defined and because the data do not adequately make frontline work and its constraints visible these limits require us to gather primary data that address how staffing is regulated how regulations are interpreted and how work is managed data are drawn from an international and comparative social sciences and humanities research council funded study of promising practices and a canadian institutes of health research funded study of healthy active aging in ltc led by dr pat armstrong the project involves a team of 25 academic researchers and double that number of graduate students the authors of this study are part of the work organization theme led by tamara daly and jim struthers 22 ethics for the project were reviewed and granted by the office of research ethics at york university the data for this paper are drawn from content analyses of a crossnational mapping of regulations rules and funding arrangements specifically related to staffing as well as from observations recorded in field notes during weeklong rapid ethnographies 23 and key informant interviews conducted in 12 ltc facilities located in bergen and oslo in norway toronto ontario vancouver british columbia and winnipeg manitoba in canada and northrhinewestphalia in germany between december 2012 and december 2014 the larger programme of research includes 6 countries 467 interviews 21 different sites and over 1000 hours of work observations with complementary field notes exemplary case sites 24 with promising practices in the provision of residential longterm care were selected in each jurisdiction following key informant interviews with policymakers and others knowledgeable about the sector we conducted observations on open and locked ltc units and public spaces starting at 7 am and until midnight and later iv longterm residential care in context canada germany and norway a broad overview of each jurisdictions longterm care legislation ownership composition and payment schemes is presented below canada ltc is an extended health service under the canada health act 1984 giving provinces considerable latitude to decide the terms of its public funding and legislation with some opting for capped budgets and others including it as an insured service admittance to a facility is provincially assessed on the basis of need and space availability there is a copay model with residents responsible for a varying payment depending on the provinceterritory forprofit providers dominate in some provinces though they own at least one quarter of the homes in most provinces many facilities are accredited voluntarily by either the commission on accreditation of rehabilitation facilities international or accreditation canada of which both are nonprofit organizations additionally health professional licensing is handled by each of the provinces there are provincial similarities in scope of practice but dissimilar or no staffing ratio standards in ontario the longterm care homes act 2007 merged municipal homes charitable homes and nursing homes into the same regulatory framework 25 beds at near full occupancy are remunerated at full capacity and receive per diem activitybased subsidies from the provincial government using a case mix formula derived from the minimum data set resident 20 assessments 26 currently there are about 78000 ltc licensed beds located across 643 homes 27 with more than 60 per cent owned or managed by commercial chain conglomerates 28 ontarios local health integration networks regional health authoritiessign accountability agreements with individual homes ontario has basic and preferred monthly accommodation fees paid by the residents standards for manitobas provincially funded personal care homes are set out in the personal care homes standards regulation 2005 29 of the 125 homes most are located in the urban regions and nearly 4 in 10 are provincially run over one third are private nonprofits and just under one third are forprofits like ontario manitobas regional health authorities hold responsibility for ltc the mdsrai assessment is used in the winnipeg region but only for planning purposes and across manitoba staffing levels are determined on a flatpayment system there are four levels of care with the fourth being the highest to supplement the provincial government funding residents pay between 34 and 79 per day depending on a persons marital status and after tax income 30 staffing levels in manitoba are standardized so that all residents receive 36 paid hours of direct care from nurses and care aides combined regardless of the level of care required by the resident this amount excludes care provided by those who perform laundry cleaning and dining care the community care and assisted living act residential care regulation governs the 281 nursing homes in british columbia 31 nearly one quarter of the homes are in the public sector one third are controlled by nonprofit religious or lay organizations and the remaining 40 per cent are proprietary 32 there is a copayment dependent on peoples aftertax dependent with a minimum user fee of less than 325 cad and a maximum of 2932 fees cannot exceed 80 per cent of a persons net income 33 germany as the fifth pillar of the social security system there is a universal national and mandatory system of soziale pflegeversicherung or social longterm care insurance in germany 34 nearly the entire population of germany has coverage with the public health insurance and the longterm care insurance system benefits also cover homebased services and cash payments to family providing care persons insured by private health care insurances are obliged to purchase equivalent coverage from private care insurance funds 35 facilities are funded from the ltci 36 and residents private copayment 37 women choose residential care more often than men often after outliving a partner while men more often choose cash payments while being cared for by partners often wives before the current system was introduced in 199596 longterm care provision responsibility resided mainly with the family 38 arguably the system is still built on the foundation of family support reliance on informal family care and marketbased formal care help with the states cost containment imperative while the system provides universal access for a defined set of care services the goal of the ltci is to control rising costs for individuals and to enable people to age in place with family supports this insurance was accomplished by the states creation of a new type of social rights establishment of specific funding maintenance of a family care requirement and bolstering marketbased options for purchasing care 39 most homes are run by nonprofits and forprofits with the remaining 618 homes run by the public and mainly by municipalities 40 there are three care levels in germany i ii iii plus an additional recognition on hardship cases level i is reflecting the lowest need and the smallest benefit reimbursement as well as hardship cases reflecting the highest need and receiving the highest benefit amounts 41 an individual needs to have basic body care needs exceeding 45 minutes for level i 120 minutes for level ii and more than 240 minutes for level iii the german system is heavily reliant on professional standards to guide structure process and outcome quality for instance the system uses national expert standards in nursing developed by the german network for quality development in nursing working with the german nursing council 42 the standards define the quality level of professional care that users of both health and ltc services can expect when being cared for by nurses and elder carers in addition germany accredits nursing homes 43 in the past quality assurance has been a role played by provider bodies such as the länder level medical advisory service of the statutory health insurance funds medizinische dienste der krankenversicherung the mdkmas conducts needs assessments for care requirements as well as for quality assurance and publishes all audit results the health insurance funds contract with ltc homes provided service funding and personnel criterion are met each german länder holds responsibility for surveilling and monitoring ltc homes compliance in terms of workforce accreditation and certification ltc providers are required to uphold provisions of a quality management system such as eqalin in 2013 just under one third of ltci beneficiaries were in residential services 44 furthermore those with the most wealth opt for services in the home or institutions while those with less financial means opt for cash payments and are cared for by relatives like norway there is free choice for users about location of care provision and providers 45 gender socioeconomic position and immigrant status all affect the role of family care levels of professional care and additional paid care services the system has been criticized for its bias favouring functional impairment over dementia and privileging germans over migrants 46 norway starting in 1988 with the passage of the municipal health care law local authorities gained responsibility for longterm care along with primary health care and various types of housing and care services 47 this multilevel government model is centred on local autonomy with integration between the central and local government levels a typical nordic pattern 48 following the acts passage spaces in ltc were increasingly reserved for older adults with extensive needs and the average stay of residents decreased 49 all while home care including 24 hour inhome nursing was expanded by 2010 most of people residing in the 997 nursing homes were aged 67 or older with extensive care needs 50 about 41000 people resided in nursing homes representing about 16 per cent of those receiving longterm care services 51 as in other countries the vast majority of health and care staff is female assessments for longterm care are conducted by the municipalities for placement into both public and private nonprofit and forprofit providers these providers compete because norwegians have what is understood as free choice to determine whether to go into a public or private facility reflecting a move within the country towards consumerism even for state funded services 52 there is debate however with some arguing that the threshold for getting into ltc is too high 53 of those living in institutions 108 per cent live in a privately owned nonprofit or commercial facilities 54 there are more privately owned facilities in the major cities with nearly half in both oslo and bergen 55 six main commercial chain firms provide services 56 municipalities have become incorporated mimicking forprofit organizations national and local taxation funds ltc and copayments are set by the municipalities 75 per cent of income over nok 6 600 up to a maximum basic amount of nok 75 641 plus any income that exceeds this up to the full cost of the place with the amount varying by municipality the government does not take property and capital assets into consideration 57 the family provides as much help as does the state when care occurs in private homes but less so when someone is in residential care as daatland and veestra note o f parents with activities of daily living needs about two out of three are institutionalized 58 the norwegian center for external quality assurance in primary health care accredits nursing homes as well as primary care physician offices and other health care institutions in summary ontario is the most privatized jurisdiction while norway is the least private copayments are required in all of the places examined although the algorithms and actual amounts vary in all instances copayment calculations are subject to some income