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creates a recipe for feelings of superiority and control of countries no longer under Swedish control and are the results of centuries of social representations reinforced via sociogenesis. If jokes about Finland as Eastern Sweden are not common, jokes about Finnish alcoholism are. These are the negative generalizations that are both surprisingly accepted and rejected within Swedish circles, a reflection of Swedes' contradictory views of self, of others, and of Finns. In regard to this Swedish view of Finns, conflicting characterizations of Finnish people have been commonplace since at least the 18th century. At that time, Finns were often labelled as savage, violent, and prone to alcoholism. However, Finns were also labelled as loyal, mysterious, and brave warriors whose sacrifices during wartime were highly honoured (Kemiläinen 2004). In the 19th century, following the loss of Finland to Russia and the erasure of Finland from Swedish history, Finns were placed into an even more romanticized space where they were savage, inferior, "Mongoloid", and violent, but also wise, philosophical, brave, and loyal (Bohlin 2018). This ambivalent characterization is best described as a "noble savage" archetype, wherein a dominant group exotifies a marginalized culture as primitive, undesirable, but admirable and exemplary at the same time. Essentially, the archetype of the "noble savage" between familiar Identities on the Periphery groups can be described as love at a distance, a description readily applicable to Swedish views of Finnish identities (Borg 2016). All of these views form a social dynamic of distant love, reinforced over centuries of sociogenesis. The aforementioned significant year of 1809, when Russia annexed Finland from Sweden, proved to be a momentous change for both countries. To cope with the new event, Finnish and Swedish cultural groups anchored it in their own familiar terms by giving the event a name (The Separation of 1809, translated by Google) and expressing it in familiar terms such as poetry, biological racism, and propaganda. Eventually, these were objectified and internalized in the cultures' identities through metaphors, artistic expressions, and collective memories, which created new social representations that are used to create and reinforce newer ones today. Thus, the issues of linguistic debate, generalizations, and history feed off of each other in a vicious cycle of falling dominoes. As we inch closer to the truth, newer questions appear: which issues came first, and which ones were the first dominoes that knocked over all the others? CONCLUSION Twenty pages are not enough to fully explore such a complex and fascinating topic, but this does not mean that this paper is fruitless. Any number of pages that can reveal the truth about how identities' social representations came to be is a worthy pursuit. Thus, as we conclude this paper, I can attest that ethnic discrimination has affected Finnish and Fennoswedish identities. However, I did not expect to find that a culture's historical usage of ethnic discrimination could turn around on itself as it did with Swedish culture's expressions of Finnish generalizations. In addition, I found that differences in identity between Finnish and Swedishspeaking Finns were most prominent in the past, however, even though cultural and ethnic differences between the two groups have decreased, they have not been wholly erased. Whether that is for bad or good is something that Finns and Fennoswedes must decide. The cultural histories and memories of ethnic discrimination have shaped Finnish and Fennoswedish identities in different directions. However, with the rise of globalization and various issues more pressing than that of language, Finnish and Fennoswedish identities and cultures have begun to shape back incongruent directions. To answer my fundamental question on the existence of Finnish ethnic discrimination, I can say that: yes, there is discrimination, but not to the claimed extent. Finns did indeed suffer from discrimination based on ethnic markers, however, the extent to which some claim a victimizing narrative is simply a reflection of Finnish historical revisionism funded by the 19th-century Russian state. Now, someone reading this may be asking the question of why studying this is important. After all, Finnish discrimination was not as widespread as some make it out to be. But that is just the point! This paper is important because we need studies that examine the ways in which discrimination, historical revisionism, and cultural memory play in changing and forming identities. If we as scholars can identify how reactionary identities are formed, we can use papers like this to help minimize the spread of misinformation. These complex and ambiguous cultural dynamics are where anthropology thrives. Anthropology allows us as scholars to contribute to modern, complex issues by analyzing them with a culturally holistic view, one that permeates nearly every facet of human life. One can even say that anthropology is the glue that holds the social sciences and humanities together. It should be up to us as anthropologists, historians, and other researchers to uncover how our pasts affect our present selves, so that we may improve, helping ourselves and others in the process. --- TABLES AND FIGURES --- VORONOVA

Identities on the Periphery want to answer is what is the source of Finland's ambiguous historical identity: were Finns victims of ethnic discrimination or is this a narrative produced by historical revisionism? To answer these questions, the paper is divided into several sections that will explore the roles of discrimination and cultural memory on Finnish identities. The sections consist of background context, methods and data, theory, historical issues, modern issues, discussion, and a conclusion. In the Methods and Data section, I outline the methods used to collect and use the sources presented as evidence in the paper. These include primary and secondary news, Reddit, historical documents, academic papers, and analyses of primary material. The theory forms the lens through which to examine the topic of discussion, which is why I employ Social Representations theory. This framework is based on the idea of collective memories reinforced by cultural representations, which was championed by Sergei Moscovici in 1961. These representations can be either hegemonic, meaning mainstream and accepted, or non-hegemonic, meaning unconventional and unaccepted (Sakki and Hakoköngäs 2020). After outlining my theoretical framework, I give an overview of Finnish historical issues, which act as evidential sources for the ambiguous Finnish identities and relationships seen today. Modern issues are expressed through stereotypes and debates over language in everyday spaces. Many issues of the modern world are direct responses to ones from the past and examining them together through a theoretical lens is the central issue in the discussion. Conclusively, I argue that both Finnish and Swedish-speaking Finns have been negatively affected by discrimination reinforced over centuries, and these effects are especially prevalent in Finnish-speaking Finns. Collective memories of oppression have substantially influenced Finnish identities, which results in the fear and lack of trust of foreigners. These are important questions to answer, not only for anthropology but all social sciences, regardless of the case study. Anthropology is the glue that VORONOVA 3 holds the social sciences together, and it is our responsibility to uncover the sources of discrimination so that we may know how to prevent it.

money as a factor in respect for people, planning expenses, money as a means of achieving freedom and power), as well as socio-psychological attitudes in the field of motivations and needs (process orientation, result orientation, altruism orientation, freedom orientation, power orientation, work orientation, and money orientation). Conclusions. The obtained results can be used in designing training and motivational programs for women in the system of state-run, commercial and public organizations. Key words: personal styles, women's behavior, attitude to money, monetary attitudes, sociopsychological attitudes, transactional analysis 1 « - » « » « » « - » « » « - » « » 99 <unk>р<unk>ан<unk>а<unk>на <unk>си<unk>оло<unk>. <unk>коном<unk>на <unk>си<unk>оло<unk>. No 4 (30) / 2023 « » « » « » (r=-0,142, p<unk>0,05) (. 1). « » « », « » « » « » « » « » « » « » « » « « » « » 100 <unk>р<unk>ан<unk>а<unk>на <unk>си<unk>оло<unk>. <unk>коном<unk>на <unk>си<unk>оло<unk>. No 4 (30) / 2023 « » « » « » « » « - » « - » « » « » « » (r=0, « » « » « » « » « ». « » « » (r= 0,182, p<unk>0,01) (. 2). « - » « » « » « » « » « » « - » « » « - » « » « - » « ». « - » « » « - » « » 104 <unk>р<unk>ан<unk>а<unk>на <unk>си<unk>оло<unk>. <unk>коном<unk>на <unk>си<unk>оло<unk>. No 4 (30) / 2023 « - » « » « » « » « » « - » « » « - » « » « - » « » « - » « » « » « » « » « » « » « » « » « » « » 105 <unk>р<unk>ан<unk>а<unk>на <unk>си<unk>оло<unk>. <unk>коном<unk>на <unk>си<unk>оло<unk>. No 4 (30) / 2023 « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « » « ».

Aim: To analyze the relationship between women's personal behavioral styles and the types of money beliefs and behavior, money attitudes and socio-psychological attitudes in the field of motivations and needs.Results. There are positive and negative statistically significant relationships between personal styles ("Parent-controller", "Parent-educator", "Functional adult", "Adaptive child", "Natural child") and types of money beliefs and behavior (money obsession, power, economy, inappropriate behavior with money), monetary attitudes (money as a good, money as an evil, money as a means of achieving success,

Introduction In 2008, an estimated 33.4 million people in the world were living with HIV/AIDS and 2.7 million people were newly infected [1]. Ninety-four percent of cases were working age adults who will become sick and die within 10 years with no access to treatment and care. Unfortunately, roughly 80% live in low and middle-income countries where access to the treatment and care remains limited, and they remain unaware of their HIV infection status [2]. This has led to major crises with consequences for human, social and economic progress unless access to treatment and care, particularly ARV, is addressed. For HIV infected individuals to receive necessary treatment and care, they need to know their HIV infection status through HIV testing. HIV testing provided on a voluntary basis should be accompanied by pre-and post-test counseling (VCT). This has major public health benefits by not only linking infected individuals to treatment and care but also in reducing further HIV transmission [3]. Quality VCT has been demonstrated to reduce HIV risk behaviors [4]. UNAIDS and WHO have supported expanding VCT to cover as many individuals as possible by encouraging countries to established national policies (in 1997) [3] andissued their HIV testing policy statement in June 2004 [5] and guidance on provider-initiated VCT in health facilities in 2007 [6]. Promoting "Universal access" at the XVII International AIDS conference in Mexico City cannot be attained without encouraging people to seek VCT; however expanding VCT had been a challenge in low-and-middle income countries. This manuscript describes the implementation of community mobilization (CM) to promote VCT services using mobile voluntary counseling and testing (MVCT) units in the intervention communities of NIMH Project Accept Thailand site and presents the results. There were some challenges to our approach, and we tested modifications to increase our success. A detailed description of the NIMH Project Accept intervention can be found in the Project Accept (HPTN 043) protocol and manuals at http://www.cbvct.med.ucla [7] and in Khumalo-Sakutukwa et al. [8]. In brief, NIMH Project Accept is the first international multisite study of a phase III community-level randomized controlled trial conducted in 34 communities at 5 sites in 4 countries (South Africa, Zimbabwe, Tanzania and Thailand) to determine the efficacy of a multilevel HIV prevention intervention, where community HIV incidence and stigma reduction are the study end points. Communities were paired within site and randomized to be either control or intervention communities. The control communities received standard VCT (SVCT) which for Thailand site was clinic-based VCT provided at district hospitals. The intervention communities received the project intervention in addition to standard VCT (CBVCT). The project intervention has three components-1) CM-mobilizing the community, stimulating interest and participation, education, stigma reduction and enhancing VCT uptake; 2) MVCT-increasing access to VCT by offering free and same day HIV test results directly in the community, hopefully increasing testing rates and changing HIV testing norms; and 3) post-test support services (PTSS)-to build support and improve the quality of life for HIV positive individuals, reduce social harms, create a support system, as well as assist HIV negative individuals to remain negative. Standard principles were followed in conducting the intervention according to the research protocol by all sites. An intervention working group was established with representatives from the intervention core of each site to address site-specific issues and development of intervention standard operating procedures (SOPs). However, modifications were made to the intervention according to site situations and cultures. The overall utilization out come of the Project Accept trial in three countries (Tanzania, Zimbabwe, and Thailand) presented by Sweat et al. [9] shows that CBVCT captured more first time HIV test cases significantly and four time higher to detect HIV cases (952 vs. 264; P = 0.03) than SVCT, across site. Project Accept Thailand (PA-Thai) was conducted in partnership with Johns Hopkins University (JHU), Research Institute for Health Sciences, Chiang Mai University (RIHES), and Chiang Mai Public Health Office (CMPHO), Thai Ministry of Public Health. The intervention was launched in January 2006. The operation and data described here are from field notes (counseling chart notes, field notes, staff meeting notes) on conducting the intervention in the intervention communities which was completed up to March 2009. A total of 39 months experience in the field during which the site made local modifications to fit with Thai culture and the local context. In this paper, we present our project CM and MVCT operations overtime and the uptakes in the seven intervention communities as well as the clients' characteristics and comparing between Thai lowland and ethnic minorities. --- Methods --- Study Setting and Community Selection Fourteen communities in six districts (Mae-tang, Chiang Dao, Chaiprakarn, Praow, Mae-Ai, and Fang) of northern Chiang Mai province were selected to be the research communities (Fig. 1). The region is mountainous, rural and home to lowland Thais and ethnic minorities including Lahu, Karen, Hmong, Lisu, Yao, and Burmese immigrant (Shan), groups who vary in geographic area of origin and language. Two communities were selected from each district, except Fang where four were selected, paired within each district for randomization to intervention or control, for a total of seven pairs at the Thailand site. Each community wascomprised of 8-23 villages from 1 to 2 sub-districts. Using baseline data, the estimated community size ranged from 5,000 to 9,200. Ethnic minorities made up 40% of residents in the 14 communities [10]. These 14 communities are similar in term of communities' resident way of life where most of them are famers or being hired for daily working in agriculture farms. Each district has a district hospital to provide health care for the district residents and others. The hospitals provide clinic-based VCT and have opts out VCT policy for pregnant women. Very few if any of an organization, other than our project, provided mobile VCT in these communities. --- Community Preparedness and Involvement Community preparedness and involvement is a main component of NIMH Project Accept. The protocol required sites to undertake a rigorous program of community pre-paredness and involvement, and required establishment of Community Working Groups (CWG) which included community leaders and stakeholders. The Thai site introduced the project to the communities by first meeting with community stakeholders including the district governors, district hospital directors and VCT unit nurses, district public health chiefs and key personnel, and sub-district leaders. In these meetings we introduced the project concepts and procedures, and asked for their opinions and support. The purpose of these meetings was to gain entry to the communities with acceptance, from the top down. After this meeting the CWG in each community was formed, comprised of village leaders, village health volunteers, persons infected with HIV/AIDS (PWHA), housewife leaders, and youth leaders. Meetings with CWGs were conducted several weeks before each research activity was conducted in the community. The meetings were mostly led by the local PI and accompanied by at least one representative from the CMPHO. The primary aim was to inform the CWGs about the activities that were going to occur and to ask for their suggestions on conducting project activities and to seek their assistance. The intervention protocol required establishing community-based outreach volunteers (CBOVs) in the intervention communities. CBOVs were community members who had the potential to volunteer to work with the project staff to disseminate project information, conduct outreach to community members for HIV/AIDS information, and encourage local participation. CBOVs were trained using a standardized project curriculum. Religious figures (monks and priests) are influential local leaders and earn much respect from community members; they were invited to join the project in each research community. The team worked with respected monks who were actively working with HIV/ AIDS issues in the province to organize HIV/AIDS education for local monks. In turn these monks assisted the study similar to CBOVs. Once understanding the project and local HIV/ AIDS issues, these religious figures could clearly explain the goal of the project to community members and effectively respond to their questions. --- Staff Composition With an estimated 40% ethnic minorities residing in the project communities, we recruited CM staff who did out-reach for community mobilization and HIV/AIDS education who could speak lowland Thai and at least one ethnic minority language. Seven ethnic minorities of 11 CM staff were successfully recruited and later more were added. Qualified nurses were recruited and trained to be HIV VCT counselors and phlebotomists using a scripted risk reduction counseling curriculum, 10-15 in number over the intervention period. Nurses from the 6 district hospitals were also trained as counselors to provide standard VCT (SVCT) for the project. These nurses joined the MVCT team occasionally. Almost all CM staff was trained to be VCT counselors after the first round when we realized the need and importance of counseling in the ethnic minorities languages for those who had limited Thai language capacity. PTSS personnel were comprised of core and local staff as well as staff from the community health centers who were Ministry of Public Health employees working part-time for the project in the evenings and weekends. --- Conducting the Intervention (Findings, Challenges and Modifications) PA-Thai launched the intervention in the seven intervention communities beginning in January 2006. CM and MVCT were conducted by round. This intervention round defined as the conduct of CM and MVCT activities sequentially in all seven communities before starting the next round. Each round took about 3-6 months to complete and by March 2009 we had completed the intervention in the seven intervention communities for a total of seven rounds. Weekly meetings to discuss outcomes, difficulties and strategies were held with the project director and senior staff, with more lengthy meetings following each completed round to address major changes for the next round of intervention. Monthly PI and senior staff meetings were held to discuss issues raised and to problem-solve as needed to adapt the intervention. For the first three rounds of intervention (Jan-Dec 2006), PA-Thai followed the conventional strategies of delivering services to the communities. The CM teams entered the scheduled villages first, followed by MVCT teams 3-5 days later to deliver VCT. In order to gradually introduce the project, HIV/AIDS education, and mobile VCT to community members the CM strategies used were going door-to-door and holding small group meetings with village members during the day to educate community members about HIV and to alert them to the upcoming availability of MVCT testing during the scheduled time period in their community. Problems encountered included too few people being at home during the day (largely being elderly women), many of whom had difficulty understanding Thai. CM staff tried joining community leader organized meetings that were already planned for the purpose of discussing village issues. During these meetings important community members were in attendance. Since these meetings had their own lengthy agendas, HIV education and mobilization activities occurred only at the end of very long meetings with members demonstrating fatigue and lack of interest. Meeting attendees also did not seem motivated to disseminate information to their community. Day-time CM organized meetings remained the CM strategy as a result, occasionally incentivized by small gifts for participation. Adjustments were made to include setting CM activities according to the dates and times suggested by community leaders, providing MVCT services during evening hours, and splitting staff into smaller teams in order to stay at each service venue for a longer period of time. However, the overall number of people who utilized the MVCT service showed a decreasing trend in rounds 2 and 3. In the middle of the third round of the intervention in November 2006, a special CWG meeting with the Chai Prakan intervention community leaders was organized. The community was selected because they experienced the greatest decrease in MVCT utilization. At the meeting, there was agreement that the community and PA-Thai project would co-host a large community event called "PA-Thai concert for World AIDS Day" on the evening of November 25, 2006. The activities included entertainment shows by well known local singers and artists, traditional shows by community youth, a PA-Thai HIV knowledge booth, donations for the community AIDS fund, World AIDS Day awareness activities, and the sale of lottery tickets for prizes. The event was a major success in raising HIV/AIDS awareness as well as increasing people's recognition of the PA-Thai project. Thousands of villagers joined the activities that night and many asked for HIV VCT. Lessons learned from the PA-Thai concert World AIDS Day is that offering VCT at events can attract large numbers of people to participate. The PA-Thai team decided to adopt similar approaches for CM and VCT strategies for the upcoming fourth round, starting in February 2007, but on a reduced scale providing events and services during evening hours, using a strategy referred to as "edutainment". All MVCT and CM staff was combined into one team to work together at the same venue for edutainment activities. The "edutainment" events were divided into several tents, with activities including VCT, HIV education sessions, blood pressure check-up, karaoke, movie projection, sport games, and prize give-always for active participants. Villagers could choose to join activities voluntarily in no particular order. There are three main CM activities which included: HIV/ AIDS related games in order to raise HIV transmission awareness, interactive group HIV/ AIDS education include VCT, and interactive group education about HIV prevention and condom use. To encourage participation in the three CM activities, a card was given to individual participants and a check mark was added when s/he participated in each activity. Participants who attended all three CM activities were eligible for lottery ticket drawing. Prizes included a small carton of pasteurized milk, cooking oil, soap, detergent, a bag of snacks, etc. Typically, the facilities were set up and ready by 5 pm and activities were finished around 10-11 pm. Loudspeaker announcement vans and door-to-door strategies just before the event were still used as needed. After three rounds of edutainment, in round seven the team attempted to enroll community members who have not yet opted to receive services and a semi opt-out strategy was adapted in addition to "edutainment". Village health volunteers and CBOVs joined forces for the opt-out strategy. These people went from house to house to collect lists of people interested in getting VCT and to give them an appointment date and time to schedule VCT services. On the scheduled date, volunteers reminded villagers again about the services. The volunteers were given a t-shirt or a jacket for their participation in the program according to the success of their recruitment. The voluntary nature of VCT was enforced during pre-test counseling. Community public venues including schools, churches, temples, and community centers were used as venues to set up MVCT units and the "edutainment" events. --- MVCT Process After setting up VCT at a selected venue, cards with unique numbers were given to individuals who desired VCT. Each individual client was assigned to a counselor for pre-test counseling. After consent for VCT and pre-test counseling were completed, the counselor led the client for a finger prick for rapid HIV testing. Two HIV rapid test kits were used in parallel, Bioline HIV-1/2 (Pacific Biotech CO., LTD., Thailand) and Determine HIV-1/2 (Abbott Laboratory, Japan). When both test kits gave the same result, the HIV infection status of the client was judged according to the results. If the results were discordant, a third kit(ACON HIV-1/2 (Acon Biotech CO., LTD., Hangzhou, and P.R. China) or Clearview HIV1/2 STAT-PAK (Inverness Medical Professional Diagnostics)) was used as a confirmation. Clients were asked to keep his/her card while waiting for test results. While waiting many VCT participants joined CM activities. The result was usually available within 30 min, and the same counselor provided the client with post-test counseling. An anonymous VCT and client centered risk reduction counseling approach was used for Project Accept. Only the unique number on the card was recorded on data collection forms and counseling chart notes. The counselor kept the card after completing post-test counseling. With this approach it was not possible to identify the client. Clients were provided a certificate of test results if requested or were referred for additional medical attention and support as needed. --- Data Collection, Management and Analysis Pre-and post-test counseling chart notes were created for the purpose of counseling individuals as well as collecting data which include demographic characteristics, history of prior VCT, and HIV risk behaviors. The data were entered into an excel spreadsheet and exported for data management and analysis in SAS 9.1 and Stata 9. As each intervention community received the same intervention strategy in each round and is similar in term of the residents' characteristics and VCT access, thus the seven communities are combined for data analysis. Frequency tabulation, percentage, and <unk> 2 test are used for data presentation and analysis. Meeting and field notes were also used. --- Ethical Review --- PA-Thai underwent ethical review at each of the three institutions involved, the Johns Hopkins Bloomberg School of Public Health, Chiang Mai University Research Institute for Health Sciences (RIHES), and Ministry of Public Health (MOPH). --- Results From Jan 6th, 2006 to March 25th, 2009, we completed seven rounds of CM and MVCT activities in the seven intervention communities with 574 days of field activities. A total of 57,007 community residents aged 16 years or older participated in CM activities, of whom 31,813 (55.8%) were female. Persons could attend CM activities repeatedly. During the first three rounds using conventional strategies, mostly door-to-door outreach and group discussion without setting up MVCT concurrently in the same day, were conducted. In round 4 we shifted to the edutainment strategy where MVCT concurrently setting up near by. The numbers of clients reached increased with the change in strategy, as well as numbers of days spent each round. When calculating number of CM participants/10 staff hours invested, theses are 53, 39, and 18 persons respectively/10 staff hour for door-to-door outreach, group discussion without MVCT concurrently setting up near by in the same day, and edutainment with MVCT setting up concurrently near by. In CM activities, which were conducted at night, persons aged younger than 16 years attended the edutainment sessions many more than persons aged 16 years and older. There were 17,785 persons aged 16 years and over who participated in VCT services: 8,503 (48%) men and 9,282 (52%) women. Of the participants 7,093 (39.9%) reported a history of prior HIV testing and 632 (3.6%) declined to have an HIV test from the project. Median age of clients was 36 years old. With same day results, higher proportions of clients received their test results (98.7%). The numbers of VCT clients show a decreasing trend in the second to third round which led to the shift of CM and MVCT approaches to edutainment from the 4th round onward. The numbers of MVCT clients then increased through the 7th round. The trends of MVCT clients are reflect in both absolute numbers but also by clients/day and clients/counselor hours available in each round (Fig. 2; Table 1). Counselor hours available were rarely oversubscribed at each MVCT event, so few clients were turned away due to lack of counselors. The average number of clients per day between 1-3rd and 4-6th rounds were significantly different (18 vs. 28; t test: t = 7.87 (df = 409), P <unk> 0.0001). The average age of clients were younger in 4-6th compared to 1-3 rd round with the medians of 35 and 38, respectively (median test: z = 6.74, P <unk> 0.0001). The seventh round is not considered as the semi opt-out strategy was used along with other strategies. The percentages of repeat testers also increased over time as forecasted. Comparisons of characteristics of the 17,153 who decided to get an HIV test for Thai lowlanders and ethnic minorities are shown in Table 2. As of December 2009, there were 44,477 persons aged 16 years and over in the intervention communities, 19,054 ethnic minorities and 25,423 Thai lowlanders. Of the population age 16 and over, 8,786 cases (34%) of lowland Thai and 8,386 cases (44%) of the ethnic minorities came for HIV test with the project (<unk> 2 = 410.5 (df = 1), P = 0.000). When compared to Thai lowlanders, ethnic minorities had a higher proportion of persons aged 30 years or younger (53.7 vs. 21.9%; <unk> 2 = 1849.4 (df = 1), P = 0.000) had no formal education (4.6 vs. 54.2%; <unk> 2 = 513.0 (df = 1), P = 0.000), had a higher proportion being first time testers (64.9 vs. 54.3%; <unk> 2 = 200.1 (df = 1), P = 0.000), and had a higherproportion with a history of drug use (6.9 vs. 5.8%; <unk> 2 = 8.3(df = 1), P = 0.004). Injecting drug users was similar among the two ethnic groups (9.6 vs. 9.4% <unk> 2 = 0.02 (df = 1), P = 0.901)). Approximately 6% of these two populations had more than one sexual partner in the prior 6 months. Of the 17,153 who decided to get an HIV test with Project Accept, 164 (1%) were HIV antibody positive, similar for Thai lowlanders and ethnic minorities (0.9 vs. 1.1%). Overall, 161 (98.1%) of the HIV positive cases received their test result (Table 3), 136 (84.5%) were newly detected cases, more commonly among ethnic minorities compared to Thais (86.4 vs. 78.9%). The majority, 109 (67.7%), had no signs and symptoms of AIDS and were healthy. Ethnic minorities were more often seen to have signs and symptoms of AIDS as compared to Thai lowlanders (35.2 vs. 27.6%), including among those new detected cases (34.2 vs. 25.0%). These comparisons are not statistically significant (see Table 3 for statistics and P value). --- Discussion Of the team experiences in conducting CM, MVCT, and PTSS in the field for over 3 years we have adapted CM strategies to better support promoting VCT uptake. We did not encounter major problems in the initial community approach to MVCT. Stake holders raised some concerned that community members would not come forward to get HIV tested because HIV/AIDS has stigmatization issues associated with it. They thought that the openness of the VCT operations in public venues would scare people away and that community members may be afraid of being labeled as HIV positive or having risk behaviors if they came forward for the test. We have demonstrated that with more knowledge and understanding of the subjects, mobile community-based VCT is a successful avenue to promote VCT. Kawichai et al. [12] and Morin et al. [11] provided surprising results that demonstrate minimal HIV testing stigma, and that stigma is not a factor influencing whether people come forward for HIV testing at mobile VCT units. The CM strategy of door-to-door solicitation had limited reach as most of the target population was usually at work. Few people attended the initial group sessions, many left during the sessions, and many made excuses to leave to return to their daytime activities or household chores. Even though more persons could be reached with the same staff effort (50/10 staff/hours) compared to daytime CM organized meeting and edutainment, the effort did not yield as many persons. Day-time CM organized meetings, include joining community leader established meetings could increase the numbers/session compared to door-to-door canvassing, with most attendees being adults. Joining organized meetings created a sense of formality and required taking time from daily work to participate. The nighttime edutainment required greater staff hours/ eligible participants for VCT. This is expected as running the event required more staff for activities and at least six staff members for each of the three tents for HIV/AIDS education, prevention, and awareness games. The activities also lasted longer than the prior approach. We found that the edutainment approach to CM was more attractive to younger people and generated more attendees/session, most often more than a hundred, sometime reaching 300 if we included those younger than 16 years. This was viewed as a benefit for educating teens and youngsters who may soon be at risk. Young adults also came forward more often for VCT using the edutainment approach. Concurrently providing HIV/AIDS knowledge along with availability of VCT assists decision-making for clients. Often the project young adults (aged 18-25 years old) VCT clients gave reasons for receiving VCT such as the following quotes "I came to cheer on my friend for the Karaoke contest but I am early, my other friends are not here yet. So I am decided to get VCT while waiting". Or "My intention for coming here is not for VCT at first but to play the games and get a prize. However, I am here anyway and it (VCT) is free, so I decided to get it". These quotes suggest that these young adults may use of "being early for CM" or "have nothing to do while waiting for playing game" be a reasons for getting VCT to avoid being stigmatized such as labeled to have HIV risk. Among the ethnic minority communities, particularly those in very remote areas, movies that were related to HIV/AIDS education in their own language were an effective means to educate them about HIV/AIDS. Thevillagers would ask for movies almost every time we visited the villages, although the same movie was often repeated. Discussion would follow after the movies to respond to questions and concerns. We assessed participant's knowledge of HIV/AIDS after the movie and found that their understanding of the issues were generally correct and accurately demonstrated HIV awareness. However, movies were less attractive to lowland Thais who had easy access to modern technology; however, karaoke singing contests were attractive to them. Lottery tickets for prizes after completing the three core CM activities was also an effective method to encourage individuals to learn about HIV/ AIDS and VCT in all ethnic groups. Mobile VCT was effective for outreach and promoting VCT among hard to reach populations [9,11,12] when accompanied with appropriate CM strategies; those who lag behind can also be encouraged. In 574 VCT field days, we tested 17,153 cases (31 cases/ day), and identified 136 new infected cases of whom 95 (70%) were had no signs or symptoms of AIDS. This case finding has implications not only for infected individuals but also for the community at large. All identified new cases received comprehensive post-test risk reduction counseling and were offered referral to care and support. Early detection of infection status will help to limit the spread of HIV by those otherwise unaware of their HIV infection. Having large numbers of people in the community (34% lowland Thai and 44% ethnic minorities of persons aged 16 years and over tested with PA-Thai) going through risk reduction counseling and learning their HIV status may also help to limit the spread of the virus, particularly among these low-education communities. In our case, almost 50% of our VCT clients were ethnic minorities of whom 54% had no formal education. A common scenario for young adultsfrom remote areas is to migrate to big cities to seek work, becoming at risk for HIV infection. Knowledge will empower them to prevent themselves from infection which should lead to reducing the further spread of the virus. There are some limitations to the study. Our results may not generalize to other populations. First, the study was conducted in northern Thailand rural areas and participants voluntarily came forward for VCT. These individuals could be biased to be either the "worried well" or to be at higher risk for HIV infection. However, the information came from a sizable sample where the bias from both groups could be balanced. Second, the data are based on selfreports which are subjected to some bias. Participants may tend to report socially desirable data to the counselors. Risk behaviors may be under-reported, and some low-risk behaviors may be over-reported by participants. In conclusion, this study suggests that VCT can be successfully promoted in populations with appropriate strategies that fit the local context. Entertainment is of human interest and can be a useful tool for drawing attention to public health issues. Integrated entertainment with HIV/AIDS community mobilization is one strategy recommended to increase HIV/ AIDS knowledge in populations which lead to VCT promotion and ultimately to stigma reduction. in conducting this research, and all study participants for their contributions. We also thank study staff and volunteers at all participating institutions for their work and dedication. --- Study setting --- Appendix

Project Accept is a RCT designed to test the efficacy of community mobilization (CM), mobile voluntary counseling and testing (MVCT), and post-test support services (PTSS) in reducing HIV incidence in three African countries and Thailand. The intervention started in rural areas, northern Thailand in January 2006. CM initially included door-to-door visits during the daytime, small group discussions and joining organized meetings and followed by MVCT. In February 2007, CM strategy using HIV/AIDS "edutainment" (education and entertainment) during evening hours was introduced. After edutainment was initiated, the number of participants increased substantially. VCT uptake increased from 18 to 28 persons/day on average (t test; t = 7.87 P < 0.0001). Edutainment especially motivated younger people, as the median age of VCT clients decreased from 38 to 35 years old (median test; z = 6.74, P < 0.0001). Providing free MVCT in community settings along with edutainment during evening hours increased VCT uptake and was particularly attractive to younger adults.

Introduction Criminology -Criminology is a study of a crime, the criminal behavior and the criminal justice system associated with it. Criminology is the scientific study of the causes, correction, and prevention of crime and those who commit it. Feminist Criminology-Feminist criminology focuses on women offenders, women victims, and women in the criminal justice system in order to understand the causes, trends, and results of female criminality. It includes the role of sex and sexism in sentencing and imprisonment, the role of victimization in women's lives, and the increase in the number of incarcerated women despite declining crime rates. Feminist criminology developed as a school in criminology because the major criminology theories were for men. It is a study mainly that focuses on women offenders, women victims and the impact of female criminality in society.Feminist criminology includes how women are ignored and stereotyped in criminology. Women committing murder, robbery, theft, and dacoity are easily escaped by the laws protecting them.Women committing the crime are generally stereotyped as mentally unstable.Claire M. Renzetti is the first person who brought the concept of feminist criminology where the author mentions the development of criminology and examines the diversity of feminism. Generally, crimes committed by women differ from male criminality. The difference can be seen in the nature of the crime, and its' consequences, combined with the method, crime weapon, and choice of victim. It is difficult to overlook the fact that crimes committed by women have a more emotional characteristic than those committed by men. --- Objective of the Study • To find out the causes of female criminality. • To know socio-economic and other factors of female criminality • To prescribe solutions to curb female criminality --- Reasons and Causes for Criminality amongst Women Women's participation in crime has been majorly associated with a large amount of indifference compared to men, in criminology.Motivation of criminality among women is mostly because of the social conditions that they face. There are possibilities that the criminality can be installed in a women's mind genetically. The character of a criminal is put in a women's brain by social exposure right from a young age which also results in behaviour development. Most of the families do not provide a woman with support, respect or acceptance in the decisions where she chooses to be self-dependent, such scenarios are leading women to rebel by giving them a platform where they are more likely to deviate or commit a crime. The social environment contributes a lot to the making of women criminals, especially in a patriarchal society. Despite a guarantee from the constitution of India of equal rights and privileges, a woman's fate cannot be changed. Even after equal involvement and excellent performance in her education and her workplace, she does not get the credit and respect she deserves.The problem manifolds when despite being capable enough, she has to obey the orders of a man of lesser ability, her own opinion is brutally crushed and overheard. She is subjected to victimization just because she is a woman. Phoolan Devi, the bandit queen is a classic example of how a victim turns into a victimizer. Further, the marital status of a woman might have a significant role in making the decision to be a part of criminal activity. Unmarried women tend to get more regular work as compared to the married ones. Corporations often consciously decide to employ married men over married women as they want to cut the burden of paid maternity leave thereby contributing to the ever-present discrimination against women in workplaces.This discrimination, in a twisted fashion, provides women an opportunity to get involved in crime, as they are already being discriminated against at the workplace. Further acknowledging the presence of commercial sex in Indian society, it is not explicitly illegal as there are no laws that punish a sex worker. However, some activities related to commercial sex such as soliciting, running brothels, trafficking and pimping are punishable under The Immoral Traffic (Prevention) Act, (1956). Due to lack of awareness, women lack basic legal rights, healthcare and support from the government and society, they end up being victimised and their safety goes for a toss.Eventually, the women who have been forced into it do not get a way out. Once they survive and climb up the ladder, they act as brothel owners or drug peddlers and get involved in other illegal activities. Due to the frustration from emotional, mental and physical abuse these women tend to supress others in order to protect themselves from being supressed and hence end up victimising others. Battered Women Syndrome is another state of affairs which not recognized under the Indian Judicial System. It is a psychological condition that can develop when a person experiences abuse for a long time in a relationship. Abuse can be sexual, physical, or psychological aggression in nature. Due to the repeated abuse, women start suffering from learned helplessness. Threat to further violence also stops them to share their concerns to someone else. This concept of Battered Women Syndrome has not been placed in Indian Judiciary to explain the reasonableness of a woman's actions in self-defence against the abuser. Society provides close supervision and social restrictions on girls. Girls are trained to be passive, domesticated, non-violent, gentle and are made to learn more of nurture-related jobs than getting involved in fighting or using a weapon. On a contrary, boys are nurtured to be aggressive and involved in activities that project masculinity. Hence, when girls grow up, they do not get involved in combats where they have to get involved in physical fights or in crimes where they have to threaten someone with their physical strength. They get more involved in petty thefts, poisoning or the crime which take less of masculine work. Freda Adler (Sisters in crime: The rise of the new female criminal, 1975) has attributed prostitution, drug addiction and female juvenile delinquents to the liberation movement of women and a way how women project assertiveness. She contends that educated girls and women are more willing than ever to challenge the traditional restrictions and social roles. Bajpai and Bajpai (2000), talk about the frustration and helplessness a woman experiences due to the lack of support and discrimination she has to face every day in her life. In this fight for their rights, the clash is unavoidable. --- Conclusion In conclusion, what needs to be analysed in the social environment of a woman, who is in conflict with law is -their upbringing, sexual socialisation, their roles in their respective families, their personal relations with their in-laws and their career preferences. Society plays a major part in a woman's life span, whether or not a woman turns into an offender highly depends on what kind of life she is living and what options does she have if she wants to change it? The irony here is that these options are very often not of her own choice but are presented by the society. Finally, both sexes are equally responsible for criminal activity. Criminals' motivations will always be a mystery, but it seems sense that they would be different for males and girls. This is because the majority of published works focus on males before being adapted to females, but this is not always the case. Since men and women engage in criminal activity at various times and in different ways, they should have distinct motivations for breaking the law. Women have a lower recidivism rate than men, suggesting that this is due to either a desire to maintain a certain lifestyle or the fear of having their children taken away and placed in foster care. Thus, criminologists deduce that there must be a substantial difference between the motivations of males and females for criminal behaviour.

In almost every part of the world, women are considered as care givers. Women manage their homes, family and children.Women are homemakers and more uninvolved.The belief that women can inflict atrocities was beyond the imagination of criminologists and most areas of criminal science banished women from its examinations.Over the years, in every religious society, women have always been considered asphysically and mentally inferior and unproductive to men. This trend might havereduced in the early 21st century due to the advent of media, women commissions,NGOs, human rights organizations, etc but we find reports of widespread violence against thecreators of life, particularly in the backward and developing nations. This paper focuses on the situation of female criminality in the recent times. It is designed to highlight the causes and consequences of criminality amongst women and potential solutions to prevent such acts.