dependent modifications the reliance and obligations of informal care providers also varies jurisdictionally german legislation is the most explicit about the primacy of family responsibility while norway is the least reliant on informal family care norways system seems most explicit about ltc being a right of citizenship though the german system is based on social rights founded on the principles of pooled risk and shared responsibility in its codified ltci scheme manitoba retains the insurance model but ontario and british columbia have created separate capped funding envelopes finally all of the systems are regionalized however this also translates into jurisdictional differences in ontario manitoba and british columbia the legislation is provincial and funding disbursement is to a regional health authority in germany the legislation is national but managed at the level of the german länder in norway the legislation places onus and responsibility on the municipal level finally all of the jurisdictions have noncompulsory private accreditation v findings this section presents findings of our jurisdictional care work regulation review and provides examples of frontline care work drawn from our ethnographic field studies in canada germany and norway in the areas of social care health care and food i care work regulation we focus on five regulatory areas first staff qualification regulations stipulate the certifications that are required to complete different care functions table i compares the studys jurisdictions norwegian care aides receive the most training with one to three years of secondary and postsecondary qualifications while canadian and german care aide training varies but generally a sixmonth course of instruction is completed at a public community college or a private career college in germany dementia care aids have been recently introduced they require much less training to practice practical nurses in canada are college trained like norwegian and german counterparts while canadian registered nurses have university degrees like their norwegian counterparts the highest trained german occupation in nursing homes is the qualified care worker who requires three years of onthejob training table ii presents comparative staff mix regulations like the oecd we found varying requirements for the ratio of professional to nonprofessional staff 59 while minimum nursing staff numbers were required in norway and canada in germany an impressive half of the staff must be qualified care workers compared with canada there are higher numbers of norwegian nurses on the floor in both european countries we found more qualified or professional staff in the homes the reverse is true in canadian settings care aides with less formal training far outnumber nurses and provide the bulk of care work as shown in table iii staffing intensity ratios calculate the minimum staffing allotment overall usually measured in hours per resident per day inclusive of direct care staff germany has regionally determined minimums tied to its care levels overall staffing levels are higher with more professional staff than in canada according to the most recent representative survey in 2010 the residentstaff ratio was 100 residents to 449 care workers 60 the norwegian informal levels also far exceed levels practiced by canadian provinces manitoba also has a minimum number of paid hours though these are shared by professionals and nonprofessionals table iv shows jurisdictional approaches to funding the ltc sector as sutherland and colleagues argue funding patterns can be populationbased global activitybased payforperformance or bundled 61 populationbased formulas calculated with age sex socioeconomic and other healthrelated characteristics are used to allocate funds from central to regional governments a variety of other models are used to directly fund organizations the pattern of funding whether global directed or activitybased can determine an organizations flexibility with respect to their staffing complement directed funding can challenge frontline staff if there are time lags between when funding flows and when workloads have already increased based on residents increased needs while global funding better allows a facility to internally shift in response to changes in need as table iv shows ontarios activitybased funding which is an even more stringent form of directed funding allows the narrowest degree of freedom around staffing flexibility regulations governing the division of labour determine who can do what work and whether work performed is more taskoriented or relational and separated or integrated table v summarizes the potential for work integration between care aides nurses and dietary workers in each site in care work a taskoriented focus for example being focused on getting certain tasks like bathing completed to meet a predetermined schedule is in contrast with one that is relational which more flexibly adapts the order frequency and duration of care to meet the residents needs ii care work organization on the frontline below we have drawn from our field notes and key informant interviews to illustrate the ways in which social care activities medication dispersal and dining care demonstrate a reactive resistive or responsive model of work organization and the division of labour in different settings in canada nurses and assistant nurses were responsible for supervision documentation and regulated acts while care aides were responsible for a range of body and care tasks differing depending on the province in general most care aides engaged in washing feeding toileting and when time permitted listening chatting and comforting residents in the canadian context the work was more constrained and divided such that care aides did body work and cleaning of some of the space including tables and beds sometimes they used computers to document but often they used paper and pen sometimes they put away laundry recreation therapists were responsible for social care and their time was usually shared with sixty or more residents there were also dietary workers who cooked and served meals and cleaned kitchens serveries and dishes canada tended to have hierarchical and taskoriented workplaces 62 outside of canada care aides roles were much more expansive for instance in germany and norway care aides had more decision latitude and more varied work they did the body work cleared tables and beds and put away laundry like their canadian counterparts however they also cooked planned baked cleaned took residents outside for walks and bought items at local stores for parties mostly this is related to the approach hausgemeinschaft and not a general pattern in germany in germany assistive personnel also ensured residents consumed medicines a social care activitiesfollowing the generally strict and hierarchical division of labour in ontario 63 specially qualified recreation therapists with at least college education performed social care in scheduled increments ontario workers complained that their work emphasized more counting than caring the work was highly prescribed documented standardized and audited as one recreation therapist noted thats what the ministry looks to when they come in when were audited we write down what programs residents attend what needs we meet socially emotionally spiritually physically and then …we do … a care plan for them … we do tick off the boxes on the computer screen … with respect to what programs they attend … and theres a psychosocial box that we have to fill in and an activity section … we have to fill in 64 in addition because the task of social care was the purview of the recreation therapists and the schedule of social care may interfere with tasks other workers needed to perform this led to staff conflicts one workers experience highlights this conflict there are times when im doing an activity and i really get upset with staff because if somebody is sitting there listening to music theyll come and just take them out to give them their bath or toilet them or whatever you take them out and theres that feeling of loss and confusion so they come back and theyre not the same some of them are agitated … and i know if they were with the doctor they wouldnt come in and take them from the doctors presence to toilet them or whatever right 65 furthermore this workers experience illustrates how though social care may be counted it does not count in terms of the hierarchy of tasks with body work and medical work coming first and little appreciation for how the social is an integral part of the care in this instance described above workers appeared to be reacting to the pressures to complete their own tasks with little attention to residents relational care needs our observations and interviews in a very large norwegian longterm care facility revealed a different pattern of integration between health and social care and a different level of staff empowerment for responding to residents needs for relational care there in a 32resident secure unit within the larger facility music therapy informed almost every aspect of care delivered to cognitively impaired residents over the past five years staff members worked together as a team in sharp contrast to the ontario sites both in terms of the teamwork and the integration of the social and medical care to implement the program the director of music therapy and her assistant trained staff in how music programs that were individually tailored to each resident could be successful in eliminating the need for psychotropic or sedating medications to manage agitation depression and aggression among residents with moderate to severe forms of dementia as she explained … the easiest way of telling it is that in the music in daily activities as you call it you use music as a stimulant in the patient for getting them calmed down … but as a music therapist you are working out ways of communicating with … the patient with music so you are sort of reflecting with the person … i ts sort of psychological processing and your goal is not to stimulate that person with the music to get them to do what you want its more like what is their meaning and you try to make meaning out of things speaking together through music so its a different way of thinking … so when i meet somebody we do music together as a verb we dont use music as an object … one of the main theories in music therapy is that everybody is born with a basis to communicate as a child … you already start to communicate and this is a musical way of communicating so we all are really musical but its not a musical way of being able to play scales or sing perfect that you have to learn but what lies underneath is the music everybody knows … and thats why everybody gets moved by music so i use this small thing to communicate with the patient 66 all staff working with residents in this secure unit received training about how to integrate singing dancing touch and rhythm into all phases of their daily interactions with them the success of music therapy on this floor has led to a dramatic reduction in the use of moodaltering medications and has contributed greatly to staff being satisfied about their work these positive results have also led to the gradual introduction of music therapy on other units a nursing social worker described its transformative impact on her job in this way i have been working a lot with music here and we see that makes residents more relaxed maybe they can tell about their past maybe they speak more people that dont have any language anymore they can suddenly sing a whole song from the memory and then they suddenly started speaking more because of the music … before maybe five six