INTRODUCTION Most of the studies on alcohol dependence are concentrated on its individual and social consequences and on early recovery phases; less is known about the maintenance stage of recovery (Prochaska and DiClemente, 1984;Prochaska et al., 1992), among both treated and non-treated subjects. Moreover, the definitional boundaries of recovery remain blurred, since professionals-addiction treatment researchers and policy makers have not yet reached a consensus on the definition of recovery that would meet the criteria of precision, inclusiveness, exclusiveness, measurability, acceptability and simplicity (The Betty Ford Institute Consensus Panel, 2007;White, 2007;Kleinig, 2008). There is also a gap between theoretical discussions on the meaning of recovery and operational criteria used by researchers who tend to define recovery as rather short periods (M length = 1.2, SD = 0.7), (Carballo et al., 2007). Consequently, less is known about the long-term processes involved in maintaining recovery-related changes and about the impact of time on the stabilization of the recovery process. Only some authors suggest that the maintenance stage can be divided into phases. Klingemann (1992) identified the sequence of phases during the maintenance stage of recovery: (a) tricks and a renewed self-confidence, (b) protecting the achievement, (c) a new life and (d) peace of mind and reconciliation with others. The last phase can be characterized by the internalization of new social roles and by the successful completion of a search for meaning in one's life (Klingemann, 1992). Similarly, in a Mohatt et al. study (2008) the last phase, named 'the life as it is meant to be lived', follows the active coping phase. From 'an outer perspective', maintenance studies are focused on the measurement and observation of factors co-varying with successful recovery. Prior studies have shown that receiving social support from family members and friends or having significant others, goes along with individuals' well-being and thereby seems to enhance their motivation and self-confidence to maintain the change of addictive behaviour (Moos et al., 1982;Longabaugh et al., 1993;Higgins et al., 1994;Beattie andLongabaugh, 1997, 1999;Fichter et al., 1997;Billings and Moos, 1998;Finfgeld, 1998;Blomqvist, 1999;Sobell et al., 2000;Moos andMoos, 2006, 2007). Blomqvist (1999) emphasizes gender bias; in his study men, significantly more often than women, cited the role of the partner as an important maintenance factor. Lack of family resources is often compensated by spiritual or religious involvement and support received from a religious community (Klingemann, 1992;Finfgeld, 1998;Blomqvist, 1999;Sobell et al., 2000;Granfield and Cloud, 2001). In Blomqvist's (1999) study, women were more inclined than men to report esoteric or spiritual experiences as important part of their recovery. In addition to family resources, the work and financial resources (Moos and Moos, 2007) are considered to be the most important ingredients of stable recovery. Maintenance studies show also an intervening effects of maintenance factors such as: improved health and feelings of well being (Burman, 1997;Moos and Moos, 2007); self-confidence (Moos and Moos, 2007); self-control and willpower factors (Blomqvist, 1999;Koski-Jännes and Turner, 1999;Sobell et al., 2000); sense of pride about what has been accomplished (Finfgeld, 1998) and a more profound sense of life (Blomqvist, 1999). These findings point out, that the meaning and individuals importance attributed to these 'factors' may considerably differ and consequently determine different outcomes. Antonovsky's salutogenic model accommodates this perspective suggesting that maybe the question which and how many resources are available to the individual in the process of recovery is after all not very relevant but the ability to use them flexibly in coping situations comes to the foreground (Antonovsky, 1995). Also Marlatt and Gordon's (1985) pathogenic model of relapse focuses on the role of low selfefficacy and lack of effective coping skills as risk factors for relapse. Indeed, in previous studies of treated and untreated individuals, fewer personal resources, such as lack of selfefficacy and coping skills, have been associated with relapse (Rychtarik et al., 1992;Brown et al., 1995;Connors et al., 1996;Miller et al., 1996;Moos and Moos, 2006). Qualitative studies, focusing on 'the inner perspective' shed more light on maintenance strategies and the interplay and actual use of structural resources during recovery from addiction. Most remitters are conscious strategists; however for some, these coping strategies are only needed in the initial phase of recovery, whereas others continue to use them on a daily basis for years (Klingemann, 1992;Finfgeld, 1998). This refers to respondents' commitments to reinvest in themselves and their longstanding values and interests; becoming more involved in or renewing their involvement in meaningful work, non-substance-related activities, volunteer work or artistic and creative endeavours. Some remitters engage in new, improved or more meaningful interpersonal relationships or a spiritual life (Finfgeld, 1998;Koski-Jännes and Turner, 1999). Work-related changes, changes in general lifestyle or in living arrangements (Finfgeld, 1998;Blomqvist, 1999;Sobell et al., 2000) as well as the resumption of leisure time activities (Klingemann, 1992) are strategies often mentioned in maintenance studies. Some strategies serve the practical task of avoiding temptations or former company (Koski-Jännes and Turner, 1999) and providing alternative rewards to those obtained from alcohol use (Moos and Moos, 2007). Other strategies include strengthening 'the right attitude': remembering of negative consequences of alcohol use (Burman, 1997;Koski-Jännes and Turner, 1999), positive thinking and future orientation (Miller et al., 1996;Koski-Jännes and Turner, 1999;Bischof et al., 2000) and rewarding oneself (Koski-Jännes and Turner, 1999). Former alcohol dependants are attempting their reintegration into society by socializing with non-or social drinkers and focusing on their own responsibilities and society's role expectations (Klingemann, 1992;Burman, 1997;Finfgeld, 1998;Blomqvist, 1999). Engagement in volunteer work may provide a framework for self-forgiveness and since helping is much better regarded in our society than being helped, it may also improve the status of recovered individual (Klingemann, 1992;Burman, 1997). For those who have recovered by the use of professional treatment or selfhelp group, further participation in alcoholics anonymous (AA) as an ongoing reminder in conjunction with observable examples of recovery may also serve as a maintenance strategy (Blomqvist, 1999;Bond et al., 2003;Moos and Moos, 2007;Kelly et al., 2009). Studies on the maintenance of alcohol addiction recovery conducted among naturally recovered individuals help to overcome the institutional bias created by treatment studies even though treatment samples still represent the lion's share of research. Moreover, differences between treated and untreated samples are deduced mainly indirectly, because comparisons of those groups within one study are the exceptionals (Blomqvist, 1999;Bischof et al., 2000;Moos and Moos, 2006). In a Blomqvist (1999) study, selfremitters' reports were mainly concentrated on the role of the partner or family members and on internal, emotional and/or cognitive changes, whereas the reports of treated remitters were more evenly distributed across a greater number of factors, including changes in living circumstances and various habits, as well as various forms of formal assistance. Self-help group members continued their involvement in AA activity, whereas natural recovery group members were absorbed by their families and leisure activities. Bischof et al. (2000) compared naturally recovered individuals with subjects who remitted with the aid of extensive self-help group participation. They identified no group differences in terms of coherence, satisfaction with life domains, temptation to drink and self-efficacy in remaining abstinent. The groups did not differ on supportive life domains except that self-help group subjects specified friends, family and religion more, and health less, as maintenance factors. Moreover, selfchange investigated on grounds of longitudinal data showed high stability (Rumpf et al., 2006). The study presented here explores issues related to maintenance of recovery from alcohol dependence in Poland among a sample of individuals who have recovered by means of self-change, self-help group participation or specialized outpatient and inpatient therapy for alcohol dependents. The article explores dependence as a social rather than biological state: defined socially and embedded in social acts that condition it; specific resources or recovery strategies are not equally distributed within societies and their recovery potential may differ in different cultures. The analysis presented here provides an in-depth qualitative understanding of what maintains recovery with a focus on the broader social context of change of addictive behaviour and including the impact of time on the recovery process. Results of the addiction recovery studies show that subjective accounts of addiction and recovery differ (Larkin and Griffiths, 2002;Klingemann, 2011). The article discusses recovery as a subjective process linking it with a conceptual framework of the meaning of recovery. In Poland, no previous systematic research has, to the author's knowledge, addressed these issues. --- METHODS --- Sample The study is based on extensive interview data from 24 men and 5 women (M age = 52 years, SD = 10 years, age range: 34-73 years). All participants had previously been alcohol dependent according to ICD-10 diagnostic criteria (M dependence = 13 years, SD = 8 years). All participants had to have at least a 2-year period of recovery (M recovery = 11 years, SD = 9 years), meaning no symptoms of dependence or harmful use of alcohol or other drugs. Complete abstinence was not a criterion for inclusion in the study. However, the majority of respondents were abstainers (n = 24). Others were moderate drinkers: their alcohol consumption did not exceed 16.3 g/day (M consumption = 6.5 g/day, SD = 7.1 g/day). --- Data collection Lack of predictive power with quantitative statistical data may result from an insufficient knowledge of the variance in meanings attributed to the same terms used in structured questions by the respondents. Qualitative research shed light on the subjective variance of meaning. This qualitative study was conducted in Poland (Greater Warsaw) between October 2006 and June 2007 using media recruitment to establish the sample (Klingemann, 2011 for the text of media call and detailed methods description). Respondents were not remunerated for their participation. In order to ensure data reliability and validity, source triangulation and methodological triangulation procedures were applied. More specifically, to ensure synchronic reliability, different methods were used to collect data from the respondents and to ensure diachronic reliability, respondents were contacted several times in severalweek intervals and some of the questions were repeated (refer to Table 1 for the overview of the data collection procedures and instruments). Two sociologists, each of whom was trained in qualitative methods of data collection, conducted the interviews. Each possessed previous research experience with substance users from different cultural backgrounds. Interviewers followed the interview guidelines of asking questions in a flexible manner, in order to merge with and facilitate the narrative flow. Consequently, the interviews were structured by interviewees, not by the guidelines. Ad hoc questions were asked only if certain topics were left out by the interviewees to secure comparability of the data and completeness of topical areas. Two trained students of social sciences meticulously transcribed the interviews recordings. Transcripts include information on non-verbal communications such as laughter, crying, silence, interview interruptions, as well as comments from the person transcribing the interviews facilitating the interpretation. In order to check the validity of the data, information was gathered both from the respondents themselves and from collaterals (meaning the person indicated by respondent who witnessed his/her addiction history, i.e. partner, adult child and friend), (Konecki, 2000;Silverman, 2001). However, to avoid biasing the sample in favour of subjects with intact social networks, nomination of collateral informants was not a criterion for eligibility. Information gathered from collateral informants was used to validate respondents' addiction history and help-seeking status. No inconsistencies were found. --- Analysis Data were collected and analysed according to the problem-centred interview (PCI) methodology using ATLAS.ti software (version 5.5.3). The concept of a PCI borrows largely from the theory-generating procedure of grounded theory (Konecki, 2000); however, the insight gained through data analysis is organized as an inductive-deductive mutual relationship. The deductive-inductive scheme allows utilization of theoretical concepts and findings from previous research, without lowering the chances for serendipity. This implies a two-step coding procedure. Initially, the transcripts were inductively coded'sentence by sentence'. The applied open-coding procedure captures the meaning of data and'sentence by sentence' procedure guarantees that no data are left out. Afterwards, the inductive codes were linked with the more general categories derived from the interview guidelines ('code by list' procedure). That second step linked the interview data with the deductive, theoretical categories. Finally, the codes and quotations were compared within each category, and new categories were created if needed. In order to identify and deduce inductively typologies, the constant comparative method was applied-different types of data as well as the categories, codes and finally the cases were compared, and similarities and differences identified and interpreted (see Witzel, 2000-for a detailed description of PCI methodology). --- Ethics Consent was treated as a continuous process-respondents were advised at every stage of data collection that they could terminate the interview at any point and that they could also refuse to give answers to certain questions if they felt they could become distressed while answering them. After the phone interview, respondents received an information sheet describing, in detail, the research objectives, contact information, assurance of confidentiality of the data and information about the benefits and risks of participation. Written informed consent was obtained from all respondents. No respondent who volunteered to participate in the interviews refused to discuss any of the pre-determined topics identified by the interviewers. --- RESULTS The analysis of the respondents help-seeking history led to the identification of five subgroups adopting different paths of overcoming dependence: (a) self-changers (SC), (b) consumers (CR), (c) AA, (d) outpatients (OP) and (e) inpatients (IP). The group assignment was the result of the analysis and interpretation of addiction history narratives: not only the contacts with addiction treatment (failed and succeeded) were taken into consideration, but also its subjective meaning (i.e. a respondent who recovered without therapeutic help, but who believes that the failed treatment attempt few years earlier was crucial for his recovery was qualified as IP). The paths differ due to the type of support used to overcome dependence and served as baseline/background for assessing-related maintenance strategies. SC used exclusively lay support and lay strategies. Those respondents have not been in touch with any therapeutic help during their recovery period. CR used some amount of professional help. However, these individuals were not 'treated' in the classical sense-they included rather, some proactive elements of professional assistance in their lay recovery programs. They treated treatment and therapeutic messages instrumentally and selectively and they had full control over the quantity, intensity and costs involved. They also mainly used services offered by the private sector. AA recovery is based exclusively on participation in AA meetings, and the AA traditions and steps. OP participated in individual or group therapy offered by OP clinics for alcohol-dependent people. IP participated in several weeks of individual and group therapy offered by specialized residential therapy centres. Both OP and IP, after having completed their therapy, often attended AA meetings, which they treated as a form of aftercare. The individual change process is embedded in a changing socio-cultural-historical context. The context of dependency treatment has changed several times over the last few decades and so have treatment methods, the legal background and treatment availability. Most of the respondents overcame their dependence after the last health system reform in Poland (which is now based on the Minnesota program rationale). However, some respondents had already recovered in the 1980s and early 1990s, i.e. during the systemic transformation and dynamic increase of self-help groups and the combination of psycho-education and aversive therapy (disulphiram) as the principle method of treatment. Treatment availability could have been an important determinant of this classification. However, a closer look shows that all respondents were aware of at least one form of treatment at the time they were considering the change of addictive behaviour. No significant demographic differences were found between those groups. No differences between groups were found with respect to severity of dependence although SC and CR experienced fewer alcohol-related problems. Four out of six respondents who reduced or stopped drinking at the very first attempt were SC. SC and CR have also slightly longer recovery period compared with the treated groups and AA although all groups can be said to be stably recovered. A detailed description of the study sample is provided (Table 2). Some respondents (especially SC, CR or OP) have managed to maintain a balanced life throughout dependence. Despite the turmoil in their lives, their friends and family stood by them and they themselves had managed to keep their jobs and hence avoid financial and housing instability. Others (especially AA and IP), described the process of 'hitting the bottom and bouncing back'. Their history of dependence was full of dramatic events and serious problems and their recovery was more of a struggle than a smooth change of addictive behaviour. Following the methodological procedure outlined earlier, a broad range of maintenance strategies and resources were reported by the interviewees. Figure 1 maps all identified codes related to the maintenance strategies and resources (as to the perceived dynamics of change see the following sections), which can be grouped into five analytical categories: becoming a new better person; adopting new values and goals; experiencing a new quality of social relationships; pursuing new meaningful activities and changes in their environment. Even though respondents differed considerably with regard to their choice of how to overcome their addiction, striking similarities appeared when their way of how to maintain change was taken into consideration; consequently the results of the analysis are presented for all groups by specific theme, not by type of recovery. --- Multidimensionality of change After identifying the range of specific aspects of change, the joint appearance or the linking of these aspects in the narratives was highlighted in a second step of the analysis. Combining a multitude of change elements emerged as an important theme from the respondents' accounts which was perceived as helpful in their decision to stop drinking; 19 respondents (65%) referred to all five analytical categories describing their maintenance efforts and another quarter of them (28%) referred to four categories. A closer look shows that not only the pattern of drinking changed but also the respondent's whole life changed, practically, symbolically and often spiritually. Some respondents took advantage of the opportunity to make a new living in a new environment, without the burdening consequences of dependence: 'Change of house, new job. Completely new people who did not know about the problem. This was more than just quitting drinking. Quite by accident, everything, whole my life began anew' (M36, CR-A). [symbols in parentheses: gender (M, male, F, female), age, type of recovery strategy (SC, self-changer, CR, consumer, AA, Alcoholic Anonymous believer, OP, outpatient, IP, inpatient), present alcohol consumption pattern (A, abstinence, M, moderation).] Multidimensional change of environment helped respondents to maintain their recovery. A new place of residence, new job, new friends-all that helped to start a new life: 'The system transformation in 1989... the wholesome change of functioning and quitting alcohol... Maybe I am wrong but it seems to me that in some way the history of my country has influenced my personal history. At some point I have changed my environment, place of living, work...'(M52, OP-M). Change sometimes was connected to a birth 11) 55 ( 14) 52 ( 7) 49 ( 4) 52 ( 13) 52 ( 10) Years of addiction, M addiction (SD) 12 ( 8) 9 ( 11) 15 ( 4) 9 ( 6) 18 ( 8) 13 ( 8) 8) 15 ( 17) 9 ( 6) 10 ( 7) 9 ( 5) 11 ( 9) Number Present consumption pattern (n) A 7 3 3 5 6 2 4 M 2 1 1 1 0 5 M, male; F, female; A, abstinence; M, moderation; SC, self-changer; CR, consumer; AA, AA participant; OP, outpatient; IP, inpatient. of a child or grandchild: 'My granddaughter was born and I was taking care of her while my daughter-in-law was at work. I saw it as a chance to have somebody who trust me, who does not think bad of me' (M58, SC-M) and sometimes to a new (or revitalised) relationship: 'I'm 52 and am still going to enjoy life. My wife came back to me. We plan to marry again' (M52, IP-A). Improved relations with partners and children are very important in maintaining recovery. Some respondents-in order to stop or to cut down on their drinking-significantly changed their life situation: their living and working arrangements, circle of friends; however, they did not intentionally and consciously go through any identity transformation-for them it was rather the return to previous (and satisfying) life and normal social roles: 'The return to normality. I used to be punctual, responsiblewhen I gave my word, I kept my word. Now again I can make plans and promises and I can be trusted' (M36, CR-A). Others emphasized the spiritual nature of their changes: 'At some point I have stopped attending therapeutic meetings, but I started to spend more time in my religious community. More I was praying to God, more I received from him' (M50, OP-A). Overcoming dependence was also connected to personal growth leading to internal transformation: 'Self-work. (... ) That was the hardest part. You have to make a great effort to change. (... ) You have to become somebody to be sober' (M60, SC-A); 'When I started therapy I have noticed, that my life is not empty anymore. I even felt better then other 'normal' people who spend their lives watching soap-operas, because I am doing something with myself' (F43, OP-A). --- Coping with stress and cravings Respondents from all groups reported the change in coping with everyday life problems: they try not let the problems to accumulate: 'Everybody has problems, I am just not letting them to accumulate anymore' (M52, IP-A), they perceive them as easier to overcome, and they feel more confident in coping with them: 'One can say, a sober person has small problem, but a drunk person perceives it as enormous and impossible to solve' (M45, SC-A). Cravings tend to appear in relatively early stages of the maintenance phase: 'Twice I dreamt that I got drunk. I cried through my dream. I was so sorry and I could not understand why I did that. I woke up all sweated. It was after two or three years of abstinence' (M43, SC-A, recovered since 6 years). Strategies used in such situations include weighing pros and cons of drinking and recollecting the negative consequences of dependence: 'To recall the problemsmy memories of unpleasant physical effects are completely blurred but my psychological condition that I do remember, it's hard to let yourself be pushed back into something like that once again, it was terrible, indescribable... I felt completely stripped of selfrespect... The thought of being in such a position once again definitely motivates you not to drink. You could easily mess everything up again. The older you are, the less time you have to pull yourself back up. (... ) I am fully aware of the danger' (M52, OP-M). Also contact with people who need support helps respondents to remember about the problems they have already overcome. --- Impact of time on consolidation of life changes The changes once introduced in respondents' lives, stressful and turbulent at the beginning, become an inseparable part of the new life style. 'Time, certainly. Every year sort of accumulates... Bit by bit, thoughts about what you've lost, becoming reconciled with your losses, stabilization, organizing your life anew' (M48, OP-A). Respondents perceive their recovery as complex process requiring strength, balance and patience -the life situation gradually stabilizes. The experience of dependency is often reframed and is no longer perceived as a source of weakness: 'There is this saying 'If it doesn't break you it will make you'. And that's very true as far as I'm concerned. I'm much calmer now than I used to be when I drank, more balanced. I think that I've crossed a threshold and learned something. I needed this fragment of my life to teach me something. It has strengthened me' (F70, SC-A). --- DISCUSSION The article addresses the subjective experience of the maintenance stage of recovery from alcohol dependence within a broader socio-cultural context. Findings of the first Polish study of available paths to recovery, including self-change, are presented. A triangulation procedure was adopted in order to ensure reliability of the data and validity of the data analysis. Although people change for a wide variety of reasons, they share a more similar repertoire of techniques to maintain the change. Our findings support the assumption that, independent from help-seeking status, more commonalities than differences exist within successful recoveries from alcohol dependence (Koski-Jännes and Turner, 1999;Bischof et al., 2000;Sobell et al., 2000). The aftercare treatment services and support of self-help groups can be perceived as additional (and helpful) resources in reaching a stable recovery, especially if similar resources in the daily life context of an individual are missing. However, recovered subjects are striving toward their societal reintegration and as over time, other resources in their life circumstances become available-professional assistance tends to be less and less needed, and at some point may even impede the consolidation of life changes. Multiple maintenance factors and strategies contributing to the stabilisation of recovery from alcohol dependence were identified. Findings from our study support results from maintenance studies among treated and non-treated subjects within other cultural contexts. However, our study shed more light on the subjective relevance and interplay of those factors and resources. Not the specific components, but the multidimensionality of change emerges as the most important feature of maintaining the recovery from addiction. Recovery appears over time as an interplay between individual actions, societal reactions and positive and negative life events while subjective accounts of maintenance stage are being continuously constructed and reconstructed. That is especially visible in our study where subjective accounts of recovery experiences from different points of time-subjects' recovery time varied from 2 to 40 years (M = 11, SD = 9)were analysed. The results from this qualitative study point to the more general aspect discussed in the literature, that the questions'recovery from what?' or 'what has to be maintained?' are negotiated during therapy and professional definitions might converge or clash with the ideas of the'recovering' individuals. Concepts which represents 'a sustainable' problem resolution and the reasons for long-term maintenance are part of the framing of the meaning of recovery. The attempts of professionals to define recovery from addiction do not focus on the 'normalization' of deviant behaviour but rather on 'voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship', where the citizenship implies working towards the betterment of one's community through participation, volunteer work and efforts to improve life for all citizens (The Betty Ford Institute Consensus Panel, 2007). Professional perception of recovery is in fact quite demanding: it is not merely expected that individuals would cease his/her drug use, but it is requiring a major restructuring of his/her social networks as well as values, knowledge and skills. It is also believed that recovering alcoholics want and should pay back or re-compensate to the society for their antisocial behaviour (The Betty Ford Institute Consensus Panel, 2007;White, 2007). Recovery definitions that place recovery within the context of global health (Foster et al., 2000;Rudolf and Watts, 2002) view the resolution of substance-related problems not as a focal point but as a by-product of broader personal and interpersonal processes. Such definitions withhold the status of recovery from someone who has achieved abstinence but has failed to achieve levels of physical, emotional, relational and ontological (spirituality, meaning and purpose) health (White, 2007). It has been increasingly recognized that the search for'standard recovery' and conditions attached to such a normative endeavour may sometimes set the bar too high. Even though humans are remarkably resilient, they cannot always erase the effects of whatever it is that afflicts them (Kleinig, 2008). Moreover, the demand of total abstinence may be also seen as societal form of punishment (Room, 2004). Turning objectives of the change and recovery process to the individual perspective we can clearly see that some recovering addicts do in fact meet even very harsh definitional criteria of stable recovery according to the terms mentioned above: both our and other studies on recovery show identity transformation and striving for honourable social identity, adopting the most valued goals of mainstream society, achieving peace of mind, personal growth, taking up creative activities as important components of recovery process (Koski-Jännes, 2002;The Betty Ford Institute Consensus Panel, 2007). However, addiction is a heterogenic phenomenon: in our study the second group of recovering alcohol dependants was identified who, in the same way as ex-smokers (Koski-Jännes, 2002), resolved dependence without any remarkable identity or values change. That is especially true for some of SCs and CR-groups not affected by treatment ideologies. This group effect can be interpreted in the background of the make up of the Polish treatment system, which is based on the medical model of addiction. Since the 1980s, alcohol dependence was treated as a chronic, progressive and incurable condition and its abstinence-oriented treatment is organized on the basis of the Minnesota model [The State Agency for the Prevention of Alcohol-Related Problems (PARPA), 2008]. The view that addiction resides solely within the individual fosters significant limitations across the Polish alcohol treatment system. In Poland professional ideologies also embraced concepts such as dry drunk, emotional sobriety and serenity. One can only graduate from a treatment programme in Poland as 'cured' if one has become a completely new person, a person who will always be in'recovery' (Larkin and Griffiths, 2002;Klingemann, 2011). The language of addiction-as-illness contains layers of assumptions and implications that ultimately render viewing addicted persons as'sick' and lacking the capacity, for the most part, to control their own actions (Larkin et al., 2006). At the same time, some Polish studies show that the professional concepts of dependence imposed on a patient during therapy or while attending AA meetings seem to fade away when the person does not stay in touch with the institution or AA group. The new social roles are internalized and addiction gradually becomes part of the past, despite the therapeutic notion of its incurability (Klingemann, 2011). --- Limitations Firstly it should be noted that this qualitative study with a sample size of 29 participants cannot provide epidemiological information on the prevalence of the identified categories in a wider population of alcohol-dependent individuals but it explores the dimensionality of subjective constructs. Secondly, qualitative data can be biased by self-attributions and social desirability. This effect has been additionally addressed in this project by the inclusion of collaterals and the triangulation of various data sources that allowed checking for inconsistencies. Furthermore, even though the validity and reliability of self-reports have been shown in addiction research (Maisto et al., 1979;Sobell et al., 1979;Cooper et al., 1981), memory effects might have an effect on the retrospective data. This potential bias has been addressed and narrowed by providing the respondents prior to the interview with 'life history charts' to be filled out thus crosschecking the assessment at the time of the interview with diaries and other personal records. Overall this data supports the accuracy of subjects' reports and are consistent with findings in previous studies using similar retrospective methods (Tucker et al., 1994;Blomqvist, 1999). --- CONCLUSIONS We perceive addiction as a social, cultural and political construct and recovery as a complex, dynamic and multifaceted process. In this process, multiple maintenance elements come together in a combination of tangible and intangible subjective attributions and decisions. Physical and socioenvironmental structures, cultural context and related life circumstances affect one's capacity to reach stable recovery from alcohol dependence. Results of our study support the usefulness of a holistic view of the maintenance stage and insight into the multidimensional'mind mapping' during the endeavour of individuals to maintain their problem resolution. --- Funding -The work was supported by Polish Ministry of Science and Higher Education as a research grant 'Ways of overcoming alcohol dependence' (grant no. 1H02E03630).

The study provides an in-depth qualitative understanding of the maintenance stage when recovering from alcohol dependence with a focus on the broader social context of change of addictive behaviour. It explores the recovery as a subjective process within the abstinence-oriented Polish treatment system organized on the basis of the Minnesota model and is probes for group differences between treated and non-treated populations. Methods: The study is based on qualitative data from a mediarecruited sample of 29 treated and non-treated former alcohol dependents (ICD-10) in Warsaw/Poland 2006/2007. They reported a recovery time of at least 2 years (M recovery = 11, SD = 9). In-depth, semi-structured interviews were analysed according to the problem-centred interview method using ATLAS.ti software. Results: A wide range of maintenance strategies potentially contributing to the stabilization of recovery from alcohol dependence was identified. However, from the respondents' point of view, the change process is contingent upon the subjective weighing of specific maintenance factors and the importance attributed to their interplay. This includes time management as well as one's ability to invest available resources and strengths in shaping and pursuing personal goals. Conclusion: More commonalities than differences can be observed between groups during the maintenance stage, regardless of respondents' type of the pathway out of addiction. However, when confronting professional concepts of recovery with subjective accounts, only a subgroup conforms to the invasive, potentially normative definitions of recovery, while others do not link their recovery with identity transformation.

undocumented individuals. 3 Most notably, American Indian or Alaska Native and Black are each more than 2-fold as likely to be killed by a legal intervention injury as White individuals. 2 While available data sources do not stratify such outcomes by justifiable or excessive policing practices, researchers consistently find that both violent and nonviolent police interactions are associated with a range of adverse health outcomes. 3 In particular, police interactions perceived as unfair or discriminatory have been associated with psychological distress and multiple adverse mental health outcomes, including anxiety, depression, and posttraumatic stress disorder (PTSD). 4 Furthermore, these adverse outcomes extend beyond the individuals involved in the encounter, with data demonstrating that elevated neighborhood-level use-of-force rates and legal intervention deaths are associated with worse adolescent development outcomes 3,5 and elevated rates of psychological distress and adverse physical (eg, diabetes, obesity) and mental health outcomes among other community members. 3,6 It is not unreasonable, therefore, to consider police-involved violence as a contributing factor to racial health disparities in chronic disease and quality of life. Researchers have mostly focused on understanding the prevalence of fatal and nonfatal outcomes, as well as the adverse health consequences associated with legal intervention injuries, but fewer have examined health system data to identify potential structural factors at the societal level that may underlie existing disparities and inequities related to legal intervention injuries. The study by Ormseth et al 7 contributes to a broader understanding of this public health issue by examining multiple years of nonfatal legal intervention injuries from across California within the context of persistent residential segregation. Consistent with other research, 1 Ormseth et al 7 found that Black residents were disproportionately injured as a result of legal interventions compared with White residents, despite adjusting for differential statewide demographics. They also identified that observed-to-expected injury ratios (based on demographics) varied considerably by county, with injury ratios highest for Black residents living in urban counties and highest for White residents living in rural counties. 7 Finally, although underpowered to detect statistical significance, it was notable that they found more highly segregated California counties (as measured by a validated index of dissimilarity measure) experienced higher observed-to-expected injury ratios for Black residents and lower observed-to-expected injury ratios for White residents. This finding is consistent with an accumulating body of literature 8,9 demonstrating the fundamental role that persistent residential segregation has in perpetrating racial disparities in health outcomes, particularly for Black individuals. Such residential segregation primarily stems from the early-to mid-twentieth century collective practice of redlining, or instituting racial zoning laws (ie, policies that established or maintained segregated urban communities) and racially restrictive covenants (ie, contracts prohibiting the sale --- + Related article Author affiliations and article information are listed at the end of this article. Open Access. This is an open access article distributed under the terms of the CC-BY License. --- JAMA Network --- Conflict of Interest Disclosures: None reported. Additional Contributions: Carrie Musolf, BA, assisted in manuscript preparation.

Policing practices have garnered increased national attention in recent years following multiple highly publicized encounters that have resulted in the death of unarmed Black citizens. 1 As a public health issue, legal interventions (ie, police or law enforcement interactions) have resulted in more than 5500 fatal and 850 000 nonfatal injuries within the past decade (2011-2020). 2 In addition to physical and sexual assaults by police that result in fatal and nonfatal injuries, police-involved violence also includes a range of psychologically harmful (eg, coercion or harassment during police encounters) or neglectful (eg, failure to aid) behaviors. 3 Such violence disproportionately affects historically marginalized populations, including American Indian or Alaska Native, Black, and Hispanic communities; lesbian, gay, bisexual, transgender, and queer individuals and individuals with other gender and sexual identities; and economically disenfranchised, disabled, houseless, and

Population Health Research Capsule What do we already know about this issue? Older adults face unique challenges related to emergency care, including decreased attention to patient-centered and goal-concordant care. What was the research question? Can emergency clinicians identify concerns and desired outcomes of older adults using the "What Matters" conversation guide? What was the major finding of the study? "What Matters" questions in the ED are feasible, with clinicians and older adults exhibiting varied alignment. --- INTRODUCTION Older adults (those aged 65 years and over) account for over 23 million emergency department (ED) visits annually, representing 18% of all ED visits nationally. 1 Older adults have been noted to face unique challenges related to emergency care, including the potential receipt of goaldiscordant care and a decreased attention to patient-centered care. 2,3 As a potential solution to address the underlying problems facing older adults more broadly in healthcare settings, the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) founded the Age-Friendly Health Systems initiative in 2017. [4][5][6][7] As of June 2021, 4 there were over 2200 age-friendly health system participants employing the framework called the "4Ms" -What Matters, Medication, Mentation, and Mobility -to ensure patientcentered and evidence-based care for older adults across healthcare settings, with wider implementation in ambulatory and inpatient settings and less attention to the ED setting. [8][9][10] Within EDs, efforts are increasing to prioritize patientcenteredness and goal-concordant care for older adults. 11,12 These areas of focus are particularly relevant and important for older adults as they have been identified in the outpatient setting to have health-related priorities aside from typical metrics such as repeat ED visits or hospitalization. [13][14][15] Furthermore, much of the available emergency care research regarding older adults' patient-centered goals currently focuses on treating clinicians performing end-of-life goals of care conversations. [16][17][18] However, ED treating clinicians are tasked with navigating older adult priorities not just during critical illness or end of life. To date, the extant literature has not assessed whether ED treating clinicians perceive priorities that differ from their older adult patients, thereby potentially introducing goal-discordant care. Identifying what matters and priorities within the broader older adult population has drawn concerns regarding implementation strategies in the ED clinical environment as the lines of questioning often are perceived as time-intensive 19 or beyond the scope of a traditional ED visit focused on a single injury or symptom. Thus far, a feasible approach aligned with the Age-Friendly Health Systems to identify what matters to older adults seeking emergency care is lacking. Therefore, we sought to describe the priorities identified by older adults' and their treating clinicians as well as the feasibility of incorporating brief questions addressing what matters in the ED. Identifying the concerns and desired outcomes of older adults in a time-efficient approach that is aligned with the "What Matters" domain of the 4Ms framework will allow more patient-centered ED care for this growing population. --- METHODS --- Study Design We performed a qualitative analysis involving cognitively intact patients and their treating clinicians. Study methods and results are presented in accordance with the consolidated criteria for reporting qualitative research (COREQ). 20 This study was determined to be exempt research by the institutional review board. --- Sample The study was conducted at two EDs -a community hospital and a Level II trauma center -within the same health system. Potential older adult participants were identified based on screening within the electronic health record, with recruitment taking place during rotating evening and day schedules. Inclusion criteria included the following: age <unk>70; English-speaking; ability to answer questions without the assistance of caregivers; and an Emergency Severity Index score of 3, 4, or 5 suggesting lower acuity at triage. Exclusion criteria included a status of medically unfit (as determined by the treating clinician) or evidence of cognitive impairment. We used the six-item screener, with a score of <unk>4 on the six-point questionnaire indicating high risk for cognitive impairment, as previously performed in ED-based research. 21 Treating clinicians, including attending physicians and non-physician practitioners (eg, physician assistant, nurse practitioner), received a $5 gift card for their time participating in the interview. Enrollment occurred between December 2020-May 2021. --- Procedures A trained interviewer (HD) obtained verbal consent and digitally recorded interviews of older adults and their Western Journal of Emergency Medicine An initial version of the "What Matters" conversation guide was tested in three EDs to gain clinician insights regarding appropriateness and feasibility (Supplement 1). We used the final two questions previously identified by expert consensus deemed to be most salient to identify what matters for older adults seeking emergency care. 23 To assess concurrent clinician impressions of their older adult patients, we asked analogous questions in a separate interview to the patient's ED treating clinician regarding what they believed mattered most to the older adult they were treating (Table 1). As suggested by stakeholder and expert guidance on the "What Matters" conversation guide, HD could ask either question 1a or 1b to ascertain fears or concerns about the older adult's healthcare in the ED, with a similar approach suggested for question 2a or 2b to identify outcomes most wanted. When identifying fears or concerns, HD's approach was to start the interview by asking question 1a. HD asked question 1b if the participant had difficulty understanding the question, needed further clarification, or it was thought that greater information could be gathered by rephrasing the question. The final interview guide was pilot tested with two ED patients prior to beginning the study. Both patients and clinicians were interviewed during the ED encounter when disposition uncertainty still existed. This occurred after the initial evaluation by the treating clinician, but before laboratory and imaging results were available to inform decision-making. HD timed interviews from the start of asking question 1 to the end of the participant's response to question 2 to assess the time and operational feasibility of incorporating "What Matters" questions into a typical ED encounter. HD collected basic demographic information and ED clinical data regarding the encounter and also recorded brief field notes immediately after the interview. No study authors were part of the participants' medical care teams. --- Data Analysis We used an iterative process of thematic analysis to synthesize the data, identify patterns, and develop themes across interviews. 24 Specifically, we used the inductive qualitative approach that relies on the synthesis of qualitative data, rather than relying on concepts considered a priori. 25 The coding team consisted of CJG, an emergency physician and health services researcher with formal qualitative training and expertise working with older adults, and HD, a masters-level research associate whom CJG trained on qualitative research techniques. Digitally recorded transcripts were professionally transcribed and corrected when the transcript passage was incomprehensible or had errors. We used NVivo 12 qualitative software (QSR International, Melbourne, Australia) to manage and analyze study data. 26 The coding team began with a line-by-line review of transcripts and open coding to identify key concepts. Following review of the first six transcripts, coders developed an initial codebook that was subsequently expanded and refined through independent and then joint review of additional transcripts. Coding discrepancies were adjudicated between coders through regular meetings, and the final codebook, containing 22 codes across four domains, was then applied to all transcripts. Both coders coded all interviews to enhance consistency. Recruitment, interviewing, and coding occurred concurrently until thematic saturation was reached. 27 We followed best practices for validity in qualitative research by maintaining an audit trail and comments and revisions from group coding meetings. [28][29][30] The study team collaboratively identified and agreed upon illustrative quotes the represented the identified final themes. To preserve anonymity, participant quotes are identified by participant type and number. --- RESULTS We screened 58 older adults for eligibility; eight refused to participate and four were noted to be cognitively impaired, 2. The most common ED chief complaint category was "fall, musculoskeletal," and a significant portion of older adults underwent both laboratory testing (93%) and radiograph imaging (70%). Interviews with older adults lasted a mean of three minutes, with a range of 1-8 minutes. Treating clinicians consisted of physicians and non-physician practitioners (Table 2). When considering responses to the first "What Matters" question regarding fears or concerns about the older adult's ED care, five main themes emerged among older adult respondents and two main themes emerged among clinician respondents. For older adults, these themes included the following: 1) concern through a family member or outpatient clinician recommendation; 2) no concern, with a high degree of trust in the healthcare system; 3) concerns regarding symptom cause identification; 4) concerns regarding symptom resolution; and 5) concerns regarding preservation of their current status. For clinicians responding to what they believed the older adult patient was most concerned about, the two themes included 1) concerns regarding symptom cause identification and 2) concerns regarding symptom resolution. When considering responses to the second "What Matters" question regarding desired outcomes about the older adult's ED care, five main themes emerged among older adult respondents and three main themes emerged among clinician respondents. For older adults, these themes included the following: 1) obtaining a diagnosis; 2) returning to their home environment; 3) reducing or resolving symptoms; 4) maintaining self-care and independence; and 5) gaining reassurance. For clinicians responding to what outcomes they believed the older adult patient most desired, the three identified priority themes included 1) returning to their home environment, 2) linking reassurance and return to home environment outcomes, and 3) reducing or resolving symptoms. Tables 3 and4 show representative quotes of the identified themes. --- Insights into Older Adults Concerns Older adults reported a wide variation of concerns when thinking about their health and healthcare during the ED visit. Older adults either presented to the ED at the suggestion of a family member or the recommendation of an outpatient clinician, while an additional group were not concerned at all with their ED care and noted their "total confidence" in the ED treating clinicians. When present, concerns and fears of older adults included symptom cause identification and symptom resolution (eg, knee pain), but more frequently also extended to include the ramifications that the acute injury or illness would have on their broader life. These areas of concern for older adults centered commonly on ambulatory "What Matters" to Older Adults in the ED status and preservation of their current abilities (Table 3). One participant stated,"I am just concerned that I will not get back to normal." (Participant) When asked to consider the older adults' concerns, treating clinicians referenced symptom cause identification and symptom resolution as the patient's greatest concern or fear, with no comment on the perceived impact that the older adult identified on daily life or function. Highlighting potential discordance regarding concerns, one older adult and their treating clinician separately noted: "I have a heart condition. I have an artificial knee, and it looks like I might be getting another artificial knee. --- Mobility is the big issue." (Participant) "I think he is concerned about his left knee pain that is recurrent." (Clinician) --- Insights into Older Adults Desired Outcomes Older adults and clinicians also reported a wide array of desired outcomes for the older adult during the ED visit. Individuals from both groups identified that the desired outcomes of older adults during ED care included returning to their home environment and reducing or resolving symptoms. Highlighting concordance between patients and treating ED clinicians, one older adult and their treating clinician separately noted: Interviewer: "What outcomes are you most hoping for from this ED visit?" Participant: "To be able to go back to the facility where I reside." (Participant) "I think ultimately she would like to be discharged and be told everything is looking good." (Clinician) Expressing desired outcomes from their ED visit, an older adult and their treating clinician also noted: "That my head is clear, and I can go home and get on with my life." (Participant) "I think they would like to go home, but they are also concerned about his head." (Clinician) However, older adults additionally noted obtaining a diagnosis, maintaining self-care and independence, and gaining reassurance as desired outcomes from their ED visit. Treating clinicians linked desired outcomes of older adults, most commonly identifying their desire to gain reassurance alongside their desire to return to their home environment. However, clinicians did not perceive that maintaining selfcare and independence were desired outcomes of older adults seeking emergency care ( --- DISCUSSION This study is the first to characterize perspectives of older adults presenting to the ED using the "What Matters" framework. The unique comparison to their treating clinicians offers evidence demonstrating alignment in some areas despite other distinct gaps between older adults and their ED treating clinicians. Importantly, this work identifies the feasibility of incorporating the "What Matters" questions in the ED. Unique to our work is the identification of what older adults are concerned about and prioritize while seeking emergency care, and whether clinicians are aware of what matters to this population. In our study, clinicians often recognized the importance of returning to the home environment for older adults, but they did not comment on patients' frequently expressed concerns regarding the impact of the acute illness or injury on their ability to return to their previous functional or broader health status. The emergency clinicians rarely mentioned functional changes as a concern of the older adult despite prior ED-and hospital-based literature identifying subsequent objective functional decline and adverse outcomes. [31][32][33][34][35][36] Our qualitative study adds to the literature base by providing more in-depth responses than possible via survey-based quantitative research. The extant literature lacks relevant feasible modalities to address the priorities of older adults seeking emergency care. Many, including the "What Matters" structured tool and the "Serious Illness Conversation Guide, 37 have been developed and assessed in non-ED settings, thereby limiting their translatability to patients seeking acute care. In our study, the average patient interview was three minutes and ranged from 1-8 minutes, suggesting a reasonable time to completion and feasibility of clinicians incorporating the "What Matters" questions within the time constraints of today's ED clinical practice. We believe emergency clinicians are best situated to ask the "What Matters" questions, as their upfront efforts to address patient priorities, concerns, and desired outcomes may ultimately save time and resources in place of potentially contentious and goal-discordant conversations after completion of the ED evaluation. Additionally, Hunold et al asked a single, open-ended question to older adults regarding what would make their ED visit successful, useful, or valuable. 38 Without restricting when during the visit the interview occurred, 62% of participants reported at least one priority in the "evaluation, treatment, and outcomes" meta-category, including treatment of the medical problem, accurate diagnosis, and competent clinical staff. Our study builds upon this work by providing more in-depth qualitative responses as well as standardizing the interview time during the clinical encounter -after initial clinician evaluation but before laboratory and imaging results. This timing ensured uncertainty regarding the disposition and allowed patients to reliably and consistently relay priorities at a critical juncture in the ED visit. It remains to be determined whether these questions may be most effective in guiding ED care if asked at the initiation of the visit, prior to evaluation. Our work has several implications regarding clinical practice. Cognitively intact older adults identified several concerns regarding their health in comparison to their treating clinicians, suggesting that emergency clinicians may be unaware of certain patient priorities during the encounter. A standardized script, such as the "What Matters" conversation guide, may prompt clinicians to incorporate patient-centeredness and shared-decision making into the patient encounters. Identifying what matters in the ED when caring for older adults is intended to promote clinicians to pursue an evaluation, treatment plan, and disposition aligned with the goals of the patient, potentially saving both time and financial resources if an extensive in-ED evaluation is not prioritized or desired by the patient. The Age-Friendly Health System initiative may serve as a platform for the broader implementation in the ED of the "What Matters" conversation guide to target increased patient-centered emergency care of older adults, creating alignment with the recent development of geriatric ED guidelines and the Geriatric ED Accreditation (GEDA) process. 39,40 Future research should build upon this foundation and quantitatively identify domains targeting what matters that can be incorporated within novel patientreported outcome measures and may benefit from determining differences between GEDA and non-GEDA EDs in addressing the "What Matters" questions. --- LIMITATIONS There are limitations of our study to consider. Our study was conducted at EDs within one health system and predominantly among White older adults, thereby potentially restricting generalizability. However, we expect that many older adults will have similar experiences as we identified thematic saturation during our qualitative analyses. Our understanding and interpretation of the data may have potentially introduced confirmation bias, which we attempted to minimize using semi-structured interview guides and discrepancy reconciliation through team discussion. Additionally, the two primary interview reviewers were not blinded to the study objectives, thereby potentially introducing bias to the decision of classification of the questionnaire domains. While we did follow multiple best practices for rigor in qualitative research, [28][29][30] we did not return transcripts to participants for checking of our themes. Finally, "feasibility" has been defined in several ways within the literature. Aside from the time taken to conduct the interviews, additional quantitative survey feedback from older adults and ED treating clinicians may be beneficial to support further operational implementation. --- CONCLUSION Patients and their treating clinicians noted similar concerns and desired outcomes when considering the priorities of older adults. However, clinicians did not as frequently recognize patients' concerns about the impact of their acute condition on overall function and daily life. We have identified the feasibility of incorporating these two "What Matters" questions in the ED and the limited time needed to identify older adults' priorities Address for Correspondence: Cameron J. Gettel, MD, MHS, Yale Medical School, Department of Emergency Medicine, 464 Congress Ave, Suite 260, New Haven CT 06519. Email: Cameron. gettel@yale.edu. --- Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. Dr. Gettel is supported by the National Center for Advancing Translational Science (TL1TR00864) and the Research Education Core of the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (P30AG021342). Dr. Venkatesh is supported by the American Board of Emergency Medicine National Academy of Medicine Anniversary fellowship and previously by the Yale Center for Clinical Investigation (KL2TR000140) from the National Center for Advancing Translational Science. Dr. Hwang is supported by the National Institute on Aging (R33AG058926, R61AG069822), by the John A Hartford Foundation, and the West Health Institute. Dr. Tinetti is supported by the John A. Hartford Foundation, the Gordon and Betty Moore Foundation, and the Robert Wood Johnson Foundation. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation or approval of the manuscript.There are no conflicts of interest to declare.

The "4Ms" model -What Matters, Medication, Mentation, and Mobility -is increasingly gaining attention in age-friendly health systems, yet a feasible approach to identifying what matters to older adults in the emergency department (ED) is lacking. Adapting the "What Matters" questions to the ED setting, we sought to describe the concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians.We conducted 46 dyadic semi-structured interviews of cognitively intact older adults and their treating clinicians. We used the "What Matters" conversation guide to explore patients' 1) concerns and 2) desired outcomes. We then asked analogous questions to each patient's treating clinician regarding the patient's priorities. Interviews were professionally transcribed and coded using an inductive approach of thematic analysis to identify emergent themes. Results: Interviews with older adults lasted a mean of three minutes, with a range of 1-8 minutes. Regarding patients' concerns, five themes emerged from older adults: 1) concern through a family member or outpatient clinician recommendation; 2) no concern, with a high degree of trust in the healthcare system; 3) concerns regarding symptom cause identification; 4) concerns regarding symptom resolution; and 5) concerns regarding preservation of their current status. Regarding desired outcomes, five priority themes emerged among older adults: 1) obtaining a diagnosis; 2) returning to their home environment; 3) reducing or resolving symptoms; 4) maintaining self-care and independence; and 5) gaining reassurance. Responding to what they believed mattered most to older adult patients, ED clinicians believed that older adults were concerned primarily about symptom cause identification and resolution and primarily desired a return to the home environment and symptom reduction.This work identifies concerns and desired outcomes of both older adult patients seeking ED care and their treating clinicians as well as the feasibility of incorporating the "What Matters" questions within ED clinical practice. [West J Emerg Med. 2022;23(4)579-588.] How does this improve population health? Identifying what matters to older adults should spur emergency physicians to pursue an evaluation, treatment plan, and disposition aligned with patients' goals.