years ago i didnt sing at all never never sang because i dont like my voice but we started this project and i started singing and i just thought that it doesnt matter if i have a bad voice its not for me its for the patient now i sing all day long i dance and sing with my patients and if theyre maybe … if they have problems brushing their teeth i can start singing a song i know they like and some manage its just moments that make things easier for them just by using music just by singing its really really interesting 67 in the german sites half of the staff need to be qualified care workers there are also care aides separately funded by the ltci one organization actively resisted state funding level limitations it increased the staffing complement by adding large numbers of student apprentices the costs of the training of the apprentices are refunded not carried by the facility they also included a sizable number of 1euro jobbers who were remunerated at 1 € per hour and additionally funded through a labour market program aimed at job retraining as a result we observed a much higher level of social interaction in this facility 68 apprentices performed bodywork and social care under the direction of the nursing staff which then enabled the nursing staff to work in a more direct way with residents in our observations we noted that the large numbers of staff apprentices and 1euro jobbers available to provide care was the precondition for the comprehensive social care that was provided on the units in this site the facility resisted lower staffing allotments in favour of a model that ensured there were plenty of people available to provide care even if they were precariously employed by actively resisting the funding constraints imposed by the legislation as a result the facility had enough people available to provide care and did not lock its doors even on units with highly mobile people living with dementia we also found that there was plenty of singing smiles and everyday activities for residents to be engaged in that supplemented the formal activity schedule one researchers field notes recorded the interactions as follows when we arrive we see two apprentices sitting with one resident and talking to each other but also to the resident other residents are sitting around the table the atmosphere feels calm and relaxed all residents are dressed nicely one woman in a wheelchair makes sounds she seems a little agitated especially if the young man takes his hand away from her hand she kisses and touches his hand she seems very much needing these contacttouches and im very impressed that i saw various staff members touching her very kindly and allowing her to kiss and touch their hand arm i ask the apprentices if they sit with the residents … every day or if they have other duties … they say that they are sitting there every day and that they are supposed to sit there and that they dont have many other things to do during this time of the day 69 in this home social care was imbued throughout the care work workers of all qualifications engaged in social care but the capacity to do so was set within the organizations active resistance to the constraints imposed by the german model that espoused cost containment even while it was more interpretive in privileging professional standards and ethics in addition even though subject to critique the facility had more people available to care by employing people subsidized by the state to get job retraining in summary these examples from the three countries reveal differences between the integration of social care with medical care and bodywork and the relative priority afforded to relational care each also illustrates how workers and organizations operated in ways that were reactive responsive or resistive to the pressures in order to meet the needs of the situation social care was a clearly defined episodic activity in the ontario sites while in the german one we visited there were blurry boundaries between health and social care and in the norway sites social care was an integral part of health as an important alternative to medication and also a way for care workers to find meaning in their work b health care medicationsmedicine dispersal usually happens close to dining times there are some commonalities amongst the jurisdictions medication dispersal usually involves nurses taking out a medications cart moving from resident to resident and often crushing and mixing tablets with soft food this is usually one persons responsibility per unit in the canadian jurisdictions giving medications is a regulated act thus there are strict regulations that distinguish it from bodywork such as washing dressing and toileting only nurses usually licensed practical nurses are permitted to perform medications dispersal and to ensure medication consumption we observed that while medication rounds occurred rns work involved computerand paperwork and addressing complex health needs meanwhile if it was the morning care aides were getting people up by providing the vast majority of body care and transport to the dining room for breakfast like breakfast lunch and dinner involved serving feeding and bussing tables in order for the lpns to avoid being called upon to do frontline care work such as moving residents requiring two people while dispensing medicines many organizations allowed signs on medicine carts that indicated that no one was to talk to nurses while doing medications work doling out medicines usually happened while residents were being brought to the dining rooms and it was done in an assembly line fashion with nurses responsible for as many as 32 residents nurses stood over residents who were usually sitting in a passive position at a dining table waiting to be served their meal in terms of work organization care aides complained about declining teamwork due to the nursing staff no longer having the time to help with bodywork when care aides were most pressed for time during the mornings the lack of extra hands often meant that care aides reacted by moving residents even those who needed two people without a partner care aides argued that managers knew about this but ignored their reactions because everyone knew that the work could not be completed otherwise like the mock routinization described by lopez 70 in one german home medications were secured at night but out in the open in the great room during the day where residents and nurses spent most of their time together much as you might find in a persons own home when it was time to consume the medicines the nurse gave the medications to the resident poured more water into the residents cup and then walked away but not out of the room and dispensed medicines to another resident care aides and apprentices sitting at the table calmly ensured that the medicines were consumed sometimes with gentle words other times by consuming something themselves by drinking thereby turning medicine time into an opportunity for social connection with a resident with dementia german regulations allow the qualified care worker to use professional judgment and this enabled the work to be seamless natural and very homelike very different from the highly clinical encounters we observed in the canadian context in this example the qualified care worker delegated only the role of watching the consumption of the medicines while she remained in the room but not standing over the person each person providing care understood that the resident was to take the medicines but done in this way the resident could take them when ready as the care aide was there to spend time with the resident the german home was less hierarchical and the division of labour was less rigidly enforced this site followed a hausgemeinschaften model where eight to twelve residents live in one unit thus there is a better staffing ratio in a facility following this concept but also because the site where we observed trained a large number of apprentices who provided an extra set of hands german legislation is weighted in favour of half of the staff being qualified care workers in terms of staffing intensity and more dependent on their professional judgment compared with the canadian jurisdictions compared with other homes in germany this site actively resisted the state imposed care gap due to austere funding by having more people around to provide care the organizations actively resisted understaffing by having more hands available to provide care who would not be considered fulltime staff and thus not subject to the rules about having half of the staff as nurses and allowing the type of social care that they wished to provide to flourish with the work more distributed in combination with more workers there was more flexibility to resist narrow job definitions and to respond to residents needs in a timely and relational way while still maintaining a complement of nurses comparable to similar facilities in one norwegian site high staff to resident ratios allowed for the work to be responsive to residents needs medication dispersal happened during quiet times when residents were resting in their rooms the nurses were unhurried in the process and took time with each resident the process happened outside of the main space where dining and socializing occurred unless a resident happened to be in that space the nurse chatted with the eight residents for whom she was responsible about onequarter to onefifth the number of residents that nurses were responsible for in canadian facilities c food meal timescongregate mealtimes are a common feature of residential care but there was tremendous variation when we compared mealtimes between canadian and european sites while all of the sites were subject to governments safe food handling regulations canadian regulations are highly prescriptive with respect to who could cook and touch raw and cooked food with ontario the most prescriptive with respect to how many hours the dietary servers must work and where the food preparation takes place central kitchens prepared the food to be ready for a certain time which largely determined the work schedules of others such as front line care workers who were not a part of meal production even though some dietary workers set and cleared tables it was usually care aides who did so and also brought residents to the dining space offered food choices delivered the prepared food helped residents with eating and drinking scraped the plates and cleared the tables the autonomy and dignity of both workers and residents were compromised because often there were between twenty and thirty people in a single dining room the regulatory goal was that each resident would be fed without delay however the resident numbers were burdensome and residents often waited for everyone to be brought to the space for medicines to be dispensed and for the food to be served facilities had to interpret frontline work organization within the confines of prescriptive dining regulations this was often done by requiring care aides to record the quantities of food and drink consumed by each resident at each and every meal with each care aide responsible for between eight and twelve residents who usually did not sit together timely and accurate recording was a practical impossibility and there was a great deal of resistance that accompanied this job function in some places care aides were required to enter information into computer programs directly following the dining hour when they could otherwise be engaging with residents in other places tickboxes on paper were filled in at the end of the shift care aides revealed that they reacted to the constraints by estimating and sometimes copying the previous days