universal healthcare is fundamental to the Nordic welfare model, social inequity in health is highly prevalent (Diderichsen et al. 2011). Recent years have seen increasing research interest in unequal access to healthcare in Denmark (Behandlingsr<unk>det 2023;Rigsrevisionen 2019;Pedersen et al. 2021). It has, therefore, been well described in quantitative studies how Danish healthcare is unequally distributed along lines of socio-economic variables. However, very few studies illuminate how specific care practices at the microlevel are influenced by social differentiation. Further, not many studies explore how discourses of active ageing actually operate as norms of segregation through professional practice embedded in the institutions of the Danish welfare state. With this article, we aim to contribute to existing quantitative research by examining qualitatively how social inequality is reproduced in palliative care practices. Palliative care is considered important for society in order to cut the increased costs of life-prolonging treatment (May and Cassel 2018), and important for patients if side effects of futile treatment make prolonging life a burden for patients and families (Davis 2015;Wiersma et al. 2019). Greater longevity with life-threatening diseases has also increased the focus on palliative care. This ideally involves a focus on alleviating "total pain" (Clark 1999), i.e. an awareness of social and financial problems, physical challenges, and existential and mental problems in facing death (see e.g. Sundhedsstyrelsen 2017), and the notion that the needs of patients with life-threatening illness must be identified early, based on the assumption that this will provide greater clarification as death approaches. --- Healthy citizenship and inequity when ageing and dying It is well argued that Western health policies rest on "a paradigm of neo-liberal governmentality through inculcating responsibility in individuals who are compelled to take up the role of health entrepreneurs, acting upon their bodies and selves to achieve an idealised form of healthy citizenship" (Crawshaw 2012, p. 201). A key feature of this is the emergence of a particular focus on "the self". This "psychologisation" or "governmentalisation" of human existence (Rose 1990;Walkerdine 2003), establishes a political logic dominated by a form of "human" profitability (Skeggs 2014). People should, thus, be "subjects of value" (Türken et al. 2015, p. 34), constantly preoccupied with a "healthy lifestyle" and "self-realisation" to enhance their symbolic value all the way to death. The idealised self-optimising subject is permeating society, culture and the way healthcare institutions organise their handling of ageing and death. As a consequence, successful ageing discourses have gained ground (Katz 2000). Harris et al. point out how these discourses often portray successful ageing in a way that "emphasized older adults' ability to choose the way they age, through making the right decisions about their lifestyles, diets, and attitudes" (Harris et al. 2016, p. 378). They also argue that this generates an "ideal of old age or'senior' citizenship" (ibid.). Carter examines discourses about successful and frail seniors and considers it likely that: "...social structures such as racism, sexism, and neoliberalism may impact the way patients are placed into the social categories of successful agers or frail agers" (Carter et al. 2020, p. 6). Our analysis explores how these overall macro tendencies establish themselves at the micro level. The question we examine is how these new distinctions between the successful ageing of subjects who take on "responsibility" for their health and the "resigned", "irresponsible", physically deteriorating agers are informed by social class. Richards notes that there has been an "equity turn" in palliative care research (2022) and advocates for researchers to take into account "the wider political, institutional, and economic conditions" (p. 10) in which poverty comes to exist and healthcare is delivered. Further, she calls for a shift in attention from measurement to a deeper awareness of explanatory factors (p. 1). This article contributes to this turn by exploring qualitatively how social class is reflected in palliative communication in ways which create unacknowledged and unarticulated practices of distinction which might lead to differential treatment. This is important because of the risk of reproducing inequity. --- Social class and classifying practices The understanding of class in this article draws on Bourdieu, since he mainly focused on the reproduction of middle-class privileges at the expense of the lower classes (Bourdieu et al. 1999). This enables us to understand how class is reproduced in the universal welfare context of the Danish healthcare system and to explore class-based implications of different patients receiving palliative care in healthcare facilities that are embedded in middle-class norms and cultures (Aamann and Erlik 2023;Aamann 2020). Bourdieu insisted that cultural practices should be treated as co-constitutive of how class relations are configured (2010). He also focused on the persistence of structures, by developing the concept of habitus to comprehend how class structures are inscribed in people's bodies and minds (Bourdieu 1990). Importantly, he reasoned that forms of capital other than economic, such as cultural and symbolic, must be included in explorations of social inequality (Bourdieu and Passeron 2006). The concept of class has traditionally been one of the major sociological concepts, but in the last 20-30 years, it has lost some of its strong position. Part of the explanation lies in the fact that industrial society with its clear stratification has been dismantled. However, the shift from industrial to financial capitalism, also known as neoliberalism (Tyler 2015), has not removed social inequality but rather increased it. In this context, it appears that class is still highly active but in more diffuse ways. Skeggs insists: "... class is so insinuated in the intimate making of self and culture that it is even more ubiquitous than previously articulated, if more difficult to pin down, leaking beyond the traditional measures of classification" (Skeggs 2005, p. 968). Neoliberalist discourses have, thus, been said to marginalise class as an explanatory factor for inequality (McLaren 2005), neglecting the structural circumstances that determine individual choices. However, Lamont (2012) states that neoliberalism reinforces class differences in terms of assessing people's moral value. Class can, thus, be understood not only as socio-economic position or as forms and amounts of capital, but also as "circulating through symbolic and cultural forms, i.e. the means by which people become judged as morally worthwhile, or as having the right kind of knowledge or 'taste'" (Lawler 2005, p. 797). Seen from this perspective, class works through relational processes that comprise "both a social filter and a key mechanism individuals utilise in placing themselves and others" (Reay 1997, p. 226). Sointu (2017) explores the reproduction of inequality in medicine; she finds that ideas of "good" and "bad" patients are at play in medical education and that these ideas are embedded in class differences. In this article, we explore how these "classifying practices" of value assignment shape palliative communicative encounters between professionals and end-of-life patients. Howarth (2007) and Conway (2013) criticise the sociology of death for not including class, which could reveal how people of different socio-economic status relate differently to death. Despite increased interest in inequity in palliative care research, there are still remarkably few studies with this qualitative, sociocultural class perspective. Especially in the Nordic universalist welfare states with their redistributive aims, there has been little research into the influence of social class in healthcare and even less in relation to palliation and death. Although social differences are discreetly admitted, Denmark is rarely considered as having a marked class system, but is rather seen as one of the strongholds of the welfare state (Faber et al. 2012). However, despite comprehensive economic redistribution and universal welfare coverage, Denmark does have a range of the traditional class inequalities well known in the UK and the US (Caspersen 2021;Udesen et al. 2020). This makes Denmark a particularly strong case for an exploration of how classifying practices, through attribution of value, impact palliative encounters. --- Palliation via communication Healthcare increasingly involves communication (Pors 2014), with patient involvement as a key concept (Phillips and Scheffmann-Petersen 2020). Firstly, enhancing patients' ability to communicate is expected to increase equality (Aamann and Olesen 2020). Secondly, it is assumed that palliative care is improved through reflexive dialogue in which a "clear and open communication about death is encouraged" (Olson et al. 2020, n.p.), partly to facilitate collaborative planning aimed at achieving a "good death". McCreaddie states that end-of-life communication is considered entirely positive, a "moral imperative" (2011, p. 46). However, the requirement for patient-centred care may clash with the ideal of a clear, open and euphemism-free dialogue, because it implies respect for the preferences of patient and family: patients might wish to avoid open communication, prefer euphemisms, and understand a "good death" differently from professionals and perhaps even their relatives. These arguments, thus, indicate a problem of assuming that dying people want to articulate their suffering and to participate actively in planning their final days. --- Materials and methods In 2018, the public authorities in one of the five regions of Denmark expressed a desire to enhance palliative care. The aim of our research was to follow the spread and effects of a conversation tool. The tool was developed by the local health authorities in collaboration with professionals and patients with the purpose of facilitating palliative dialogues across hospitals and communities. The concept of "total pain" guided the tool, which focused on psychosocial challenges by asking patients questions like "How are you doing?", "Is there anything about the disease you would like to know?" "What gives you quality of life?" "What troubles you?" and "What do you hope the healthcare system and healthcare professionals can do for you?". The tool was formed as a small booklet with one question on each page and space to write notes below each question. Aamann and Dybbroe were hired to do an evaluative research project. This included two work packages: one focused on patients and their perspectives (2018)(2019) and the other on organisational frameworks and interprofessional cooperation (2019)(2020). The research was designed as a multisited ethnographic investigation (Marcus 1995) and the palliative conversation tool was followed at different sites. Following the understandings of reflexive ethnography (Davies 1999) and critical ethnography (Madison 2004), we were aware of observed practices as performance of cultures. Twelve patients were chosen by the professionals and followed by the researchers. The patients had various life-threatening diseases and were at different stages and ages. Fourteen palliative care clinicians and three GPs also participated. The majority of the palliative care clinicians had a bachelor's degree in nursing, were very experienced in the field and had had specialised training in palliation. As white, female, middle-class researchers it was easy to blend in to the field. We observed palliative conversations, and invited patients and professionals to share their stories, experiences and perspectives on these conversations. We, therefore, organised two focus groups with professionals, and a workshop with 16 professionals from different parts of the region. We also had discussions with the early palliative care board, representing patients, researchers and professionals. Finally, we regularly discussed our observations with patients, professionals and relatives. The actors involved were, thus, never objects of scrutiny, but active participants (Fetterman 2018). All participants gave their informed consent, both orally and through their active participation (see Thagaard (1998) and Tj<unk>rnh<unk>j-Thomsen and Hansen (2009) for the question of informed consent and ethical reflexivity). Participation was completely voluntary for both patients and professionals, and they were informed that they could withdraw from the project at any time. Field notes were written without personally identifiable information and with pseudonyms for names of places and people, as well as changes of gender, diagnosis, etc., where this was considered irrelevant to the study. The data consisted of over 317 pages of transcribed interviews, informal everyday conversations and field notes. After the fieldwork had ended, the data were analysed using a dialogical communicative approach (Olesen et al. 2018). We noted differences and their relation to sites and contexts, which produced the research theme of "inequity in palliative care communication practices". --- The cases We have selected two patients at opposite ends of the Danish class society, in terms of their different forms and amounts of capitals. This is interesting because the palliative care provided was identical and the same nurse initiated the palliative conversations. The two cases are chosen because they illuminate patterns identified in the whole data set. As noted by Flyvbjerg: Atypical or extreme cases often reveal more information because they activate more actors and more basic mechanisms in the situation studied. In addition... it is often more important to clarify the deeper causes behind a given problem and its consequences than to describe the symptoms of the problem and how frequently they occur. Random samples emphasizing representativeness will seldom be able to produce this kind of insight; it is more appropriate to select some few cases chosen for their validity. (Flyvbjerg 2006, p. 229) The cases work like a magnifying glass for differentiation practices occurring more widely across the data. Both patients are male; they have different, fatal lung diseases. Patient 1, the privileged patient, is approximately 80 years old. He has not yet been declared terminal when Aamann meets him. The disadvantaged patient, Patient 2, is about 70 years old. He has recently been declared terminal. This life expectancy is representative of social inequality in health in Denmark. Life expectancy for men with little education is seven years shorter than for well-educated men (Udesen et al. 2020). The men live under the same local authority. Patient 1 lives in a busy town, while Patient 2 lives in a small village at some distance from main roads, which is a common difference between wealthy and poor Danes (Andersen et al. 2021). A few days before the conversation, the men received the small booklet. They were asked to prepare for the conversations by reflecting on the questions and noting down the main points. --- Case 1: praising the successful and active agers The palliative care nurse explained to Aamann, before the care visit: he is well-off. The nurse has helped Patient 1 decide whether to set up a fund, as there are no inheritors. The amount is around 55 million Danish kroner. 1Patient 1 lives in a new two-floor flat near the town's lively shopping and pedestrian street. There is a door phone and a wide, comfortable staircase, with a large roof terrace between the floors with lush lavender in flower pots and neatly arranged wicker garden furniture. Patient 1 and his younger friend greet us in the hall and show us into the first living room. We see two sofa sets and many oriental, antique figurines, vases and lamps, clearly expensive collectibles. At the other end of the room is a large, private roof terrace with panoramic views of the marina. Patient 1 has not written anything in the booklet, he says casually, but they have talked about it, Patient 1 and his friend assure us. "That's quite OK", says the nurse reassuringly, even though patients are supposed to write their answers on the dotted lines under each question. The conversation begins as the nurse asks: "How are you doing?" Patient 1 explains that his situation is stable; the disease has not changed recently. He can also see that "many of the people I went with [to fitness training], they HAVE gone". He mentions a 60-year-old who "has already gone". "But", says Patient 1, "they didn't do anything either. I have lots of things to keep me occupied: my cottage, my garage, etc". The conversation turns to important everyday things and life quality. Patient 1: "Well, I reckon it's all about shopping a bit, talking to people and driving around a bit, you know". Patient 1's friend: "And when you go and do things in your garage". He has recently bought the garage and "does some business with cars". Nurse: "And it's good exercise for your lungs, getting out and about". The nurse wonders whether Patient 1 ever has bad days. Yes, but then he just lies on the sofa. She nods approvingly. Patient 1 does not have breathing problems when sitting down and otherwise, he says, it is a bit like exercise: "You get short of breath, then you just have to stop and catch your breath and then you continue a bit later". The nurse praises him: "That's the right attitude!" Now the nurse asks if there is anything about the disease Patient 1 would like to know. They talk about the future. Patient 1 is worried about the stairs and has been out looking at some accommodation for seniors: "Yes, of course I could buy a small flat, but that doesn't solve my problem of being with someone...". The nurse says: "We'll find a solution" and explains about care assessors. She also writes down her phone number: "You are always welcome to call me". Patient 1 suggests they stop talking, because the cleaning help is coming. The nurse asks if it is a private company, but they are from the council; he receives cleaning help one hour a week. The next question is about hope. Patient 1 hopes that he will continue to be able to drive his car, so he can get around. "Does he worry about anything", the nurse asks. "Nah!" he replies: "'Cause I'm not the type to complain about everything". The nurse asks: "How do you feel about our talk?" Patient 1 answers, reclining on the sofa: "Well, it was fine, I thought-to talk a bit about everything". Patient 1's argument that other participants in the rehabilitation group have already died because they did not "do anything" forms part of the active ageing discourse: death can be postponed through activity. Patient 1's own level of activity, thus, seems to confirm his value: because he is enterprising, he succeeds in keeping the disease at bay and appears as a "valuable" self who takes responsibility for his own health. Interestingly, however, Patient 1's activities are not primarily physical exercise: he drives around, talks to people, visits his cottage and conducts some car business in his new garage. Yet the nurse believes it helps his lungs. By linking Patient 1's social activities to keeping his lung disease in check, the nurse helps Patient 1 to understand himself as someone who takes responsibility for his own health and who actively fights the progression of the disease. Although Patient 1 has not prepared properly for the meeting by writing in the booklet and sometimes just "lies on the sofa", he is met with respect and recognition from the nurse. Patient 1 is, thus, continuously supported by the nurse's approving remarks. She also places him and herself in the same boat by establishing a "we" and by giving him her direct phone number. The appreciative nature of the conversation seems to draw on precisely the discourses of active ageing. The conversation supports Patient 1 and for him, old age is apparently, as it is promoted, "the longest holiday of your life" (Gilleard and Higgs 2011, p. 137). This conversation is about (confirming and supporting) Patient 1's quality of life and it is, thus, an example of comforting and caring palliative communication. Let us now turn to the second case: --- Case 2: misrecognition of disadvantaged agers Patient 2 is a retired manual worker; besides his lung disease, he also has a pacemaker. His wife works in a factory and is, therefore, often away from home. They live in a small village without shops. Many houses are dilapidated with scruffy facades. They live in one of the older houses, opposite an abandoned factory with broken windows and a collapsing roof. In their garden are numerous rubbish bags and empty cigarette packets. In the hall is a large cat box with gravel around it, and various items scattered about on a small chest with no drawers. Aamann joined the nurse when she visited the family at their home in order to have a supportive talk with the wife of Patient 2. At the time of the palliative conversation with Patient 2, he is not at home, but has a two-week stay at the care facility where the nurse works. The nurse introduces Patient 2 on the way to his room by saying: "There are some problems with compliance". He continues to smoke and refuses to exercise: "He only talks about it but doesn't do anything about it". He has come to the facility to exercise, but he "doesn't want to get out of bed". But Patient 2 is also there to give his wife some respite, the nurse explains. "Recently there was a conflict, he couldn't move from his bed to the car, he thought he couldn't get into a wheelchair, but with a little pressure he managed it", the nurse explains. We enter Patient 2's room. It exudes institution with worn furniture, a neutral poster on the wall, practical cold lighting from tubes in the ceiling. There is a loud TV and a small bedside table full of boxes of medicine, bottles of pills, juice, a radio, a thermos flask, coffee cup and sugar lumps. He is lying in bed smoking an e-cigarette. Patient 2 says the booklet is on the table. The nurse searches there in piles of newspapers, while Patient 2 assures her that he and his wife "have done as they were told": last night they went through the booklet and his wife has written in it. "But maybe she took the booklet home with her", says the nurse, "let's use my booklet instead". The nurse starts the conversation by asking Patient 2: "How are you doing"? Patient 2 does not seem happy with the place he is in. He says: "it is worst in the morning. They come with so many things and activities, it gets too much", and then he gets short of breath and panics. He also tells me: "One day I had stool and she wouldn't change my pad unless I could get up myself. And I couldn't. And then she left". When his wife came later, she got very angry: "She could see the mess in my bum", he says. The nurse rounds off the topic by saying: "That doesn't sound reasonable. You had a need, which was met by a demand that you couldn't fulfil". The conversation turns to important everyday things and life quality. Patient 2 is happy that his wife gets a little respite. She has bad arthritis and is burdened by caring for her ill husband and by her physically exhausting work. The nurse explains about the difference between the diseases: "The lung disease is something you will die from, while the arthritis is very painful but not life-threatening". She continues: "You know it's a progressive disease where you get worse and worse? Have you thought about deactivating the pump function when it's really bad?" Patient 2 replies quickly and breathlessly: "No and I don't think we should talk about it either, because then I'll just lie here thinking about it! But... I've got some leaflets at home I could look at". Now the nurse asks if there is anything else about the disease Patient 2 would like to know. He cannot remember. Nurse: "Is it perhaps difficult to describe it with words? Have you tried to write the thoughts down?" Patient 2 says his eyes are getting worse and that he cannot really read or write any more. Nurse: "Have you been to an optician like I have suggested earlier?" "No...", Patient 2 sighs heavily: "'cause we cannot really afford new glasses and I can't apply for financial support, cause I don't know how to fill out the forms online". He has asked the staff at the care facility, but they are busy and the same goes for the cleaning help at home -they come for one hour every three weeks and they move on quickly. The nurse offers to help him to apply. He seems grateful. "Do you worry about anything?" the nurse asks. "Yes, 'cause they don't come when I call them. They just say, 'Someone else is in a worse state than you'." When the nurse asks Patient 2 what he hopes for, he replies: "That the staff ask me how I am. And maybe chat a bit. Patient 2 is clearly having difficulty in living up to the implicit norms of active ageing and exercising. He lies passively in bed watching television or listening to the radio while smoking. He also gets stressed when the nurses show up in the morning with a lot of activities. In relation to the focus on people's will and ability to "take on responsibility", Patient 2 does not perform legitimately. He is not a "successful ager" as he does not exercise or show any desire or ability to conform to "active ageing" or a "healthy lifestyle". It is interesting that the nurse says to Aamann that Patient 2 does not "want" to get up and "only talks about it", suggesting laziness and lack of willpower and selfdiscipline, or even disobedience. By contrast, Patient 2 himself says he cannot get up. The comment about the refusal to change Patient 2's pad is intended to show that the nurse acknowledges Patient 2's situation, but it is also a value judgement on his performance and his situation: it does not state that the demand was "unreasonable", merely that Patient 2 "was unable" to fulfil it, which, thus, makes him appear indirectly responsible. Patient 2 clearly prefers to live his final days without considering how and when death might occur. He does not want to talk about it, although he mentions some leaflets, perhaps to appear obliging instead of rejecting the nurse's suggestion. This theme appears in the conversation at a time when the talk was supposed to be about important everyday things and life quality. Although the palliative care here works as a form of "social palliation" for Patient 2, as he gets to complain about his problems and is partly supported by the nurse, it is nevertheless remarkable that the main "relief" for Patient 2 is to talk about the disrespectful way he is treated by healthcare workers. --- Results: different lives and different palliative encounters The professionals' attitude and the patients' approaches to the conversation It is striking how the two patients have prepared differently and how the professional attunes differently. Patient 1 and his friend have written down nothing and the overall impression is that Patient 1 has made little effort to prepare for the conversation and has a rather nonchalant approach to it. But the nurse does not consider this to be disqualifying. In contrast, Patient 2 eagerly explains that he and his wife have "done as they were told": they "went through the booklet" and his wife has "written in it". He, thus, seems quite obedient and responsible. Unlike with Patient 1, however, the nurse does not say it is "quite OK", when it turns out the booklet has gone missing. The difference in the two men's approaches to the conversation demonstrates their economically unequal positions: while Patient 2 is greatly dependent on free access to care and financial support, Patient 1 has the money to buy services he does not receive or is dissatisfied with. The implications of this are that Patient 1 holds an attitude of carefree superiority; he does not need to prepare properly, because he does not need to fear sanctions. By contrast, Patient 2 is very dependent on care and benefits, and seems to feel that he must cooperate and obey orders like writing "answers" in the booklet. It is even more striking that the nurse introduces the patients to Aamann in quite different terms. Patient 1 is not described as problematic, although he seems less compliant than Patient 2, who is presented as having "problems with compliance" despite his eagerness to cooperate. The nurse also says that Patient 2 "only talks about" doing things, whereas it was quite acceptable for Patient 1 to lie on the sofa. We also see that the nurse trusts Patient 1 much more than Patient 2: she expresses full confidence in Patient 1's ability to make the "right" choices, such as lying on the sofa on certain days. Conversely, there is doubt about Patient 2's ability to assess his own activity level. According to Sointu (2017), clinicians' perceptions of patients draw from a repertoire of social stereotypes. For example, "good" patients are seen as active participants who are involved and motivated to "learn about their disease and take charge of it" (ibid., p. 68). In contrast, "bad" patients refuse "the responsibilities of the'sick role'" (ibid., p. 69); they resist doctors' recommendations and make bad choices. They neither take an active part in their healthcare nor do they communicate well (p. 70). These norms are present in our study, where it seems that the nurse considers Patient 1 a "good" patient and Patient 2 a "bad" patient. --- Talking about death Patient 2 receives a challenging question about turning off the pacemaker and the oxygen. It is worth noticing that the question is not in the booklet and that Patient 1 is not asked explicitly about his forthcoming death. This may be because Patient 2 is closer to death, but nevertheless it is thought-provoking that the question is posed in relation to important everyday things and life quality, where the nurse elaborates on the differences between the illnesses that Patient 2 and his wife are dealing with. This leaves an impression of a lack of compassion towards him. Patient 2 is, however, clearly reluctant to talk about death. Instead of reflecting on his wishes and worries, he becomes short of breath and states that he would rather not speculate on it. Institutionalised terms such as "involvement" and "dialogue" very often presuppose a reflexive self, which is a class-based and, thus, unevenly distributed resource (typically acquired through education) (Skeggs et al. 2008;Aamann 2017;Sointu 2017). Howarth (2007, p. 425) discusses the problem of the need to participate actively in communication about one's death, because the main interest in this seems to come from better-off middle-class people. She argues that a form of stoic calm characterises working-class culture, which conflicts with the implicit perception that all end-oflife patients and their families need to articulate their suffering using the correct, selfreflexive terminology. The problem is, thus that because the conversation indirectly requires the desire and ability to reflect upon and talk about death, Patient 2 is perceived as someone who may suffer from "poor illness insight"/have compliance problems. However, a conversation between a healthy professional at work and an ill person in a low position in society with a loss of previous social identity is asymmetrical per se, which can make equity difficult regardless of the professional's intention (Miczo 2003). Furthermore, Patient 2's fear of death might be an obstacle to professional procedures, because it may prevent identification and documentation of his "final wishes". --- Different classes-different access to active ageing The distinctions between good and bad patients are closely related to class inequality (Sointu 2017) and there are, thus, many people who are unable to be a "good" patient, performing a health-entrepreneurial, valuable self. As Liveng (2016) argues: "When desirable old age is unambiguously presented as 'active', this conceals the fact that older people's possibilities to live up to its normative ideals are unevenly distributed" (p. 148; author's translation). According to Dumas and Laberge, "class dispositions towards physical activity manifest themselves during ageing" (Dumas and Laberge 2005, p. 186). They also note: "different classes enter ageing with different habitus. The working classes, for example, may be more disposed than the middle or upper classes to accept bodily decline as inevitable rather than to seek improvement in their bodies" (Dumas and Laberge 2005, p. 188). In this perspective, Patient 2 may have an understanding of body and self that conflicts with the normative ideals, as he might have accepted the weakening of his body and, thus, finds it pointless to exercise. Further, he becomes confused and anxious when the staff come to his room with a range of activities. The same applies to Patient 1, at the opposite extreme: his habitus fits into the dominant narrative of being active and keeping the disease in check. The two men's previous work and life conditions are a point to consider here: Patient 1 was a businessman, while Patient 2 did hard manual work. Further, there is a marked difference in their financial basis for enterprise and optimisation. Patient 1 buys a garage for fun, while Patient 2 cannot afford reading glasses. It is striking that the nurse seems unaware of these differences in terms of class. Arguably, instead of compensating for inequality, she is reproducing it by attributing different symbolic and moral value to the "good" and the "bad" patient. This can be attributed to neoliberal individualisation in which class inequalities are typically neglected and disadvantage is understood as a result of psychological deficits and moral deficiencies (Reay 2005). Patient 1's driving around and chatting with people is valued as rehabilitation by the nurse. There may be good reason for this: Macdonald, whose field is dementia, points out that relationships are a vital aspect of dementia care, because "to live is to be held in connection" (Macdonald 2018, p. 290). This obviously works for Patient 1, who is free to choose what he wants to do. He is also a busy man, rounding off the conversation because the cleaning is coming. He expresses a kind of moral superiority when he emphasises that he is not the type to complain about everything -subtly distinguishing himself from people who do complain. For Patient 1, it is quite natural to "keep going": his life is pleasant, with interesting hobbies, socialising and financial freedom. Conversely, Patient 2 is bedridden and has poor finances. Yet he expresses a strong desire to "be held in connection": his greatest hope is that the staff: "would just ask how I am. And maybe chat a bit". In contrast to Patient 1, however, Patient 2 finds that no one shows interest in him; they do not come when he calls. Sointu noted: "Even when, formally, all patients receive the same care, informally, medical students observe good patients being afforded time, care and appreciation that bad patients are thought not to deserve or want" (2017, p. 71). In line with this, Patient 1 is offered help if he decides on publicly funded senior housing instead of buying a flat himself, although he would probably be able to manage by himself. Meanwhile, Patient 2 seems to be perceived as "undeserving" as he is judged as a "bad" and irresponsible patient; he needs welfare payments and does not make an active effort to keep going, but is then sanctioned. Inequity in palliative care: class and active ageing when dying --- Discussion We have seen how the discourse of active ageing generates class-based

The purpose of this article is to explore social inequity in palliative care in Denmark, a country that is seen as a stronghold of universal health care. Using data stemming from 2 years of research, we have selected two cases for analysis. They consist of palliative conversations with two quite different patients. Drawing on sociocultural class theory, we find that the conversations involve social exclusion processes due to discourses of active ageing. We find that one privileged patient performs in line with an entrepreneurial self and is supported by the nurse. The other, disadvantaged patient performs in a passive way, and the conversation mainly alleviates the disrespect he has experienced in healthcare encounters. We conclude that palliative care reinforces classifying practices and distinctions between "good" and "bad" patients, when active ageing becomes a dominant factor. We suggest improving the quality and sensitivity of medical training and call for increased reflexivity among professionals on the unequal situation of patients in order to reduce inequity in access to health care when close to death.In this article we investigate how palliative care is affected by discourses of active ageing. We analyse palliative care conversations and our specific interest lies in how social differentiation is embedded in discourses of active ageing which imply a middle-class ideal of a self-entrepreneurial subject. All citizens in Denmark are entitled to free public healthcare. Elderly and palliative care is also a public responsibility, although private services co-exist. Although

a strong desire to "be held in connection": his greatest hope is that the staff: "would just ask how I am. And maybe chat a bit". In contrast to Patient 1, however, Patient 2 finds that no one shows interest in him; they do not come when he calls. Sointu noted: "Even when, formally, all patients receive the same care, informally, medical students observe good patients being afforded time, care and appreciation that bad patients are thought not to deserve or want" (2017, p. 71). In line with this, Patient 1 is offered help if he decides on publicly funded senior housing instead of buying a flat himself, although he would probably be able to manage by himself. Meanwhile, Patient 2 seems to be perceived as "undeserving" as he is judged as a "bad" and irresponsible patient; he needs welfare payments and does not make an active effort to keep going, but is then sanctioned. Inequity in palliative care: class and active ageing when dying --- Discussion We have seen how the discourse of active ageing generates class-based distinctions between "good" and "bad" patients. We have shown how the ideal of old age intrudes into the healthcare system and thereby influences the handling of ageing and death, illustrating how active ageing permeates palliative care to create normative expectations with demands that many end-of-life patients might be unable to meet. In line with Sointus' point about how clinicians' perceptions of patients draw from a repertoire of social stereotypes, a further important point is that healthcare professionals in Denmark also belong to the broad middle classes (Pedersen and Caspersen 2020, p. 8). Previous studies of Danish prevention policy show that clinicians' work is largely coloured by the professionals' personal tastes and preferences, based on their class (Harrits and M<unk>ller 2016;Aamann and Dybbroe 2018). Furthermore, nurses are also subject to the neoliberal discourses of value accumulation by taking on the role of health entrepreneurs to enhance symbolic value. Since class is increasingly configured through the symbolic value of the self, it can be almost impossible not to adhere to the distinction between legitimate and illegitimate end-of-life patients. This hegemonic middle-class consciousness blocks awareness of class differences in the ability to comply with the norms of ageing. This study has several limitations due to its methodological choices: it is a small study and, thus, not representative of Denmark as a whole, although it does include data from both a rural and an urban area. Furthermore, the patients were not subsequently interviewed about their palliative care experiences, and the professionals were not interviewed with a focus on class. There are several reasons for this: the perspectives presented in this article were only systematically analysed after the project had ended. Further, class is often perceived as illegitimate since it raises questions about moral worth. In qualitative interviews, therefore, informants are often evasive when class is mentioned explicitly (Aamann 2017;Popay et al. 2003). Skeggs argues that to speak about class is different from living it; people seldom consider themselves or their practices in terms of class. Unlike gender and ethnicity, which are often explicitly referred to, class works as a "structuring absence" (Skeggs 1997, p. 74). It is, thus, debatable whether interviewing the patients or the professionals would have further illuminated the processes explored here. However, interviewing healthcare professionals about social inequality might have clarified how the discourses, the culture and the institutional framework encourage them to adopt middle-class positions and praise active ageing in palliative care conversations. --- Conclusion In this article we have explored how discourses of active ageing establish new distinctions between "successful" and "irresponsible" agers and how this aligns with class as conceptualised by Bourdieu and Skeggs. We have shown how classifying practices of value attribution shape palliative encounters. We have analysed two cases and revealed how the quality of palliative care varies even when the service provided is identical; privileged Patient 1 is supported through acknowledgements and is, thus, approached as a subject of value, i.e. a "good" patient, while disadvantaged Patient 2 is met with a form of indulgent patience and dignity violations, since he is a "bad" patient. It is particularly interesting that class is reinforced in palliative care in a universal welfare state with equal rights to publicly funded healthcare. It is notable that Patient 1, who is supported by his wealth, is assumed to need help and receives it, while Patient 2, who needs greater social, financial and health-related support, is allocated a lower level of service. We can, thus, conclude that palliative care is unequally distributed along class lines, and appears to be yet another good for well-situated privileged patients, who already reap the most benefits from healthcare in the Nordic welfare states. If social class plays no part in our understanding of differences in health professionals' ways of interacting with ageing and dying people, there is a significant risk of reproducing such socially differentiated practices. Several quantitative studies have described this differentiation, but without explaining why and how it takes place. In this qualitative study, our particular aim was to understand how the notion of active ageing becomes a horizon for palliative care which obscures an understanding of the importance of social class in palliative practices. The analysis, therefore, reveals how inequality in palliative care takes place, unnoticed by healthcare systems, professionals and quantitative research. Unequal health is not mainly created in the healthcare system, as it is a consequence of inequality in society. But in order to achieve equity, it is crucial to address the socially unequal situation of patients. We, therefore, suggest improving the quality and sensitivity of medical training. This could help mitigate some of the negative effects of class highlighted in this article, such as the reliance on stereotypes when providing patient care. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The purpose of this article is to explore social inequity in palliative care in Denmark, a country that is seen as a stronghold of universal health care. Using data stemming from 2 years of research, we have selected two cases for analysis. They consist of palliative conversations with two quite different patients. Drawing on sociocultural class theory, we find that the conversations involve social exclusion processes due to discourses of active ageing. We find that one privileged patient performs in line with an entrepreneurial self and is supported by the nurse. The other, disadvantaged patient performs in a passive way, and the conversation mainly alleviates the disrespect he has experienced in healthcare encounters. We conclude that palliative care reinforces classifying practices and distinctions between "good" and "bad" patients, when active ageing becomes a dominant factor. We suggest improving the quality and sensitivity of medical training and call for increased reflexivity among professionals on the unequal situation of patients in order to reduce inequity in access to health care when close to death.In this article we investigate how palliative care is affected by discourses of active ageing. We analyse palliative care conversations and our specific interest lies in how social differentiation is embedded in discourses of active ageing which imply a middle-class ideal of a self-entrepreneurial subject. All citizens in Denmark are entitled to free public healthcare. Elderly and palliative care is also a public responsibility, although private services co-exist. Although

Introduction The use of simulation devices in medical education is centuries old and includes anatomical models in the teaching of anatomy, threshold innovations such as <unk>smund Laerdal's Resusci Anne, modern high-fidelity manikins, simulated patients and virtual reality [1]. Simulation is defined as follows: A technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions [2]. Examining the features and use of simulation technology, the Best Evidence Medical Education (BEME) review of the literature from 1969 to 2003 [3], the authors concluded that the quality of published research for this period was generally weak. However, the available evidence suggested that high-fidelity simulations facilitate learning under the right conditions. A follow-up review of the literature from 2003 to 2009, using combined critical and realist review methodology, identified 12 features of best practice for simulation-based education (SBE) and concluded that simulation technology can produce substantial educational benefits [4]. Revisiting this review in 2016, McGaghie et al. [5] found that the evidence supporting SBE as a powerful educational intervention was growing. In England, the Chief Medical Officer's report for 2008 'Safer Medical Practice: Machines, manikins and Polo Mints' states that, 'Simulation offers an important route to safer care for patients' and does so by improving performance, reducing errors and strengthening team work. The report recommends that simulation 'needs to be more fully integrated into the health service' [6]. This theme was further developed by Khan et al. [7] who built an argument for increasing expansion of SBE driven by patient safety and improvements in healthcare. They concluded that the continuing advances in simulation technology and an in-depth understanding of educational principles and practical applications of SBE to outcome-based programmes will help bridge the gap between the classroom and clinical environment. This application of theoretical knowledge to the practical management of patients (the theory-practice gap) and the transition from student to doctor are key areas of interest in SBE research [8]. Reviewing the evidence for simulation to help bridge the perceived educational gap in students' training and resolve the disconnect between classroom and clinical environment, Okuda et al. [9] found multiple studies that demonstrated the effectiveness of simulation in the teaching of basic science and clinical knowledge, procedural skills, teamwork and communication but only a few studies showing direct improvement in clinical outcomes. In summarising the outcomes of technology-enhanced simulation training for health profession learners, Cook et al. [10] found that compared to no intervention, technology-enhanced simulation is associated with large positive effects for knowledge, skills and behaviours and moderate effects for patient-related outcomes. Reviewing the literature, Bell et al. [11] found a mixed picture as to the effectiveness of simulations as training tools and called for more theory-driven research focussed on the instructional capabilities of the technologies used in simulation. Echoing this call for more theory-driven research, Sevdalis [12] stressed the need for simulation studies to move away from presenting self-report data from small numbers of attendees to those that present a deeper theoretical and practical understanding of effective SBE. More recently, in the editorial marking the launch of Advances in Simulation, Nestel [13] reinforced the value of studies that deepen our understanding of SBE interventions and stated that '(when studying) more complex uses of simulation technologies, researchers have a responsibility to thoughtfully align research paradigms with hypotheses and research questions.' This call for more theory-driven research is not confined to SBE. Cook et al. [14] proposed a framework to classify the purpose of educational research studies in four leading educational journals. The framework classified studies into one of three categories: description, justification and clarification. Their results showed that only 12% of reported articles could be classed as clarification studies with description at 16% and justification at 72%. Applying this framework to over 1300 abstracts from four major SBE conferences over 2 years (2014 and 2015), Graham et al. [15] found that only 9.3% of abstracts could be classified as clarification studies (description 54.4% and justification 36.3%). There are a multitude of evaluation instruments and methods for the SBE researcher to choose from. In reviewing the published evaluation instruments for human patient simulation within nursing education, Kardong-Edgren et al. [16] found a lack of reliable and valid instruments to evaluate learning outcomes. They suggested a moratorium on 'the indiscriminate development of new evaluation tools' which focusses on self-reported satisfaction and confidence which could lead to the development of 'a mile-wide and inch-deep evaluation landscape'. They recommend the use of multiple instruments to evaluate a simulation in order to capture all the learning domains and to explore how actions in the simulations carry over into the clinical arena. However, the evaluation instruments reviewed did not address the issue of how or why the interventions being studied achieved their outcomes. Whether an intervention is successful or not was highlighted by Ogrinc and Batalden [17] who argued that traditional study designs such as randomised controlled trials, nonrandomised and prospective cohort studies while useful, depending on the focus of the evaluation, fell short in a key component, namely being able to identify the depth of contextual information that is helpful when replicating the findings in another setting. One such study design is the Context, Input, Process and Product evaluation (CIPP) model [18] which seeks to answer four kinds of questions. These are 'What should we do?', 'How should we do it?','Are we doing it correctly?' and 'Did it work?' However, it does not specifically address the questions 'How and Why the intervention worked?'; the answers to which are required to provide a deeper theoretical and practical understanding of effective SBE [12,13]. One evaluation methodology that explores both the context and underlying mechanisms of how and why a programme works (or not) is realist (realistic) evaluation [19]. --- Realist evaluation Realism is a philosophy which positions itself between positivism and constructivism. Positivism describes reality as fixed and our knowledge of that reality, which is neutral/value free, can be described by theories that are objective and generalizable. Positivist research aims to discover what exists through prediction and control using mainly quantitative methods with the researcher being an independent observer [20]. Conversely, constructivism views reality and knowledge of that reality as not fixed but socially constructed and this knowledge has both multiple constructions and values. Constructivist researchers are active participants in the research and use both quantitative and qualitative methods [21]. The realist view of knowledge is that there is a real world, and through our senses, brains and culture, we process our knowledge of it [22]. In relating this to the clinical environment, there is a real world of patients, signs and symptoms (positivism) and these are open to a variety of interpretations which depend on the complex interaction of external influences on the clinician (constructivism). Realist evaluation seeks to answer the question 'What works for whom, in what circumstances and why?' [23]. In answering this question, the realist researcher seeks to identify, test and refine the components of an educational programme that work as well as those that do not. The three fundamental components that realist evaluation seeks to investigate are context, mechanism and outcome. In other words, educational programmes work (successful outcome) when they provide appropriate opportunities or resources (mechanisms) to groups under appropriate conditions (context). This is known as the 'context-mechanism-outcome (CMO) configuration' [19] and can be written as the formula context + mechanism = outcome. There is no set limit on the number of proposed CMO configurations that are constructed for the educational programme under investigation; the key element is the relationship within each CMO [17]. The researcher gathers data in order to test the proposed CMO configurations. Simulation is a complex educational intervention with multiple interacting components which can make it challenging to evaluate. However, realist evaluation may provide more useful information about its effectiveness than traditional models of education evaluation [24]. So how might a realist evaluation of an SBE programme be designed? The guiding framework is the realist evaluation cycle which has four key steps [19]. Step 1. Formulate a working theory. One of the key areas of interest within SBE is the impact of medical school simulation-based learning on newly qualified doctors' performance [8]. Exploring this example, the working theory would be 'A one-day simulation-based course would enhance the transition from final year medical student to newly qualified doctor'. Step 2. Hypothesis. Formulate the hypothetical CMO configurations, i.e. what might work for whom in what circumstances and why? Table 1 presents an example of the proposed CMO configurations for the SBE course aimed at final year medical students. Step 3. Observations. Test the theory by gathering data on the CMO configurations using a mixed methods approach (quantitative and qualitative data collection and analysis). The researcher is not limited to a particular method but can choose whichever approach to collecting and analysing the data that suits the intervention under study. Step 4. Programme specification. Reveals what did work for whom in what circumstances and why. This provides a refined theory which will inform future interventions and programme evaluations. The process then continues in an iterative cycle. --- Context The context reflects the reality into which an intervention is introduced and provides the conditions (Table 1) that trigger the mechanisms to produce the desired outcomes [19] and requires that all elements that are relevant to the mechanisms be considered [17]. Just as all social programmes are introduced into pre-existing social contexts, so SBE programmes are introduced into pre-existing healthcare and or educational contexts. Therefore, researchers should not ignore the contexts of M1. Providing the opportunity to experience and explore the role of a newly qualified doctor in a simulated setting. O1. To foster an understanding of the role of a newly qualified doctor. C2. Final year medical students who have extensive knowledge and clinical experience but have not had the responsibility of managing the acutely unwell patient. M2. Presenting a variety of realistic simulated medical and surgical emergencies using a high-fidelity manikin. O2. To assess and manage the acutely unwell patient using a structured approach. C3. The majority of students have observed the management of a cardiac arrest. M3. Allowing the students to manage (as a team) a simulated cardiac arrest. O3. To increase understanding of team work and communication. C4. Before commencing as newly qualified doctors the students undertake a 6-week assistantship. M4. Exploring the role of the newly qualified doctor and setting goals for assistantship. O4. To identify and set goals for assistantship. C5. The students have varying levels of confidence. M5. Providing immediate feedback and exploring the factors that influence when and why the students call for assistance. O5. To recognise personal limitations and when to call for help. their programmes and to do so is regarded by Pawson and Tilley as one of the 'great omissions of evaluation research' [19]. In their critical review of simulation-based research: 2003-2009, McGaghie et al. [4] highlighted 12 features and best practice of SBE that teachers should know in order to use simulation technology to maximise educational benefit. A number of these related to context and included how the intervention integrated into the wider medical curriculum and its outcomes, simulation fidelity, instructor training and the educational and professional context within which the interventions occurred. However, they cautioned that the introduction of a complex service intervention, such as SBE, into medical education environments would not be easy and with time may re-shape the goals and practices of those same educational programmes, thus changing the original context [4]. Acknowledging the importance of context and prompted by the recognition that SBE has several unique features including a wide variety of simulation modalities and instructional design, Cheng et al. [25] called for those reporting simulation-based research to provide more detailed descriptions of the context within which their interventions occurred. The key elements to report are participant orientation, simulator type, simulator environment, simulation event/scenario, instructional design or exposure and method of feedback/debriefing. While some of these contextual elements are easily described and can, to a limited degree, be standardised for research purposes, e.g. fidelity of simulator and scenario design [26] others are not. In our experience, these elements usually relate to the students and how they construct their own version of the 'contextual reality' as they interact with the faculty, each other and the environment [27]. This interplay between individuals and the educational programme means that the causal mechanisms are located in the social relations and context as well as the individuals [28]. Drawing on the experience of a realist evaluation of a simulation-based course for final year medical students (unpublished) conducted as part of a higher degree (ACG) examples of contextual elements that can affect learning and may not be easily identified through other evaluation approaches includes students who have significant anxieties about SBE, those delegates 'forced' to attend by their line managers, inadequate orientation to the simulated environment, instructor training and experience and the timing of the course in relation to other significant events, e.g. final examinations. --- Mechanism Explanatory mechanisms are the central tenet of realist evaluation and comprise the processes/resources and responses (reasoning) of stakeholders to those processes/ resources, operating in a given context, that generate the outcomes of a programme [19]. Mechanisms can be 'visible' and form part of the design of an evaluation or 'invisible' and only come to light during the evaluation process [23]. Mechanisms are said to fire or be triggered in a given context to create an outcome. Pawson and Tilley explain this using the gunpowder analogy [19] in which the chemical composition of the gunpowder is the mechanism that creates an explosion (outcome) when a spark is applied. However, if the conditions (context) are not favourable, e.g. damp gunpowder or no oxygen present, then there is no explosion. This 'on/off' response has been challenged by Dalkin et al. [29] who argue that activation of a mechanism operates on a continuum similar to a light dimmer switch. They believe that this has more explanatory value in understanding how interventions work leading to a graduated response of outcomes and fits with our experience where learning outcomes do not usually operate on a met/not met basis, e.g. unskilled/completely skilled or no confidence/complete confidence. In helping to clarify the concept of mechanism, Astbury and Leeuw [30] highlight what mechanisms are not. Firstly, evaluators should make a clear distinction between mechanism and programme activity. For example, it is not an SBE intervention in and of itself that generates the outcomes but the knowledge gained or the increase in confidence of the participants. Secondly, mechanisms should not be considered as independent causal variables; rather, they attempt to explain why variables are related. That is, how did the SBE intervention cause an increase in participant confidence and how did this generate the observed outcomes. Another challenge for the realist evaluator is to distinguish between context and mechanism. To help differentiate between the two, Dalkin et al. [29] proposed an alternative operationalization of Pawson and Tilley's formula, context + mechanism = outcome [19], which explicitly disaggregates mechanism into its component parts; the resources offered and the changes in reasoning of the participants. The new formula is written as M (resources) + context <unk> M (reasoning) = outcome and provides both an operational and conceptual clarification of mechanism [29]. For example, Cheng et al. [25] list'simulator type' as a contextual element; however, applying the revised formula what was previously considered contextual becomes part of the mechanism. Simulators vary in type and level of 'fidelity' and their effective use depends on matching the educational goals to the simulation tools used and taking into account the level of expertise of the participants [4]. As a result, the'simulator type' becomes the M (resource), the participants' level of expertise is the context, how the participants interact with and learn from the simulator is M (reasoning) and the outcome is the measurable change in the participants' skill and/or knowledge. When considering the concept of mechanism (resources and reasoning), educators should be cognisant of the educational theories/conceptual frameworks that underpin the resources they offer as well as the change in reasoning that may occur as a result and should declare these in their evaluations. So what are some of the educational theories/conceptual frameworks that underpin SBE? In their realist review, McGaghie et al. [4] identified the following: feedback, deliberate practice, mastery learning, team training and high-stake testing (can also be considered an outcome) while Ker and Bradley [31] highlighted social constructivism, experiential learning, reflective learning and activity theory. More recently, Graham et al. [15] reported the ten most commonly declared educational theories/conceptual frameworks in abstracts from simulation conferences. These were, in descending order, cognitive theories, experiential learning, gaming theories, learning styles, deliberate practice, inter-professional learning, mastery learning, realism, self-regulated learning and the flipped classroom. Table 1 shows the proposed mechanisms for the simulation-based course for final year medical students. Using mechanisms M2 and M4 as examples, we can explore the M (resource), M (reasoning) and educational theory for each. M2. The M (resource) is the high-fidelity manikin chosen because the students have extensive clinical experience (context) and so expect to elicit realistic signs and symptoms from the manikin as well as have it react in real time during the scenario. The M (reasoning) is the students recognising the value of a structured approach to managing the acutely unwell patient while putting theory into practice. The underlying conceptual framework is activity theory which states that learning, knowledge and activity are intrinsically linked and there is a relationship between one activity system and another, in this case, the simulated and the clinical environments [31]. It also stresses the concept of contradiction and tension in learning [32] which in this example is between the students' theoretical knowledge of how to manage the acutely unwell patient and their practical ability to do so. The desired outcome is the students become more proficient in using a structured approach when assessing and managing the acutely unwell patient. M4. The M (resource) is giving the students the opportunity to manage the scenarios as if they were the newly qualified doctor on the ward, and the context is the impending 6 week assistantship. The M (reasoning) is by allowing the students to explore the roles and responsibilities highlighted by the scenario, they would set personalised goals for the assistantship (outcome). The underlying conceptual framework is self-regulation theory which seeks to optimise learning and performance using goal-directed behaviour [33]. This list is not exhaustive, and each researcher should identify the key mechanisms they consider to be operating within their own SBE programme that are thought to produce the desired/measured outcomes. --- Outcome and data collection Outcomes of educational interventions can be expected (mastery of a skill), unexpected (collateral effects on the participants or their place of work), positive (an increase in knowledge) or negative (psychological harm from a poorly conducted debrief session). In addition, programme outcomes cannot just be viewed as undifferentiated wholes but rather as the complex outworking of multiple mechanism/context effects [19]. There are a number of approaches available when describing and evaluating the outcomes of educational programmes. Bloom's taxonomy [34] classifies the learning outcomes that educators set for their educational programme into three domains: cognitive, affective and psychomotor. Using this framework, the outcomes for the simulation-based course for the final year medical students (Table 1) are cognitive-to foster an understanding of the role of a newly qualified doctor and to increase understanding of team work and communication, affective-to recognise personal limitations and when to call for help and psychomotor-to assess and manage the acutely unwell patient using a structured approach and to identify and set goals for assistantship. Kirkpatrick's hierarchy [35] is one of the most widely applied approaches and describes the value and worth of training. It has four levels, with the evidence for higher levels being harder to collect: (level 1) reaction-how do the participants react favourably (or not) to the event, (level 2) learning-what knowledge, skills and attitudes do the participants acquire as a result of the event, (level 3) behaviour-to what degree do the participants apply what they have learned during the event and (level 4) results-what targeted outcomes occur as a result of the event at an organisational level, e.g. improved patient outcomes. Another approach is the use of translational science outcomes which has been highlighted as useful for SBE research [8,36,37]. There are four levels which are said to move from 'the bench to the bedside [8]'. These are (T1) educational effects achieved in educational laboratories, (T2) improved patient care practices, (T3) better patient outcomes and (T4) collateral educational effects. Realist evaluation uses a mixed methods approach to data collection [19] which involves the collection, analysis and interpretation of both quantitative and qualitative data in a single study [38]. This has been shown to be of benefit when studying complex interactions [39]. The triangulation of data from different sources allows for a richer and fuller explanation of the data [40], and the evaluation takes the form of an iterative explanation-building process [41]. This methodological diversity has been recognised as an important development within medical education [5]. The aim of the realist researcher is to understand the patterns of outcomes that result from the firing of different mechanisms in different contexts and the relationship between them [17]. Taking the evaluation of the simulation-based course for final year medical students as an example, a routine course evaluation questionnaire using a 5-point Likert scale [42] completed immediately after the course would provide Kirkpatrick level 1 data about the students' satisfaction with the course, the effectiveness of the debriefing, relevance to their work, length and timing of the course. Kirkpatrick level 2 and 3 data could be obtained from a follow-up questionnaire, with space for free text, sent out after the students complete their first rotation as newly qualified doctors that investigates what lessons had been learned from the course and whether these had been applied in their new role. Further qualitative data can be obtained from individual interviews or focus groups [40] which explore the proposed CMO configurations. That is, the effect of context, the proposed enabling mechanisms and the extent to which the outcomes had been achieved and if not, why not? Patient outcome and quality of care data are more challenging to collect requiring the researcher to identify or construct suitable databases that can be used to study the outcomes at an organisational level [8]. --- Discussion Using a methodology that clarifies why an intervention works (or not) by examining all of its component parts, context, mechanism and outcome, allows others to better interpret the results, deepens understanding and helps to advance SBE research [8,12,13]. In our unpublished evaluation, we discovered that although the students reported that the course had helped with the transition from student to newly qualified doctor, not all of the students were setting goals for their assistantship. The focus group data revealed that the timing of the course (context) before the final examinations meant that the students' priorities were the exams and not setting goals for the assistantship. Thus, the context prevented the mechanism (exploring the role of the newly qualified doctor and goal setting) from firing which adversely affected the desired outcome. Pawson, by his own admission, does not claim that realist evaluation is perfect and mentions a number of difficulties that arise when trying to apply realist principles [23]. These include the absence of an explanatory focus, using only one data collection method, failure to investigate the CMO configuration and the restrictive word counts imposed by some publications. From our own experience, the practical challenges included a poor response rate (26.3%) to the follow-up questionnaire, no one turning up to one of the arranged focus groups and too many turning up to another potentially inhibiting some of the quieter members of the group. So what has realist evaluation delivered so far in the field of healthcare? In their review of realist evaluations, Marchal et al. [28] found 18 papers describing realist evaluations across a variety of healthcare settings. They showed that the uptake of realist methodology has been slow; however, they argue that even a superficial application of realist evaluation has advantages as it explores the processes and context rather than just the intervention and its outcomes (did it work?). They admit that more clarity is needed concerning how the terms-context and mechanisms-are defined and call for more conceptual work to allow a greater understanding of these issues. Krupat [43] has called for research that is conceptual and thoughtful and identifies the mechanisms that mediate and moderate the relationship between action and outcome. Exploring and developing theories about mechanisms can add value to programme evaluation by revealing why a programme works which in turn can better inform the design and evaluation of future programmes [30]. Regehr has highlighted the need for health profession education research to re-orientate its alignment with the imperative of proof to one of understanding, and from the imperative of simplicity to one of representing complexity well [44]. Realist evaluation is a methodology that is able to address these issues by exploring all aspects of an intervention. There are challenges in performing realist evaluations, but we encourage the simulation community to adopt its principles and by doing so help clarify and define the contexts, mechanisms and outcomes that are unique to our'simulated version of reality' and help answer 'What works for whom in what circumstances and why?' [23]. --- Availability of data and materials Not applicable. --- Abbreviations BEME: Best Evidence Medical Education; CIPP: Context, Input, Process and Product; CMO: Context, mechanism and outcome; SBE: Simulation-based education Funding While no funding for this manuscript was received, the period of study for the degree of Master of Medical Education (ACG) was funded by the Montagu Clinical Simulation Centre as part of its commitment to staff development. Authors' contributions ACG produced the first draft of the manuscript, and both ACG and SMcA made significant contributions to the critical revision of subsequent versions of the manuscript and approved the final version for submission. --- Authors' information --- Ethics approval While no ethics approval for this manuscript was required, it is based on a research dissertation submitted to and accepted by the University of Dundee in partial fulfilment of the degree of Master of Medical Education (ACG) and supervised by SMcA. Ethics approval for this project was obtained from the University of Dundee Research Ethics Committee (UREC 15163). --- Consent for publication Participants took part in the study voluntarily and were informed of the proposed use of anonymous information for possible publication and written consent obtained. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article describes the key features of realist (realistic) evaluation and illustrates their application using, as an example, a simulation-based course for final year medical students. The use of simulation-based education (SBE) is increasing and so too is the evidence supporting its value as a powerful technique which can lead to substantial educational benefits. Accompanying these changes is a call for research into its use to be more theory-driven and to investigate both 'Did it work?' and as importantly 'Why did it work (or not)?' An evaluation methodology that is capable of answering both questions is realist evaluation. Realist evaluation is an emerging methodology that is suited to evaluating complex interventions such as SBE. The realist philosophy positions itself between positivist and constructivist paradigms and seeks to answer the question 'What works for whom, in what circumstances and why?' In seeking to answer this question, realist evaluation sets out to identify three fundamental components of an intervention, namely context, mechanism and outcome. Educational programmes work (successful outcomes) when theory-driven interventions (mechanisms) are applied to groups under appropriate conditions (context). Realist research uses a mixed methods (qualitative and quantitative) approach to gathering data in order to test the proposed context-mechanism-outcome (CMO) configurations of the intervention under investigation. Realist evaluation offers a valuable methodology for researchers investigating interventions utilising simulation-based education. By investigating and understanding the context, mechanisms and outcomes of SBE interventions, realist evaluation can provide the deeper level of understanding being called for.