input raising serious questions as to the reliability of the data and showing the extent to which this documentation was less important than other tasks that competed for their time facilities reacted to regulations about when residents should eat by documenting residents preferences in care plans for instance they only allowed someone to sleepin and receive a later continental breakfast if they could care plan it while following european regulations for safe food handling in germany and norway food could be prepared freshly on the unit or reheated from food prepared in central kitchens the unit stoves were used at predictable though not fixed times in relation to the residents needs the result was the smells of food wafted through the air we observed that the workers also engaged the residents in the work for instance one care worker in germany set the table while the residents passed the cutlery the residents participation made activation a normal part of the day and not a defined and separate activity the residents also handwashed and put dishes in the dishwasher in this site when potatoes were left from lunch the workers asked residents what should be done with them they participated in decisions about how the potatoes would be cooked later that night one of the residents who liked to clean up collected the dirty dishes from the table and was allowed to wash and put the dishes away we watched and the staff did not rewash the dishes afterwards staff cut apples and shared them at the table while also eating a slice themselves to stimulate the social nature of dining residents could have wine or other alcohol at the table residents swept floors and workers did not resweep residents cut and workers did not recut for supper on the dementia unit a family member helped prepare potatoes and an omelette the food was soft easy to chew and swallow smelled palatable and included thin slices of cucumber there was a single plate of bread cheese and meat for the table and people chose what they wanted from it bottles of water were left on the table and residents poured water for one another this hausgemeinschaftsmodel places emphasis on residents involvement in housekeeping keeping a more homelike atmosphere having smaller groups and the presence of at least one care worker always in the common space v discussion and conclusions we found marked jurisdictional differences both in terms of regulatory approaches and how care was provided on the frontlines how regulations structured frontline care work was evident when we compared how activity medication dispersal and dining were performed in the canadian german and norwegian jurisdictions in this section we locate each jurisdictions position on the prescriptive interpretive regulatory axis discuss frontline reactive resistive and responsive care work organization and propose an analytic framework that links the regulatory form to frontline work organization i prescriptive and interpretive regulatory axis prescriptive regulation identifies what should be done and which staff should do it and delineates when and how they should do it in contrast interpretative regulation is more openended it identifies that care should be provided but not which staff should do it nor when and how it should be done germanys legislation is focused on delineating national regional local and family responsibility care is defined and care workers are expected to provide care that is in accordance with the generally recognized state medical and nursing knowledge 71 however as our ethnographic study showed facilities can engage in rule bending to accomplish their care goals in norway the legislation is highly interpretive as mia vabø and colleagues argue eldercare is regulated not by special laws but by general legislation care services are offered to all citizens in need of care regardless of age income family relations and so on 72 the norwegian act identifies that health services are a municipal responsibility but health professionals responsibility to carry the services out according to their professional standards the european acts we reviewed are similar in ascribing agency to health professionals and thus relying on professional standards and ethics as a framework the canadian context is more varied the most minute care tasks are detailed in ontarios prescriptive legislation including from how to handle continence care and residents weight changes to how often linens should be laundered in contrast manitobas legislation is interpretive with broad categories of care work laid out and general guidelines provided for instance soiled linen should be collected regularly surfaces cleaned as often as necessary meals offered at reasonable intervals in each 24 hour period and nursing services organized and available to meet residents nursing care needs in accordance with guidelines approved by the minister and consistent with professional standards of practice 73 however on the issue of pharmacy and medication management the manitoba legislation is quite prescriptive in british columbia the act is more interpretive around care staff assist with activities of daily living consistent with the health safety and dignity of persons in care it is more prescriptive with respect to facility design elements and dining hours but still remains more interpretive than ontario in allowing for more time during the morning rush and brunch on weekends and holidays table vi summarizes these findings overall we noted the following associations prescriptive regulatory environments tend to be accompanied by a lower ratio of professional to nonprofessional staff a higher concentration of forprofit providers a lower ratio of staff to residents and a sharper division of labour on the other hand interpretive regulatory environments tend to have higher numbers of professionals relative to nonprofessionals more limited forprofit provision a higher relative ratio of staff to residents and a relational division of labour that enables the care to be more fluid and responsive in one us study it was found that higher numbers of nurses produced fewer deficiencies in care 74 with higher numbers of professionals around to guard against deficiencies a jurisdictions regulatory tendency towards interpretation might reflect its reliance on professional ethics and frontline judgment as its overarching regulatory benchmark ii responses from the frontline as we found when considering the example of music therapy in ontario highly prescriptive regulation seems to impact frontline care workers abilities to perform teamwork and integrate health and social care geraldine leetreweek argues that when we consider the care and the worker separately it is easier to identify the space for resistance as an everyday strategy to control and get through work for example private nursing homes workers controlled their work by making the care depersonalized engaging in noncompliance or selective adherence to tasks and coming to their own conclusions about residents behaviours 75 in the german site resistance was not an individual struggle it was taken up by the organization hiring many apprentices helped to provide more social care overall and it enhanced the working and living environment indeed as has been demonstrated aptly in other sectors the adoption of new public management involving heavy regulatory oversight and onerous reporting requirements has significantly changed the university environment from a collegium to a workplace 76 how states choose to govern has implications for the quality of the workplace indeed how care workers retain decision latitude within highly prescriptive structures is demonstrated by several studies of frontline care all conducted within highly regulated systems rule breaking has emerged in the literature as an important coping mechanism for instance canadian care aides decisions when performing dementia care were found to be discordant with organizational and legislative rules 77 which led aides to break rules in order to be able to provide care furthermore this occurred on a casebycase basis with supervisors complicity in some canadian facilities the only time lpns are on the floor is during the medication dispersal they are behind desks filling in paperwork at other times to allow them to concentrate facilities have allowed the use of do not disturb signs which may in fact further weaken their connection with nonprofessional staff and allow for rulebreaking similarly in the us lopez reports informal patterns of work depart significantly from official procedures designed to protect the health and safety of longterm care facility workers and residents underlining the routinization of rulebreaking furthermore with insufficient federal funding which limits facilities ability to hire sufficient staff to meet basic care standards care aides could not complete work on time and thus engaged in a mock routinization of the work that broke or bent important care rules and compromised quality of care 78 we noted that rules were broken and bent when workers needed to actively react or resist in order to attend to the needs of the situation similarly ryan deforge and colleagues identify care workers workarounds as a way to address workplace structures to show how reacting to mandated practices helps workers to provide care 79 donna baines notes that the context within which care work occurs means that care workers toil on a compulsioncoercion continuum this happens because care workers often perform unpaid work to keep their jobs while at the same time feeling a compulsion to do so because of a sense of duty obligation and genuine care 80 by examining government regulation and the care planning processes in ltc facilities one study found a large time burden created by the formal care planning process and documentation observing that fear of citation can lead facilities to write less specific care plans 81 jennifer black and colleagues reporting on ltc dietitians surveyed in british columbia found the majority perceived implementing new residential care regulations increased their workload thus suggesting they did comply with the regulations 82 in our study canadian facilities used care plans to document any deviations from official rules and documentation took up the majority of lpn and rn time demonstrating that the nurses used care plans as a means to depart from the official rules we found that the most highly privatized jurisdiction had the most prescriptive regulation studies have shown higher quality is associated with nonprofit and public facilities public and nonprofit facilities more often increase the number of care workers as they fund the work from other sources of funding as one german site illustrated having apprentices available to supplement care is an active form of resistance to conditions of underfunding and provides a calmer and more therapeutic environment in which to provide care also of note the european facilities we examined had smaller units and did not amalgamate their dining spaces into larger ones instead the spaces were congregate but intimate and more on the scale one would find in a large family home other studies have shown that even highly detailed regulations can be interpreted in different ways regulation and external oversight can be primary drivers of improvement initiatives in ltc 83 although the content and consequences of regulations are not always apparent to frontline staff or administrators 84 and interpretations can vary for instance one study that investigated inhouse puréed food production in an ontario ltc found variation in how government guidelines were interpreted 85 in germany and norway frontline workers had responsibility for far