INTRODUCTION In contemporary society, achieving gender equality has emerged as a central objective in the pursuit of social justice and societal progress. Despite substantial advancements towards this cause, a persistent and deeply entrenched obstacle continues to impede women's progress in their professional pursuits: the inequality that exists from centuries (Susan,2022). This term encompasses the intangible yet formidable barriers that hinder women's growth and mobility and restrict their access to their limited positions in societies. Over the course of history, women have encountered numerous challenges that restrict their opportunities and prevent them from enjoying the same privileges as their male counterparts in similar positions. The gender inequality serves as a symbol of these imperceptible obstacles that perpetuate gender disparities and hinder women's advancement in various societies, sectors, and countries (Albrecht, 2022). This essay aims to delve into the concept of gender inequalities, explore its implications for women in their lives, and unravel the multifaceted challenges it poses. By analysing the underlying causes and consequences of this phenomenon and proposing potential strategies for reducing these gender inequalities, we can deepen our understanding of gender inequality and actively contribute to the creation of inclusive and equitable environments for women. --- OBSTACLES FACED BY WOMEN The obstacles encountered by women in their life journeys have persisted throughout history, transcending time and cultural boundaries. Whether in the realms of finance, marketing, human resources, or procurement, women often find themselves navigating through deeply male-dominated environments. This systemic gender disparity can be attributed to a complex interplay of social, cultural, and institutional factors. The concept of the gender inequality is symbolic of the invisible barriers that limit women's growth and mobility, and it manifests differently across countries and businesses all over the world. Despite significant promotion of diversity in companies, as well as legislation for equal opportunities for women and men, it must be noted that women still remain largely in the minority in decision-making positions. This observation reflects the phenomenon of gender inequality that constitutes vertical discrimination within societies against women (James,2021). Although gender inequality has generated research interest, some authors have pointed out that theoretical models have made little attempt to develop an understanding of this phenomenon and its implications. However, despite these initiatives and the increasing number of qualified and trained women, it is clear that they are still largely underrepresented in the decision-making process in most sectors (Powell,2021). Indeed, despite the current enthusiasm for diversity in companies and regulations for equal opportunities for both genders (e.g., the anti-discrimination law of May 10, 2007, and by extension, the gender law), the numbers have not changed much in the last decade. Women constitute fewer leadership positions. In 2018, women occupied 16% of positions on the executive committees of large Belgian companies:2 better than ten years ago, when the rate hovered between 9 and 10%, but still low compared to the overall employment rate of women and their share of the population of university graduates (60%). --- DEVELOPED VERSUS DEVELOPING COUNTRIES Nevertheless, women in developed countries find it comparatively easier to work in corporations relative to those in developing countries. This is accounted for by various reasons as developing nations, in particular, present unique challenges that exacerbate gender inequities. For example, in countries like India and Pakistan, deeply rooted societal norms and limited access to education perpetuates gender disparities in the workplace or work culture and society overall from the very start. This implies that, in a developed country like the US, women find it easier to go out, look for a job, and start working, because their society accepts women as part of its workforce (Vroman,2021). That being said, every country has a different level of gender inequality. A cardinal factor that affects the density of gender inequality is a country's policies. China is a fitting example of this fact. When the Chinese government developed and implemented its One-Child policy, Chinese women were able to join the workforce in large numbers, because their responsibilities at home were reduced (Anders,2022). --- METHODOLOGY AND FINDINGS The methodology that was used to understand the extent of inequality faced by women in the society was surveys. Surveys are the best method to use when trying to collect qualitative data because the researcher is able to collect detailed data in a time-efficient manner. The survey consisted of 10 questions. It was limited to this number of questions because participants often feel they are unable to fill longer surveys. The survey also consisted of closed ended questions so that the responses of the participants could be easily interpreted while analysing the findings. The respondents could tick yes or no only as an answer. The survey was given to 350 women who were all working different jobs. The survey consisted of the following questions: Q1. Do you think there is gender inequality in your country? Q2. Do you feel that women are given the same work opportunities as men? Q3. Do you think stereotypes formed against women play a role in increasing gender inequality in the society? Q4. Do you think the role of women should be limited to taking care of their families? Q5. Do you think the gender of a person should decide whether they get a promotion at work or not? Q6. At your workplace, are women treated equally as compared by their male co-workers? Q7. Do you think women are given the same promotional opportunities as men? Q8. Are there more men at a higher position in your company as compared to women? Q9. Do you think men are better suited to be CEOS? Q10. Do you think women in developed countries are treated better than women in developing countries? The findings of the surveys were very interesting with similar answers from most of the participants. Majority (65%) of the participants believed that a gender inequality existed in their country. 60% of the respondents believed that women were not given equal opportunities. 68% believed that stereotypes against women do play a role in increasing gender inequality. 80% answered no to women being restricted only to taking care of their families. 78% believed that women were not treated equally and were not given higher positions in the office and 85% believed that women in developed countries were treated better than women in developing countries. --- DOMESTIC RESPONSIBILITIES OF WOMEN In sharp contrast to this, a family, on average, has more than three children in each household in the rural areas of many developing countries. This increases the domestic responsibilities of the women who marry into these families, ultimately reducing the number of women in the workforce. Similarly, the values instilled in people in some scarcely developed third world countries hold them back from viewing women as an equal part of their workforce. It is important to acknowledge that despite advancements, gender inequalities continue to persist within corporations in developed countries as well. However, this observation does indicate that proactive measures have been implemented to mitigate the prevalence and impact of such barriers (Morgen et al, 2022). Moving on, developing countries face the unfortunate reality of limited awareness surrounding gender inequality, resulting in minimal progress being made within corporate settings to address the gender gap. This stark contrast can also be attributed to disparities in educational opportunities between developed and developing nations. The level of education attained by women in a given country directly influences their awareness of gender inequalities, and conversely, their lack of awareness perpetuates sexism. Therefore, it has become evident that recognizing the issue of gender inequality is an essential prerequisite for devising effective measures to dismantle this ever-existing phenomenon (Morgen et al., 2022). --- Gender Inequality As a Major Hurdle Apart from the gender inequality, women face multifaceted hurdles in their professional lives. Sexual harassment, a pervasive issue plaguing workplace, poses a significant barrier to women's career advancement and growth in society. Sexual harassment in the workplace and in the regular lives of women remains a distressing reality for countless women, undermining their rights, dignity, and professional aspirations. Studies consistently highlight the alarming frequency of sexual harassment incidents in workplaces and in societies overall (Richardson,2020).According to a report by the Equal Employment Opportunity Commission (EEOC), nearly 75% of women have experienced some form of workplace harassment, with a significant portion of these cases involving sexual harassment. Additionally, a survey conducted by the International Labour Organization (ILO) revealed that approximately 32% of women worldwide have experienced workplace sexual harassment. Human Rights watchdog reports that in Pakistan, 68% women are sexually harassed. Still, many of them remain silent and reluctant to lodge formal or informal complaints of their disturbing experiences because of the fear of losing job, shame, stigmatization on women's repute and not wanting their families to know about the issue. In Nepal, research on sexual harassment in the workplace revealed that the problem is highly prevalent in workplaces, as 53.84 per cent of women workers reported that they have faced the issue of sexual harassment in their workplaces. In Japan, a study conducted by the Ministry of Labour found that out of 2254 women respondents, two third were subject to some form of sexually harassment. Caran et al. (2010) has conducted research to find out the existence of sexual harassment (SA) among professors in a public university in Brazil. 40.7% of the participants admitted being victims of SA at work, while 59.3% knew a fellow who had suffered SA and 70.4% stated that it is a common problem in the Institution. Women tend to face sexual harassment in every aspect of their life, whether its professional or private. --- Harassment of Women in Workplaces It is important to identify the link between gender inequality and their role in societies and at the workplace. As far as the harassment of women at workplace in the developed world is concerned, two third of the complainants alleged that their harasser was in a superior position to them, reflecting a traditional sexual harassment profile of a superior/subordinate relationship. Anita Hill, a prominent advocate, remarked, "Sexual harassment is about power. It's about power in the workplace, power in your home. It's about power." This quote underscores the power dynamics at play and the urgent need for systemic changes that challenge and dismantle oppressive structures. On the one hand, it is an oversimplification to say that having more women in higher-level positions would stamp out all sexual harassment problems, but on the other, it is hard to deny that if more women are in supervisory, managerial, and executive jobs at a company, it is more likely to be proactive about addressing the problem and holding harassers accountable. The sexual harassment faced by women in their private lives can be resolved only by attributing the same level of power to men and women (Edin,2022). The persistence of gender inequality in terms of opportunities and representation further impedes female progress. One reason why men tend to advance more quickly in the corporate world compared to women is the presence of gender discrimination, which is fueled by unfounded stereotypes that view women as too "feminine" (Branson, 2006). Researchers have faced challenges in drawing definitive conclusions due to the limited representation of women in top positions. For instance, in Fortune 500 companies, only 14.8% of board seats were held by women (Catalyst, 2007). Even in countries like Australia, Canada, Japan, and Europe, the presence of female directors is scarce. The percentages of female directors in these countries range from as low as 0.4% to 10.6% (Equal Opportunity for Women in the Workplace Agency [EOWA], 2006; European Professional Women's Network [EPWN], 2004). --- STUDIES CONDUCTED ON OBSTACLES FACED BY WOMEN Recent studies have delved into new areas of investigation. For instance, cross-sectional evidence collected by Baxter and Wright (2017) highlights the importance of tailored surveys that target working women who have experienced repeated promotion denials. Such research endeavours aim to gather accurate data and generate insights into the prevalence and impact of the gender inequality faced by women. The promotion denials reflect a broader systemic issue of gender bias and discrimination, limiting women's professional growth and reinforcing the inequalities that exist. Studies conducted by Anders Bjorklund (2018) in the US show that, on average, men had a higher chance of promotion than women at all levels of the hierarchy, denoting gender inequality at multiple stages in the corporation. During this study, a sample comprising women was asked about the negative effects of gender inequality on their professional lives, and predictably, 80% of them had similar answers. In a study by Edin & Richardsson (2017), where the age, experience level, and the quality of work done by the employees were controlled by researchers, it was discovered that men were promoted to higher levels while women were discriminated against throughout the hierarchical levels and every level of society. Ferre and Purkayastha (2019) demonstrated that the way in which institutional structures and social environments are built ensures the persistence of women's inferiority at jobs and in societies in general. Men are awarded privileges solely because of their gender. According to Dana M. Britton and Christine L. Williams (2020), women are faced with systematic obstacles at every level of the organizational hierarchy and face difficulties in every aspect of their lives. These barriers can take the form of an inherent gender bias that manifests itself in a variety of ways i.e., rarely getting promoted during promotional processes. Prejudice and gender oppression ingrained in men constitutes two of the main reasons behind gender inequalities in many societies. Gender bias engenders an inferior position for women. As a consequence, they become more susceptible to other adversities like sexual harassment that violates their rights. Meanwhile, the prevalent mindset among people fails to advocate, or even attempt, the equal treatment of women. Men are given dominance in both workplaces and societal roles. When male managers are instructed to make hiring decisions, especially promotion decisions, they tend to focus on many irrelevant aspects such as the ill-founded belief that women leave the organization upon or during pregnancy (Denton & Zeytinoglu, 2022). The skill set of the woman, her dedication, and her loyal service to the company are regularly overlooked. Instead, the negatives garner the focus of these supervisors when promotion decisions are taken (Zane, 2021). In most of the cases, men were promoted to positions of senior authority when the decision was up to male managers. This panel, consisting of male managers who sit at top positions in every firm, exceedingly reinforces the gender inequality (Kirchmeyer, 2020). --- Role of Men in Causing Gender Inequality Both senior and junior male managers hold the belief that women lack the competence to effectively balance their familial and professional responsibilities. They assume that when faced with a choice between pursuing their career aspirations or prioritizing their families, women would opt for the latter (Zane, 2021). These generalizations create a significant barrier in breaking through the gender inequalities and ensuring that women have equal access to the career opportunities deserve and work hard to earn. To weaken this gender inequality and promote gender equity in the workplace, it is crucial to address and eliminate preconceived misconceptions. It requires challenging the notion that women's commitment to their families undermines their professional abilities. Research and evidence have consistently shown that women are capable of successfully managing both their personal and professional lives. Moreover, it is important to foster a work culture that supports and accommodates the diverse responsibilities and aspirations of all employees, regardless of their gender. This includes implementing family-friendly policies, flexible work arrangements, and providing support systems that allow individuals to strike a balance between their work and personal commitments. The role of women in societies should be given the due importance it deserves. The barriers women face when they are promoted to managerial positions are counted amongst the less destructive obstacles in their work-lives in comparison to others such as sexual harassment which harms their self-esteem and their prestige in both professional and personal spheres. The impact of gender inequalities extends beyond the limitations of promotions; women also face other challenges which violate their rights as employees. James et al. ( 2019) proposed categorizing different forms of gender inequalities, such as pay gender inequalities, managerial promotion inequalities, and prestige gender inequalities, to better understand their causes and effects. --- The Labeling Culture And Its Implications Let us have a look at the formidable impact of the gender inequality in the corporate sector where it continues to thrive as a pervasive phenomenon. According to a report published by Catalyst, a leading non-profit organization focused on workplace equality, women hold only 29% of senior management positions globally. This stark underrepresentation of women at top leadership levels highlights the persistent existence of the gender inequality (Catalyst, 2021). Research conducted by Eagly and Carli (2007) reveals that gender stereotypes and biased perceptions contribute to the gender inequality. Stereotypes associating men with leadership qualities and women with communal traits create unconscious biases, influencing the evaluation and promotion processes within organizations. These biases perpetuate the gender inequality by impeding women's progress towards executive roles fuelled by various causes like the labelling culture across organisations. The labelling culture often results in the assignment of negative attributes to women who challenge traditional gender norms by aspiring leadership roles. Women who exhibit assertiveness, confidence, and ambition may be labelled as "bossy," "aggressive," or "difficult to work with," while their male counterparts displaying the same behaviours are seen as competent and driven. This gender-based perceptions creates a double standard, undermining women's credibility and hindering their chances of career and professional advancement. The impact of the labelling culture goes beyond individual experiences. It permeates the organizational culture, shaping norms and expectations around gender roles and leadership. As a result, even well-intentioned policies and initiatives aimed at promoting diversity and inclusion may fall short if the underlying toxic culture is not addressed. Women in leadership positions have to adopt a leadership style that is compatible with the company's traditionally male-dominated culture (Mayer, 2022). They feel forced to adopt directing methods that will be met with appreciation from their male managers and senior male executives. As a result, they are unable to adopt the leadership style that they are most comfortable with, inhibiting them from working in a manner which is the most fulfilling to themselves (Oakley, 2021). The independence of women as managers is challenged because they are restrained from being true to themselves and their teams as leaders. --- ADVANTAGES OF DIVERSE LEADERSHIP Studies have shown that diverse leadership teams yield significant benefits for organizations. A report by McKinsey & Company indicates that companies in the top quartile for gender diversity on executive teams are 25% more likely to have above-average profitability than those in the bottom quartile (Hunt, Layton, & Prince, 2015). This data emphasizes the business imperative of reducing gender inequality and fostering gender equality within corporate leadership and the society. The gender inequality in politics remains a stubborn challenge for women around the world, restricting their advancement to the highest echelons of political power and leadership. A closer look at the facts and figures reveals the extent of the gender inequality and the uphill battle women face in the realm of politics. One striking fact is the underrepresentation of women in political leadership positions. According to the Inter-Parliamentary Union's data from September 2021, women constituted only 23.7% of national parliamentarians worldwide. This glaring disparity extends to heads of state or government, where women remain a minority. Such substantial underrepresentation highlights the ongoing struggle women encounter in accessing and assuming influential political roles. Decision makers in the political arena form their decisions based on the subconscious premise that there should be a higher percentage of men than women on every platform; this constitutes an incumbency advantage or inertia towards women (Welsh, 2020). The justification offered by these decision-makers is that it seems unreasonable to select women in a field where women have been historically absent (Purcell, 2022). Politics is yet another career domain where disparity among the two genders is crystal clear to anyone who is even mildly inclined towards these matters (Lynn, 2021). The role of Chief Staff Officer is bestowed upon women as a reward for their years of loyalty to a political candidate. They are not offered the same opportunities in terms of the position that they autonomously aspire to achieve. In contrast, men benefit considerably from this gender disparity, making their way up the political ladder astoundingly quicker (Wirth, 2022). Estimates suggest that achieving gender parity in political leadership globally could take another 50 to 100 years at the current rate. These figures underscore the urgent need for concerted efforts to dismantle the gender inequality, promote gender equality, challenge biases, and create inclusive political environments that empower women to participate fully in the political spheres. --- Gender Stereotypes And Their Implications The growth of gender inequality is fuelled by implicit bias and unconscious gender stereotypes. This bias hampers the recruitment process, creating an unfair hiring system for women (Purcell, MacArthur, and Samblanet, 2010). To gain a comprehensive understanding of the extent of the gender inequality effect, recent studies have examined not only the gender ratios and percentages of women at different hierarchical levels but also the gender pay gap within organizations (Jones et al., 2021). Shockingly, even in companies that exhibit relatively equitable gender representation, substantial pay disparities exist, highlighting the deep-rooted nature of gender inequality in the workplace. HR departments' attempts to design gender-neutral selection processes often fall short, contributing to the perpetuation of the gender disparities that exist (Kleinberg & Raghavan, 2019). Legislations concerning equal pay exist in a lot of countries, but they are not effectively executed in practice (Frankforter, 2019). Whether they are teaching jobs or corporate jobs, men are paid more than women without consideration of any other factor than gender (Linney, 2018). Anti-sex discrimination laws have also been formulated in various countries, but their implementation has been excruciatingly slow, while women continue to be heavily discriminated against, especially in the corporate sector. These laws and regulations will not do much to reduce gender inequality if they are not administered properly, and soon (Borg & Gall, 2017). While it is important to acknowledge the structural barriers that contribute to the gender inequality, it is equally essential to recognize that fellow female workers can inadvertently reinforce these inhibitions. Internalized biases and misogynistic stereotypes perpetuated by women themselves can impede their professional advancement. This phenomenon, known as the "queen bee syndrome," reveals a complex dynamic within workplaces. --- The Role of Mentoring Research indicates that women in leadership positions may be less likely to mentor or support other women, hindering their progress. A study published in the Harvard Business Review in 2008 found that women in senior positions were more reluctant than their male counterparts to mentor or advocate for other women. This behaviour can stem from the scarcity mindset, where women perceive limited opportunities for advancement and see other women as competitors rather than collaborators. Sheryl Sandberg, Facebook's COO and founder of the "Lean In" movement, pointed out in her book, "Lean In: Women, Work, and the Will to Lead," that women sometimes hold themselves back by not supporting each other. She writes, "Too often, women become envious or resentful of their female colleagues because they perceive them as competitors." This phenomenon is not solely anecdotal; studies corroborate its existence. The 2020 Women in the Workplace report, conducted by LeanIn.Org and McKinsey & Company, revealed that women are less likely to receive advice from senior leaders or have opportunities for career advancement compared to their male counterparts. This disparity can be partially attributed to the lack of support and sponsorship from fellow female workers. However, it is crucial to avoid generalizations and recognize that this behaviour is not universally characteristic of all women in the workforce. Many of them actively champion and support their female colleagues, challenging the gender disparity with power. These women understand the importance of collaboration, networking, and uplifting one another to collectively overcome systemic barriers burdening them for centuries. Prominent figures have spoken out about the significance of female solidarity in dismantling the gender inequality. Madeleine Albright, the first female U.S. Secretary of State, once stated, "There is a special place in hell for women who don't help other women." Albright's quote emphasizes the responsibility of women to support and empower one another to reduce inequality based on gender and achieve equality. --- STEPS THAT CAN BE TAKEN TO REDUCE GENDER INEQUALITY In order to reduce gender inequality, it is important to first recognise the factors that contribute to its persistence. Following are the most prominent factors that play a key role in increasing gender inequality: • Implicit Bias in Evaluation and Promotion: Implicit biases, often unconscious, affect decision-making processes and hinder women's advancement. Research conducted by Yale University revealed that both male and female evaluators are more likely to associate men with leadership potential and higher competence, leading to unfair evaluations and promotion decisions. This bias increases the gender inequality by overlooking women's qualifications and potential. --- • Lack of Flexible Work Arrangements: The absence of flexible work arrangements can pose a significant challenge for women in their career progression. Many of them juggle multiple responsibilities, including caregiving and household tasks. Without flexible schedules or remote work options, it becomes challenging for women to achieve a work-life balance, leading to a stalled career progression. --- • --- Male-Dominated Networking and Sponsorship: Networking and sponsorship are crucial for career advancement. Many industries and organizations still constitute male-dominated networks and sponsorship structures. Men are more likely to have access to influential networks and senior mentors who can complement their careers. This disparity in networking limits women's visibility and access to rewarding relationships, adversely impacting their advancement opportunities. • Stereotype Threat: Stereotype threat refers to the fear of confirming negative stereotypes associated with one's social group. Women may experience stereotype threat in male-dominated fields, leading to reduced confidence and performance. A study published in the Journal of Personality and Social Psychology found that women's performance in quantitative tasks declined when reminded of gender stereotypes. This phenomenon hampers women's ability to thrive and be recognized for their skills, ultimately reinforcing the gender inequality. --- • Maternal Bias and Maternity Penalties: Maternal bias as a form of gender bias affects women who become mothers. Research has shown that women experience reduced perceived competence and commitment to their careers after having children. It often leads to "maternity penalties" in the form of decreased promotion prospects, lower salaries, and limited access to intellectually stimulating assignments. The perception that motherhood compromises commitment and availability create additional barriers for women's growth. • Institutional Barriers and Organizational Culture: Structural and cultural barriers within organizations contribute to gender inequality. Limited availability of family-friendly policies, such as affordable childcare or parental leave, can hinder women's career progression. Additionally, organizational cultures that prioritize long hours and a "face-time" mentality disadvantage women who seek work-life balance or alternative approaches to leadership. --- • Unconscious Bias Training Insufficiency: While unconscious bias training is increasingly adopted by organizations, its impact may be limited without comprehensive implementation. A study published in the Journal of Experimental Social Psychology showed that brief unconscious bias training programs had minimal long-term effects on reducing biases. Organizations need to invest in sustained and comprehensive training efforts to address biases effectively. • Gendered Communication Styles: Gendered communication styles and expectations can negatively impact women's progression. Research has shown that assertive communication styles, typically associated with leadership, are more readily accepted by men, while women are often expected to exhibit communal and nurturing behaviours. This discrepancy can lead to women's ideas being overlooked or undervalued, limiting their visibility and influence within organizations. • Lack of Sponsorship: While mentorship provides guidance and advice, sponsorship involves influential individuals advocating for an individual's career advancement. Women often face a shortage of sponsors who actively champion their professional growth. A study by the Center for Talent Innovation found that women were 54% less likely than men to have a sponsor, which can substantially impede their access to critical opportunities and visibility within the organization. • Gendered Performance Evaluation Criteria: Performance evaluation criteria that are gendered or biased can also hinder women's progress. Research has indicated that traditional evaluation metrics may not fully capture the leadership skills and qualities that women bring to the table. Gender-neutral performance assessment frameworks that account for a diverse range of leadership styles and competencies are needed to mitigate this bias. • Lack of Access to Stretch Assignments: Stretch assignments or high-profile projects are vital for career growth, skill development, and visibility. However, women may face minimal access to these opportunities due to bias, perceived riskaversion, or traditional gender roles. The Center for American Progress reported that women are less likely than men to be given challenging assignments that can showcase their abilities and pave the way for career advancement. --- • --- Limited Boardroom Diversity: The composition of corporate boards has a significant impact on organizational decisionmaking and culture. Research has consistently shown that diverse boards, including gender diversity, lead to improved performance and innovation. However, women's representation on boards remains low in many companies. The 2020 Women on Boards Gender Diversity Index revealed that women held only 22.6% of board seats in Fortune 1000 companies. The lack of diverse perspectives at the highest level of authority increases the gender inequality and hampers gender equality in leadership. • Digital Gender Divide: The digital gender divide refers to the disparities in access, usage, and skills related to digital technologies between men and women. In today's digital age, technological proficiency is increasingly crucial for career advancement. However, women regularly face barriers such as limited access to technology, stereotypes that discourage their interest in STEM fields, and biases that hinder their progression in high-tech roles. Bridging the digital gender divide is essential to ensure more equal opportunities for all genders in emerging industries and digital-centric workplaces. • Unconscious Bias in Artificial Intelligence (AI) Systems: As AI technology becomes more popular in various aspects of organizations, the presence of unconscious biases in AI systems can increase the gender disparity. AI algorithms trained on biased data can perpetuate discriminatory practices in recruitment, performance evaluation, and promotion decisions. For instance, if historical data reflects biased gender patterns, AI systems may unintentionally reproduce those biases, leading to unequal treatment of women. Addressing and mitigating unconscious biases in AI systems is therefore crucial to ensure fair and equitable opportunities for career advancement. --- • Online Harassment and Cyberbullying: The rise of online platforms and social media has opened new avenues for professional networking and communication. However, women are disproportionately affected by online harassment and cyberbullying, which can have significant repercussions on their professional lives. Research by the Pew Research Center has shown that women experience higher rates of online harassment, including sexist and misogynistic attacks. Such harassment may erode women's confidence, impede their participation in online professional spaces, and limit professional opportunities for them. --- CONCLUSION Taking it all into account, it is reasonable to assert that the issue of the gender inequality remains a significant and persistent challenge for women. Cross-sectional evidence collected by researchers globally has proven quite useful because it has laid foundation for further research in the future. Baxter and Wright (2017) remarked that accurate data on the gender disparity phenomenon can be collected only if the right people are asked the right questions at the right time. Another conundrum explored by Hibbs & Locking (2021) when surveying women on this topic was the possibility of a mightier gender inequality at the upper levels of hierarchy than the lower, and that if this is the case, is this phenomenon consistent throughout developed and developing countries? An interesting question that arises here is: are men aware of the ascending gender discrepancy and the unfair distribution of promotional opportunities? Such questions form basis for further research. All in all, the problem of gender inequality can be resolved only when this phenomenon is recognized by both men and women across the globe. Despite progress in various aspects of gender equality, women continue to face obstacles that hinder their progressive mobility and limit their access to top leadership positions. The gender inequality, often defined as the barriers that prevent women from reaching the highest echelons of power and authority, is just one among several hurdles that women encounter in professional environments. Numerous studies conducted worldwide have shed light on this issue, revealing that even in countries like Sweden, often perceived as having relatively higher gender equality, there is pervasive discrimination against women when it comes to their placement in senior roles within businesses. The Scandinavian countries, known for their progressive policies and commitment to gender equality, have made significant strides in reducing gender gaps in various areas. However, the gender discrepancy has not vanished, indicating that there are deeper-rooted systemic factors at play that need to be addressed. This realization has sparked increasing attention to the subject, leading to ongoing studies and research aimed at understanding and addressing the gender inequality more effectively. Researchers, policymakers, and organizations are working together to unravel the complexities of this issue, examining its causes and consequences, and proposing strategies for breaking this barrier. The recognition of the disparity in gender as an everincreasing problem has also been amplified by women themselves due to negative conditioning and internalized misogyny, who are now more conscious than ever of its existence and are experiencing its adverse effects to an alarmingly high extent. Noteworthy findings from various studies indicate that even when controlling for variables like age and race between both genders, the gender discrepancy remains intact due to insufficient measures taken to address it systematically. While individual efforts and initiatives have made a difference for some women, comprehensive and coordinated action is necessary to dismantle the structural and cultural barriers that perpetuate gender disparities in the workplace. To address inequality and decrease its negative impacts, it is crucial to identify and mitigate the underlying causes both internally within organizations and externally within society as a whole. Implementing diversity-enhancing policies at all levels emerges as a viable corrective measure. Organizations need to adopt proactive strategies that go beyond tokenism and foster a culture of inclusion and equal opportunity for all. One key aspect of this approach is the implementation of policies that promote diversity and inclusion within organizations. This can include targeted recruitment efforts aimed at attracting and hiring qualified female candidates, as well as the establishment of mentoring programs that provide guidance and support to women as they navigate their professional journeys. Addressing this issue requires more than just internal organizational efforts. It necessitates a broader societal transformation to challenge deeply ingrained prejudice and norms that perpetuate gender inequality. This includes initiatives to promote gender equality in education, media representation, and cultural narratives. By challenging traditional gender roles and expectations, we can create an environment that encourages women to aspire leadership positions and provides them with the necessary support to succeed. In addition, creating a culture that values and celebrates gender diversity is crucial in dismantling the biases that contribute to the gender disparity effect. Organizations must foster an environment where gender equality is not only respected but actively promoted. This can be achieved by challenging preconceived notions, promoting inclusive behaviours and attitudes among employees, and providing training and awareness programs to address unconscious biases. Furthermore, organizations should prioritize the development and advancement of women leaders through targeted leadership development programs, networking opportunities, and sponsorship initiatives. By recognizing and valuing the unique perspectives and contributions of women, organizations can create a more equitable and inclusive workplace that makes all members better off. To conclude the discussion, the gender inequality remains a mighty barrier for women, even in countries with a reputation for gender equality. That being said, by implementing proactive measures to address the underlying causes and promoting inclusion, organizations can pave the way for women to break through these barriers. It is essential for corporations to recognize the potential of women in leadership positions and to provide the necessary support system for them to thrive. Only by collectively working towards gender parity can we create a truly equitable and healthy society that fosters the talents and contributions of every individual, regardless of race, gender, or ethnicity. Implementing diversity-enhancing policies at all levels emerges as a viable corrective measure (Purcell, 2019). This includes strategies such as targeted recruitment efforts, mentoring programs, and flexible work arrangements (Carter & Silva, 2023). The result of these efforts, if appropriately and adequately implemented, will emerge in