fewer residents and provided customized food plates when residents were ready to eat do more prescriptive rules regulations and oversight of ltc improve or diminish care there can be serious problems with abuse deficiencies and violations 86 and regulations can be a guard against these but there is a downside to heavy and highly prescriptive regulation julianne payne and jeffrey leiter examine hospital and nursing home management comparing australia and the united states they found managers perceived increased regulation and reporting as obstacles in the context of declining state support market competition and increased client demands 87 likewise nancy foner argues that bureaucratic rules associated with medical care complexity and state regulation interfere with nursing home aides abilities to provide compassionate and supportive care 88 in our study we found that highly prescribed rules led to work that was inflexible and incongruous in contrast the flow of the day was calmer in the german and norwegian sites where there was less paperwork and more time to provide health and social care given that more prescriptive regulation tends to occur in jurisdictions where care aides are in more regular contact with the residents and far outnumber nursing staff it is not surprising that some studies conducted in similar jurisdictions have found that formalization the degree to which rules and procedures are followed by the organization and employees in carrying out different activities was positively correlated with job satisfaction among long term care staff 89 indeed another found that certified nursing aides and licensed vocational nurses in nursing homes accepted regulatory oversight as important for providing good care 90 it is possible that in the presence of less formal training and no selfregulating body care aides may like the clearly delineated job roles that come with more prescriptive regulations however acceptance is different than adherence and as mentioned above there have been plenty of studies that demonstrate the myriad workarounds that care aides put in place in order to get the job done an important consideration may also be the extensive initial and specialized training for care aides as is done in the european settings when considering training kihye han and colleagues found that certified nursing assistants in ltc were more satisfied with their jobs if they worked in states with stricter regulation requiring additional initial training hours 91 other scholarship suggests that staff do follow make an effort to follow or should follow rules and regulations in the course of their work katherine mcgilton and colleagues for instance found charge nurses in ltc perceived a need to balance competing resident family staff management and regulation demands while completing all of their responsibilities 92 iii lessons for care work regulation frontline care workers our findings show how the regulatory approach to staffing and administrative funding is highly prescriptive in ontario while the regulatory and funding orientation in norway tends to be more interpretive german facilities also have some latitude to interpret regulations as a result care work in ontario tends to be very task oriented with definite divisions of labour that hindered workers abilities to provide quality care in other words the prescriptive regulations did not promote a high standard of relational care nor did they promote good working conditions instead regulations promoted reactive work organization we found that resistive work organization emerged within conditions of austerity when interpretive regulations conceded to professional judgment and organizations then had flexibility to provide care organizations also loosely interpreted rules around who was to be included as staff so as to increase the number of bodies without affecting the need to hire even more nurses than would be considered standard finally we found a more responsive model accompanied regulation that was more interpretive privileged professional decisionmaking and provided funding sufficient to meet most residents needs baines and daly argue that the forms of resistance that are associated with feminized work are often overlooked because they are not large scale highly visible strategies 93 however care workers do resist overbearing and punitive regulation in order to attend to the needs of the situation thus care workers who retained more decision latitude and the opportunity to engage in more relational work geared to better meet the timely needs of residents and coworkers experienced more responsive work organization the more interpretive regulations in norway yielded more responsive work organization and hold promise for the provision of relational care that is supportive of workers and residents needs sharmila rudrappa elevates individual acts with her concept of radical care work which describes her findings of racialized female workers going from being passive recipients to active agents who participated in making a more equitable world 94 as a consequence it is important not only to look at common strategies for resistance but also to identify how the orientation of regulation offers different spaces for resistance in some countries with growing privateforprofit sectors there is a desire to heavily regulate in order to better control the care provided what this analysis however shows is that the form and content of regulation matters greatly for the ways that front line workers can care and that deprofessionalizing this sector may increases the need for prescriptive regulation that in turn hinders the provision of good quality flexible care

this paper examines the tension between macro level regulation and the rule breaking and rule following that happens at the workplace level using a comparative study of canada norway and germany the paper documents how longterm residential care work is regulated and organized differently depending on country regional and organizational contexts we ask where each jurisdictions staffing regulations fall on a prescriptioninterpretation continuum we define prescription as a regulatory tendency to identify what to do and when and how to do it and interpretation as a tendency to delineate what to do but not when and how to do it in examining frontline care workers strategies for accomplishing everyday social health and dining care tasks we explore how a policylevel prescriptive or interpretive regulatory approach affects the potential for promising practices to emerge on the frontlines of care work overall we note the following associations prescriptive regulatory environments tend to be accompanied by a lower ratio of professional to nonprofessional staff a higher concentration of forprofit providers a lower ratio of staff to residents and a sharper division of labour interpretive regulatory environments tend to have higher numbers of professionals relative to nonprofessionals more limited forprofit provision a higher ratio of staff to residents and a more relational division of labour that enables the work to be more fluid and responsive the implication of a prescriptive environment such as is found in ontario canada is that frontline care workers possess less autonomy to be creative in meeting residents needs a tendency towards more taskoriented care and less job autonomy the paper reveals that what matters is the type of regulation as well as the regulatory tendency towards controlling frontline care workers decisionmaking and decisionlatitude

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background the underfive death rate is the probability of a child dying before attaining five years of age it remains the most useful indicator of child wellbeing 1 which reflects the overall strength of the health system of countries and the value the society place on health care 2 the millennium development goal 4 sought to reduce the global underfive mortality rate by twothirds between 1990 and 2015 concerted efforts were made to ensure the realization of this goal through the promotion of exclusive breastfeeding good nutrition optimal vaccinations correct management of common childhood infections ensuring a safe environment and access to potable water 3 these interventions led to the prevention of about 4 million u5d between 2000 and 2015 4 the reduction was most dramatic in countries with the highest u5d 3 however the majority of u5d recorded at this time was from subsaharan africa and southern asia 34 and these were mainly lowand middleincome countries it was therefore not surprising that most of these countries could not meet up with the mdg 4 goal there were inequalities in the reported u5d within lmic with variations across location sex and socioeconomic class 5 sex differences in u5d have been observed in different parts of the world and the pattern depends on the socioeconomic development of countries for developing countries the natural setting supports female survival advantage 6 this is because male infants have some inherent biological features which make them less likely to survive compared to females these features include the effect of the xlinked immunoregulatory genes which gives females more resistance to infection 78 waldron affirmed that higher proportions of males being born prematurely with the accompanying complications and there is the risk of lung immaturity in males as a result of the effect of testosterone on the lungs which predispose them to respiratory distress syndrome 7 for developed countries male disadvantage disappeared over the years as a result of the improvement in child healthcare 69 but the female survival advantage persists till age five 10 however the natural female advantage for survival can be lost in settings where females are deprived of access to health care 11 and good nutrition as well as exposure to harmful environments 69 this is a common finding in many lmic where male preference have persisted as a result of deep seated patriarchal cultures seen in these countries 12 it is not clear if the earlier listed interventions had benefitted both male and female children equally or if there is a sex disparity in their survival in the presence of disparity it will be imperative to investigate the factors which contribute to sex disparity in u5d as this can reveal specific contributions to u5d and provide guidance for more targeted approaches and intervention in addressing the problem a cursory examination of most national u5d data will mask inequalities and not make them obvious this can hinder the invention of novel and equally effective approaches that can work synergistically with existing strategies to effectively address u5d the united nations suggested that a closer look at existing data can give rise to more novel approaches to flatten the curve of u5d in developing countries 3 one way of achieving this is the decomposition of factors that contribute to the disparity this will allow for the appreciation of more intricacies in the factors that could be associated with the inequality and its outcomes can be an invaluable tool that can lead to the production of cutedge interventions to reverse the trend of u5d in developing countries more efforts are required in lmic where the bulk of u5d still occur for these regions to achieve the goal of sustainable development goal 32 which is to ensure health for all ages 13 also the countries which succeeded in achieving the mdg 4 need to keep up the efforts to achieve sdg 32 by continuing the effective interventions and exploring other novel approaches therefore the goal of this study is to decompose the factors associated with sex differences in u5d in the lmic we posit that due to the male preference culture that is prevalent in many lmic there will likely be more profemale u5d inequality in these countries methods study design and data we obtained underfive children data from the demographic and health surveys the dhs holds approximately every five years across the participating lmic the icf collects the data in conjunction with the designated organizations in the participating countries typically the survey is crosssectional nationally representative and populationbased we pooled data from the most recent dhs conducted between 2010 and 2018 and in the public domain as of 10 september 2020 a total of 59 lmic met these inclusion criteria and their data were included in this study we pooled the data of 856987 underfive children from 66495 neighborhoods across the 59 lmic sampling strategies the dhs utilized a similar clustered multistage sampling procedure in the participating countries based on countries sampling frames drawn mostly from the last census counts countries were stratified using the existing geographical and administrative structures the multistage mechanism included the statesdivisions regions in the first stage districts as the next stage in some countries and finally the clusters as the last stage the clusters were the primary sampling units 1415 the households were then selected from the psus from which women aged 1549 years were interviewed the surveys generated different datasets we used the child recode data that captured diverse information on all births of the interviewed women five years before the survey sampling weights were computed and provided alongside the data by dhs these computations were based on the multistage sampling method to ensure the representativeness of the sample concerning the general population the dhs uses similar surveys and research protocols standardized questionnaire similar interviewer training supervision and implementation in all the countries the full details of the sampling methodologies and other information are available at dhspr ogram com variables dependent variable the dependent variable was ud5 which was defined as death among live births within the first five years of life that is deaths within 0 to 59 months of birth 14 to ascertain the correctness of this outcome mothers were first asked if they had given birth to any child five years preceding the date of the study they were then asked to recount the date of birth and were assisted to estimate such dates when necessary they were asked if each of those children were alive or dead the dates of death or the ages at death for the dead children were then used to determine u5d therefore u5d was binary alive or dead before 5 th birthday main group variable the main group variable is the sex of the child male or female independent variables the variables identified to be associated with childhood deaths in the literature 16 17 18 19 20 were selected using moseleys systematic conceptual framework on the study of child survival in developing countries 17 the variables were made up of individuallevel and neighborhoodlevel factors individuallevel factors the individuallevel factors consist of a childs characteristics mothers characteristics and the households characteristics childs characteristics were weight at birth birth interval birth order and whether a child is a twin while mothers characteristics were maternal education maternal age marital status maternal and paternal employment status and health insurance households characteristics were the sex of the head of the household access to media sources of drinking water toilet type cooking fuel housing materials household wealth index and place of residence the sources of clean fuel are electricity liquefied natural gasbiogas and unclean fuel include wood charcoal kerosene straw shrubs animal dungs and grass the improved sources of drinking water include a protected well borehole bottled water and spring rainwater while spring water tankers unprotected well with drum sachet water surface water and other sources constituted the unimproved sources the housing material was based on a composite score according to the type of wall floor and roof materials if cementcarpetrugceramic tilesvinyl asphalt strips were used for the floor the floor quality is coded 1 else it is coded 0 in the same vein wall material quality is coded 1 if it is made of cement blocksbricks else 0 if roof material is made of calaminecement roofing shinglescement fibresceramic tileszinc it is coded 1 else 0 if all the materials fall under 1 they are regarded as improved else they are unimproved 1415 neighborhoodlevel factors we defined neighborhood as the clustering of children the dhs uses clusters as the psu 1415 hence neighborhood in this context is the clustering of children within the same geographical environment and children were neighbors if they belonged to the same cluster in this study we considered neighborhood socioeconomic status as a neighborhoodlevel variable it was computed using the principal component factor method from the scores that were aggregated from the proportion of respondents within the same clusters without education belonging to a household in the two lowest wealth quintiles no media access and unemployed the xtile function in stata version 16 was used to categorize the scores into five categories least disadvantaged 2 3 4 and most disadvantaged 5 statistical analyses we used both descriptive and inferential statistics in this study descriptive statistics including charts tables and percentages were used to show the distribution of the children by country regions u5d and other key variables a bivariable analysis was conducted using the ztest for equality of proportions of u5d among male and female children within each country and region we also determined if any association existed between the explanatory variables and u5d among the male and female children the risk difference in under5 deaths among male and female children were computed a rd greater than 0 suggests that u5d is higher among male children than among female children while a rd 0 signifies no difference and a negative rd indicates that u5d was higher among female children than among male children the rds were computed to identify the countries where significant differences existed in the u5mr by gender we estimated both random and fixed effects of the rd the fixed effects are the weighted countryspecific rd and the random effects are the overall rd irrespective of a childs country of residence as shown in fig 1 the purpose of the random effect was to estimate the overall prevalence and distributions of prevalence of u5mr among males and females irrespective of the countries the children are located the fixed effects are to establish and identify the countryspecific estimates charts were used to show the distributions of the rds by the countries we categorized the countries into four distinct categories based on their prevalence of u5d and the size of their rd high u5d and high promale inequality high u5d and high profemale inequality countries low u5d and high promale inequality low u5d and high profemale inequality the mantelhaenszel odds ratio and tests of heterogeneity of ors were used to ascertain that the countries were different with regards to the odds of u5d among the male and female children a test of homogeneity of ors among all the countries with a significant or of u5d was also used to determine if the odds of having u5d in those countries were homogenous lastly the multivariableadjusted logistic regression method was applied to the pooled crosssectional data from the u5d promale countries to carry out a decomposition a significant at 005 in the ztest of equality of proportions analysis using the multivariable fairlie decomposition analysis procedures sampling weights were applied in all our analyses to adjust for unequal cluster sizes stratifications and to ensure that our findings adequately represent the target population multicollinearity among the independent variables was tested using the colin command in stata version 16 the command provided the variance inflation factor the vif is approximate of 1 ranging from 1 to infinity the r 2 value is obtained by regressing the j th independent variable on other independent variables all variables with vif 25 were removed from the regression analysis literature has shown concerns about vif 25 18 health insurance cover media access paternal employment status type of cooking fuel and housing material were not captured in some countries and were dropped in the decomposition analysis the decomposition analysis was conducted by obtaining the logit estimates of the magnitude of contributions of the factors to gaps in u5d between males and females as the dependent variable among those countries that had significant rds decomposition analysis we applied multivariable fairlie decomposition analysis based on the binary regression model the fda is one of the decomposition techniques used in the quantification of the contributions to differences in the prediction of an outcome of interest between two groups in multivariate models 19 the method is an extension of the blinderoaxaca decomposition analysis 20 21 22 which has been roundly criticized for inefficiency in handling the logit and probit model 2223 the fda was purposively developed for nonlinear regression models including the logit and probit models 24 the fda was carried out by calculating the difference between the predicted probability for one group using the other groups regression coefficients and the predicted probability for male children using its regression coefficients 23 the fairlie decomposition technique works by constraining the predicted probability between 0 and 1 fairlie et al showed that the decomposition for a nonlinear equation y f can be expressed as y a y b 1 st ������������������������������������������������� ⎡ ⎢ ⎢ ⎣ n a � i1 f � x a i βa � n a n b � i1 f � x b i βa � n b ⎤ ⎥ ⎥ ⎦ 2 nd ������������������������������������������������� ⎡ ⎢ ⎢ ⎣ n b � i1 f � x b i βa � n b n b � i1 f � x b i βb � n b ⎤ ⎥ ⎥ ⎦ where n a is the sample size for group j in eq y is not necessarily the same as f x β unlike in boda where f x i β the 1st term is the part of the gap in the binary outcome variable that is due to group differences in distributions of x and the 2nd term is the part due to differences in the group processes determining levels of y the 2nd term also captures the portion of the binary outcome variable gap due to group differences in fig 1 risk difference in underfive deaths between male and female children by countries in lmic unmeasurable or unobserved endowments in other words the explained factors are those factors attributable to gender differences in individual observable characteristics and life circumstances while the unexplained factors are related to gender differences in the unobservable characteristics and life circumstances the estimation of the total contribution is the difference between the average values of the predicted probabilities using coefficient estimates from a logit regression model for a pooled sample β the independ ent contribution of x 1 and x 2 to the group the gap can be written as and 1 n b x n b i1 f α x a 1i β 1 x a 2i β 2 f α x b 1i β 1 x a 2i β 2 1 n b x n b i1 f α x b 1i β 1 x a 2i β 2 f α x b 1i β 1 x b 2i β 2 respectively the contribution of each variable to the gap is thus equal to the change in the average predicted probability from replacing the group b distribution with the group a distribution of that variable while holding the distributions of the other variable constant further numerical details have been reported 23 24 25 26 27 we implemented the fda in stata 16 using the fairlie command results sample characteristics and analysis of inequality table 1 shows that the overall sex ratio of the children was 106 there were more reported males than female children in the survey across all the countries except for angola congo congo democratic republic lesotho namibia and zimbabwe the highest proportion of male children were found in armenia papua fig 2 risk difference between children from houses with sex differentials in underfivedeaths by countries in lmic new guinea and the philippines the overall weighted prevalence of u5d was 51 per 1000 children 55 among males and 48 among females the prevalence of u5d among male children ranged from 4 per 1000 children in armenia to 120 in sierra leone while it ranged from 2 in albania to 107 in sierra leone among female children the ztest of equality of prevalence among male and female children was statistically significant in burundi ethiopia malawi rwanda tanzania uganda angola cameroon chad congo gabon zambia zimbabwe benin burkina faso cote divoire nigeria senegal sierra leone tajikistan bangladesh india pakistan and yemen table 2 shows that u5d was highest among multiple births compared with singletons the lowest death rates were in the neighborhoods with the least ses disadvantage with 35 among males and 30 among females all the explanatory variables considered were significantly associated with the u5d among all the children combined and by gender divides risk differences in u5d among male and female children the risk differences a measure of inequality in the risk of having u5d among male and female children across the countries studied were presented in figs 1 2 and3 also a metaanalysis of the prevalence of u5d among male and female children in each of the countries was carried out and presented the results in fig 1 the prevalence of u5d was generally higher in male children in all the countries except liberia in west africa the kyrgyz republic in central asia bangladesh and nepal in southern asia armenia in western asia turkey in southern europe and papua new guinea in oceania profemale inequality was however not significant in any of these countries irrespective of regions the fixed effects of promale differences in u5d were widest in cote divoire while the fixed effect of profemale rd was widest for turkey 531000 the random effects that is the rd of u5d irrespective of country of residence per 1000 children was 75 5891 evidence of significant overall promale inequality in u5d the greatest contribution fig 3 scatter plot of rate of underfivedeaths and risk difference between sex of children in lmic to the random effect was found in india at 29 while the least was in lesotho at 07 as shown in fig 1 in figs 2 and3 the red and orange colors indicate statistically significant promale inequality and insignificant inequality respectively based on rd five of the nine countries in eastern africa five of the six countries in middle africa two in southern africa and four countries in west africa showed statistically significant promale inequality three countries in southern asia one country each in central asia western asia central america and the caribbean the level of the heterogeneity of the rds was 67 relationship between the prevalence of underfive deaths and magnitude of inequality the relationships between the prevalence of u5d and the magnitude of malefemale inequality a function of rd across the 59 countries involved in this study are presented in fig 3 countries such as cote divoire chad sierra leone nigeria and burkina faso had high u5d and high promale inequality liberia and lesotho had high u5d and high profemale inequality tajikistan south africa senegal and egypt low u5d and high promale inequality while countries such as turkey and the kyrgyz republic had low u5d and high profemale inequality decomposition of gender inequality in the prevalence of under5 death the mantelhaenszel pooled estimate of the odds ratio of having u5d controlling for the countries of the children we estimated or 117 and tested a null hypothesis or1 and obtained z 15545 and p 0000 and test of heterogeneity x 2 7183 degree of freedom 58 and p 0000 isquared 193 of the 59 countries statistically significant promale odds ratio was found in only 25 countries the countries were afghanistan angola benin burkina faso cambodia cameroon chad cote divoire ethiopia haiti india indonesia kenya malawi mozambique niger nigeria rwanda senegal sierra leone tajikistan tanzania timor leste uganda and zambia we then computed mantelhaenszel pooled estimate of the odds ratio of having u5d among the children in the 25 countries with promale inequalities while controlling for the countries we had or 118 and tested the homogeneity ors x 2 5049 df 24 and p 0001 these 25 lmic promale inequality in u5d were included in the fda figure 4 show the detailed decomposition of the part of the promale inequality caused by compositional effects of the determinants of u5d the explained are depicted by red color while the unexplained portions of the promale inequalities are depicted by the blue color in fig 4 the lighter the red color the lower the percentage contribution of the explained portion and the lighter the blue color the lower the percentage contribution of the unexplained portion there were wide variations in the factors associated with the promale inequalities across the countries we found a connection among birth order birth weight birth interval and having multiple births as factors associated with u5d while other variables formed another cluster different factors had the largest association with u5d in different countries in most countries birth order birth weight birth interval and multiple births contributed most to u5d specifically in india the largest contributions to promale inequality in u5d were birth interval and birth order in afghanistan birth weight birth order and birth interval contributed 560 340 and 200 of the unexplained determinants of u5d respectively while maternal age contributed 210 of the explained determinants for timor leste the greatest contributors to the inequalities were household wealth quintile ruralurban differences in place of residence and mothers marital status while birth interval and birth weight were the greatest contributors to promale inequalities in ethiopia the contribution of the neighborhood factors to u5d inequality were mostly from explained determinants and they were not as strong as the contribution of individual factors as seen in fig 4 the highest contribution by residence location was seen in afghanistan and timor leste while neighborhood socioeconomic class had even less contribution to u5d inequality with the highest contribution were seen in haiti and cambodia discussion in this study we identified sexual inequality in the burden of u5d in lmic using pooled data from 59 countries also we quantified the individualand neighborhoodlevel factors explaining the malefemale differences in u5d this study showed that u5d in most lmic had a highrisk difference with promale inequality but with variations in the contributions of the determinants of u5d however most of the identified determinants were explainable this showed that the natural female advantage at survival was still at play in many of these countries 28 and this reflects the level of development of the health system that is required to provide the platforms to reverse the natural male childs predisposition to an early death it also implies that the identified determinants can still be addressed to reduce u5d in these countries the four scenarios that considered the prevalence of u5d and the level of inequality provided thoughtprovoking insight into the spread and persistence of u5d in the countries studied the natural scenario of high u5d and high promale inequality was expected in countries where the health system is underdeveloped 2930 however the explanation for this gender inequality in u5d may be misleading as subtle gender discrimination against female children is still seen in the affected countries for example for nigeria adeyinka et al made predictions using under five mortality data from 1964 to 2017 that there will be a switch to profemale inequality in the future 31 this prediction was made based on the estimates from the use of artificial intelligence and modelling techniques to project the future pattern of u5d in nigeria similar discrimination against the female children has been reported in india as well where male infants were being selectively vaccinated compared with females 32 giving the males a higher odd of survival this is already evidenced in the higher number of u5d being recorded for female infants in some states in india 33 other discriminations against female infants which results in higher female mortality include selective abortion of female fetus higher household fund dedicated for the care of male infants and general neglect of female children 33 if the discrimination against female children is not effectively addressed 34 the gains from reduced u5d from improved health system will be subsumed sooner or later also the countries with high promale inequality need to learn from countries with low u5d and make extra concerted efforts to reduce u5d with the already available strategies which are effective fig 4 decomposition of promale inequality attributable to compositional effects of underfive death determinants in 25 countries implementation strategies may need to be reviewed to identify problem areas that have been hindering the progress of halting u5d in these countries of the 10 countries with excess female mortality as reported by alkema et al 35 only bangladesh and nepal still had profemale inequality in this study this suggests a reduction in female discrimination in the remaining eight countries 35 it is also interesting to observe that both india and china were long known to contribute significantly to profemale inequality in asia 10 but india in this study had promale inequality similar to reports from an earlier study 30 this might be as a result of underdeveloped health system which still exist in some states in india 36 countries with high u5d and high profemale inequality usually have the problem of female inequality as the u5d pattern does not fit into the natural pattern high gender inequalities have been reported from both liberia 37 and lesotho 38 with the latter country also struggling with the effect of hiv which have been shown to have a higher impact on women 39 countries such as turkey and the kyrgyz republic with low u5d and high profemale inequality have some underground mechanisms that promote discrimination among females this is because with a reduction in overall u5d the female survival advantage is expected to be preserved for example turkey has been shown to have a culture of male preference and male children receive more attention than females 40 altindag et al reported that women in turkey preferentially use contraceptives following the birth of a male child which results in more spacing of children and give the male children a better opportunity to survive 40 however such use of contraceptives was not done following the delivery of a female child thereby giving them less chance of survival there is also a high level of female inequality in the kyrgyz republic despite improvement in childhood anthropometric indices at the national level even though poverty still contributes significantly to stunting 41 infection is still responsible for a good percentage of childhood illnesses in many lmic countries because of suboptimal living standards and inadequate childhood vaccinations and male children are more at risk of death because of the less resistance to infection due to their genetic makeup 8 the facilities and skills to support premature infants and infants with respiratory distress are also not readily available and the male child is also more predisposed to developing both conditions than their female counterparts 4142 the countries with no significant sex disparity in u5d were mostly the uppermiddleincome countries that have more resources to ensure better living conditions and provide improved health care services that can mitigate the peculiar health challenges that predispose the male child to higher mortality this trend however suggests inequality as it points to likely female discrimination 43 because an improvement in the health system is expected to improve the survival of both male and female children there is a need for further investigation to understand why there are no differences in the u5d in both sexes in these countries it is however important to note that there were countries that were not as economically buoyant as these earlier ones but still had no sex disparity in u5d they include tajikistan kyrgyz cambodia the philippines and honduras a closer examination of the focus and investment in the health sector of these countries provides some likely reasons for the absence of disparity for example in tajikistan there have been giant strides in economic growth in the last two decades which has resulted in a drastic reduction in poverty level among the populace because of investment by the world bank this includes investment in under five health 44 with significant improvement in underfive nutritional indices and healthcare workers management skills for childhood diseases 45 however as earlier pointed out there is a need for further research to exclude discrimination against female children which may be responsible for the inequality in u5d seen in these countries the contributions of the explained and unexplained components among countries with promale u5d inequality varied across the affected countries in india birth order conspicuously contributed to this inequality but there have been conflicting reports on how birth order affects u5d in this country while singh and tripathi reported that u5d was associated with birth order one and two from nationally representing data 46 sahu et al reported that the risk for u5d was higher among birth order 4 and above in rural communities in india 47 the argument in the first study was that lower birth order was associated with younger maternal age which could affect the skills required for under five care and predispose to u5d also higher birth order in a rural community may stretch the already limited resources that are needed to ensure optimal care of children the mothers in the second study were also mostly uneducated and this is a strong predictor of u5d however both birth order and birth weight were unexplained contributors to promale u5d in afghanistan in this country it was reported in an earlier research that both large and small for gestational age and birth interval lesser than 24 months were associated with early neonatal deaths and the males significantly had a higher odds of dying than females 48 these are in consonance with the findings from the current study however reports from another study in the same country showed that birth interval of 48 months and the male gender were protective from lbw a condition that is among the leading cause of neonatal mortality 41 this appears contradictory to the findings from this study as afghanistan had a promale u5d inequality the role of birth weight in the promotion of male inequality in afghanistan need to be further investigated for better understanding multiple birth was also an explained contributor in senegal but unexplained in tanzania the associated complications of multiple birth have been well documented but its role in promale u5d inequality needs to be understood in order to address it in tanzania the last authors however reported that the male child was less likely to have lbw further investigation is required to ascertain the reason for this in addition to the high promale inequality in u5d among these lmic there was high heterogeneity in the rd and this may be due to the different levels of health system development and variations in the predisposing factors as shown in the variation in the explained components of u5d this is likely related to the differences in the stage of economic development and the priority given to u5 health care among these countries whereas it is logical to expect that countries with high u5d will have promale inequality all the independent variables included in our model were significantly associated with u5d just as reported in earlier literature 16 49 50 51 52 the result of the fairlie decomposition analysis shows that u5d was due to more of explained components than the unexplained component which implies that reduction of u5d is possible if more strategic efforts are employed in lmic income countries among the variables considered maternal education appears to be an important determinant that is associated with u5d as it can influence the presence or otherwise of the other factors 12 a woman who is educated is more likely not to have an underage marriage 5354 so she will not have her babies too early and even if she has the children late she is more likely to have supervised antenatal care and delivery 5556 that will ensure the safety of her baby an educated woman is also likely to have access to the media have health insurance 57 and be employed her partner is also more likely to be employed and even if she is unmarried she will be in a better position to successfully head a household it is worth reiterating that femaleheaded households were associated with less u5d in this study which is similar to what has been reported earlier in the literature 5158 the likely reason is a better understanding of maternal and childhood conditions and this will lead to less bureaucracy in the decisionmaking process about accessing health care services for children furthermore an educated woman is more likely to have the socioeconomic advantage that will prevent her from being poor and have fewer factors that can predispose her to have low birth weight babies like malaria and hiv 12 if she has a low birth weight baby she will have better access to good management and not patronize substandard treatment centers she is also more likely to do family planning which will help in spacing her babies and this will prevent her from having too many babies therefore an investment in female education by these lmic will go a long way in reducing u5d for the few unexplained components of the determinants more investigative researches are required to explore them for example it is important to understand why birthweight was an unexplained component of u5d in afghanistan and why the contribution of birth interval to u5d cannot be explained in india the contribution of neighborhood determinants to u5d inequality was however not as much as those by individual factors this may be as a result of shared cultures and national policies whose effects are likely to be farreaching and this could have mitigated the differences expected in u5d as a result of the different categories of socioeconomic classes and locations of residence although residence location had the highest contribution to u5d inequality in this study in afghanistan there have been contrasting reports of how location affects u5d in this country kibria et al reported that rural infants were more likely to die in afghanistan in their study of a nationally representative population of underfives but this association became insignificant after adjustment for maternal age and place of delivery 59 this contrasts with reports from other countries 60 61 62 where residence in rural areas was associated with higher newborn mortalities higher incidence of lbw and lower apgar scores study strengths and limitations this study is one of the first analyses in lmic that investigated individual and neighborhood factors contributing to sexual inequalities in u5d across 59 lmic the use of large nationally representative data enhanced the quality of our findings in terms of generalizability also the fda applied in our study is an improvement over the commonly used blinderoaxaca decomposition analysis which has been reported to be inefficient in handling logit and probit models 21 22 23 however the study is not without some limitations first the measure of child mortality which is dependent on information provided by mothers may underestimate the actual rate as a result of recall bias most mothers may not be comfortable with talking about their dead children and so may not give accurate responses the traditional practices in some countries also forbid parents from reporting the death of their children secondly the crosssectional nature of the study means that causal inferences cannot be made from our findings conclusions in conclusion significant sex inequality exists in u5d among lmic with mostly male proinequality there were different determinants for this male proinequality in the structural and compositional components considered across the different countries concerned however the pattern of this sex inequality reflected the presence of both weak health systems and female inequality these countries will need to address the failing health system address gender inequality and invest in female education to stem the tide of preventable u5d in lmic if the sdg 3 is to be achieved contribution to knowledge the contribution of the study to knowledge is in two folds it identified countries with significant gender differences in underfive deaths it quantified the contributions of the explored characteristics to the gaps inequalities in sex differential in underfive deaths among countries with significant differences abbreviations funding the authors received no funding for this study competing interests the authors declare that they have no competing interests

background there exist sex disparities in the burden of underfive deaths u5d with a higher prevalence among male children factors explaining this inequality remain unexplored in lowand mediumincome countries lmic this study quantified the contributions of the individualand neighborhoodlevel factors to sex inequalities in u5d in lmic methods demographic and health survey datasets 20102018 of 856987 underfive children nested in 66495 neighborhoods across 59 lmic were analyzed the outcome variable was u5d the main group variable was the sex of the child while individuallevel and neighborhoodlevel factors were the explanatory variables fairlie decomposition analysis was used to quantify the contributions of explanatory factors to the malefemale inequalities in u5d at p 005 results overall weighted prevalence of u5d was 511000 children 55 among males and 48 among females p 0001 higher prevalence of u5d was recorded among male children in all countries except liberia kyrgyz republic bangladesh nepal armenia turkey and papua new guinea profemale inequality was however not significant in any country of the 59 countries 25 had statistically significant promale inequality different factors contributed to the sex inequality in u5d in different countries including birth order birth weight birth interval and multiple births conclusions there were sex inequalities in the u5d in lmic with prominent promaleinequality in many countries interventions targeted towards the improvement of the health system that will in turn prevent preterm delivery and improve management of prematurity and early childhood infection which are selective threats to the male child survival are urgently required to address this inequality