The main method used was a survey which around 350 working women from multiple countries including Pakistan, Turkey, and Lebanon responded to, regarding different aspects of their professional ideologies and observations. Extensive secondary research was employed to explore the issues of role of women in society, sexual harassment faced by women in their homes and workplaces, and the magnitude of gender inequality in developing versus developed countries. The main findings concluded that gender inequality is a long-standing hurdle in the path of women. It exists at all levels in the society and is not limited to a single culture or country. The gender inequality is not the only barrier faced by women in their journeys; however, it may pave way for other obstacles like sexual harassment. The measures presently taken to combat the negative impacts of gender inequality on women are inadequate and require more thought and better implementation for them to prove fruitful in eradicating the issue.

biases. Furthermore, organizations should prioritize the development and advancement of women leaders through targeted leadership development programs, networking opportunities, and sponsorship initiatives. By recognizing and valuing the unique perspectives and contributions of women, organizations can create a more equitable and inclusive workplace that makes all members better off. To conclude the discussion, the gender inequality remains a mighty barrier for women, even in countries with a reputation for gender equality. That being said, by implementing proactive measures to address the underlying causes and promoting inclusion, organizations can pave the way for women to break through these barriers. It is essential for corporations to recognize the potential of women in leadership positions and to provide the necessary support system for them to thrive. Only by collectively working towards gender parity can we create a truly equitable and healthy society that fosters the talents and contributions of every individual, regardless of race, gender, or ethnicity. Implementing diversity-enhancing policies at all levels emerges as a viable corrective measure (Purcell, 2019). This includes strategies such as targeted recruitment efforts, mentoring programs, and flexible work arrangements (Carter & Silva, 2023). The result of these efforts, if appropriately and adequately implemented, will emerge in form of a better and fairer world.

The main method used was a survey which around 350 working women from multiple countries including Pakistan, Turkey, and Lebanon responded to, regarding different aspects of their professional ideologies and observations. Extensive secondary research was employed to explore the issues of role of women in society, sexual harassment faced by women in their homes and workplaces, and the magnitude of gender inequality in developing versus developed countries. The main findings concluded that gender inequality is a long-standing hurdle in the path of women. It exists at all levels in the society and is not limited to a single culture or country. The gender inequality is not the only barrier faced by women in their journeys; however, it may pave way for other obstacles like sexual harassment. The measures presently taken to combat the negative impacts of gender inequality on women are inadequate and require more thought and better implementation for them to prove fruitful in eradicating the issue.

Introduction Adolescent pregnancies remain a public health concern globally. 1 The greatest proportion of adolescent pregnancies occur in less developed countries and mostly among those with no education and those from poorer households. 2 It is estimated that around 21 million adolescent girls between 15 and 19 years of age get pregnant annually in developing countries. 3,4 Further projections indicate growth in adolescent pregnancies globally by the year 2030 mainly due to the ever-growing adolescent population worldwide especially in African countries. 5 Pregnancy and childbirth among adolescents have both health and social ramifications. Health-wise, pregnancy and delivery complications are the leading causes of death for girls 15 to 19 years worldwide. 6 Babies born to adolescent mothers have elevated risks of childhood morbidities and mortalities. 7 Socially, adolescents who become pregnant face stigmatizing or other negative responses from people within their environment, including their family members and friends, as well as the health care setting. 8,9 They often tend to practice unsafe abortions in countries with restrictive abortion laws, 10 which may cause several complications with permanent health consequences or even death. 4,11 Globally, around 3.9 million unsafe abortions occur among 15 to 19-year-old girls each year. 4 Additionally, adolescent pregnancy interferes with the girls' future education and limit opportunities for employment. 12 The use of contraceptive methods have been proven to prevent unwanted, early pregnancies and in turn unsafe abortions. 13 However, research shows that the use of effective contraceptive methods is rather low among sexually active African youth, including Ghanaian youth, 13 with even lower rates among rural area dwellers and those in the lowest wealth quantiles. 14 Available data suggest that the use of condoms is relatively more common among adolescents compared to the other birth control options because of its ready availability and low cost. 15 However, though condoms prevent pregnancy and sexually transmitted infections (STIs), depending only on condoms for protection bears several risks, especially for the girls. Condoms can only be an effective way of protection when used correctly and consistently. For correct condom use, one relies on the partner's willingness to use them, but this can be a challenge for adolescent girls, who lack the skills and competences for condom use negotiation. 16 Moreover, in stable relationships, research reports decrease in consistent condom use over time, relating their use with being loose or not trustworthy. 17 For maximal protection for adolescents therefore, the dual method approach; ie, using condoms and a hormonal contraception seems the best option. 18 While there is an extensive body of scientific literature on factors influencing condom use, 19,20 studies focusing on factors that influence hormonal contraception use are limited. To be able to address the problem of low hormonal contraception use, a clear understanding of all related individual and environmental factors is needed. We therefore carried out a qualitative study to understand the barriers to hormonal contraceptive uptake among adolescent girls in Kintampo, a rural Ghanaian community, which has a high annual births by adolescent (15%), 21 a rate above the national average of 14%. 22 Yet, hormonal contraceptive use among adolescents is low with an estimated prevalence of 13% among sexually active girls. 23 This manuscript uses the socio-ecological model 24 to guide our understanding of the factors associated with non-use of hormonal contraceptives among adolescent girls 15 to 19 years of age in the Kintampo area of Ghana. The socio-ecological model posits that human behavior is influenced at multiple interacting levels, including the individual/intrapersonal, the interpersonal, the community, the institutional and the public policy levels. 24 In this study, we have focused on the individual, interpersonal, community and institutional level factors. Individual level factors influencing hormonal contraceptive use in adolescents have been related to poor understanding of several aspects of hormonal contraceptive use, including the different types of hormonal contraceptives available and how the methods work, 25 poor knowledge on side effect, 26 and poor knowledge on cost and legality of use. 27 Also, limited awareness of methods perceived to be right for adolescents, poor knowledge on sources of obtaining the methods, poor self-efficacy and skills to use the method, have been related to poor uptake of hormonal contraceptives. 28 Moreover, poor compliance, negative experiences with specific hormonal contraceptive methods (eg, extreme bleeding related to use of implants), fear of side effects of specific methods and fear of related health risks of hormonal contraceptive use in general, have been associated with low uptake. [29][30][31] In addition, Adolescents' fear of negative stigmatizing responses related to early sex and contraceptive use from their parents, peers, religious leaders amongst others have been reported to negatively affect hormonal contraceptives use amongst them. 16,[32][33][34] At the interpersonal and community levels, varied social norms exist in different cultures 35 and they either motivate or demotivate the performance of certain behaviors. 36 Societal norms related to sexual morality in many African cultures disapprove of all forms of illicit sex. 37 People who deviate from societal norms face undesirable responses including ostracism and stigmatizing responses. 37 Studies have reported that, social norms that discourage premarital sex and contraceptive use, negatively affect intentions to use, 38 as well as actual modern contraceptive use amongst adolescents. 39 At the institutional level, lack of access to youthfriendly health facilities, poor health professional-patient relationship, lack of privacy and confidentiality at health https://doi.org/10.2147/OAJC.S320038 --- DovePress Open Access Journal of Contraception 2021:12 facilities, lack of in-depth discussions during consultation, and cost of hormonal contraceptive methods 15,29 affect use of hormonal contraceptive methods. Next to empirical findings on factors explaining nonuse of hormonal contraception, several health-behavior related theories may provide additional explanations. [40][41][42] Applying the Health Belief Model (HBM), adolescents may not be using hormonal contraceptives because they do not perceive themselves as susceptible to unwanted pregnancy. Also, they probably do not perceive the consequences of unwanted pregnancy as severe and do not believe in getting any potential benefit from using hormonal contraceptives. Further, adolescent's perceived barriers to hormonal contraceptive use, and lack of self-efficacy to use, may explain why adolescents do not use hormonal contraceptive methods. This is evidenced by findings from Hall's systematic review of literature in using the HBM to guide the understanding of modern contraceptive behaviors and practice with in the general population. 40 In-depth information on factors influencing uptake of hormonal contraceptive methods in Africa is limited in general and more so in sub-Saharan Africa. 43 Besides, majority of scientific publications do not differentiate in their outcome measure between hormonal contraceptive methods and other non-hormonal contraceptive methods including condoms. 15 In this qualitative paper, we explored the factors that limit uptake of hormonal contraceptives from the perspective of adolescents in the Kintampo area of Ghana. --- Methods --- Study Area Description This study was conducted in the Kintampo area, which is situated within the forest-savannah transitional ecological zone in the Bono East Region of Ghana. It covers an area of about 7162 Km 2 with an approximate resident population of 150,000. The population is youthful with over 45% under the age of 15 years. 44 About 40% of adolescents 15 to 19 years of age are sexually active. 23 With a total fertility rate of 4.7 births per woman, 15% of annual births are attributed to girls 13 to 19 years of age. 21 Contraceptive prevalence among adolescents (10-19 years of age) is 25%. 45 The male condom is the most commonly used contraceptive method (82%) among adolescents in this region while hormonal contraceptives are only used by about 13% of sexually active girls. 23 --- Study Design This was an explorative study using qualitative data collection methods from April to June 2018. Two focus group discussions (FGD) made up of 10 and 12 respondents respectively and sixteen in-depth interviews (IDI) were carried out among adolescent girls to determine factors that negatively affect the uptake of hormonal contraceptives amongst them. Both methods were used because the IDIs are effective at generating in-depth, personal and private information; complimented by FGDs that produce interesting group outputs, showing divergence or convergence of opinions between the group members. 46,47 --- Study Population and Description of Participants The study included 38 adolescent girls aged 15 to 19 years (M = 17.0 SD =1.1738). Thirty-six out of the 38 girls had been to school with the highest level of educational attainment being Senior High School (15/36). The remaining 21 girls either had a primary level or junior high school level of education. Two girls had never been to school. About half of the girls (18/38) lived with both parents; the others (20/38) either lived with a single parent, other relatives, or lived by themselves. Most participants were Christians (34/38) and the four others were Muslims. About two thirds (23/38) had a boyfriend at the time of data collection. For pregnancy prevention, a few (5/38) used the male condom. Others also used rhythmic and withdrawal methods. None of the participants stated to have ever used hormonal contraception. --- Description of Study Tools An interview guide made up of semi-structured questions was used for data collection. Guides for both the FGDs and IDIs contained the same questions. The guides were developed based on an extensive literature review of the factors that are reported to be associated with hormonal contraceptive use among adolescents globally, guided by the Socio-Ecological model. The interview guide was structured thematically under sections such as awareness of hormonal contraceptive options and their mode of action, attitudes to hormonal contraceptives, normative perceptions about hormonal contraceptive use among adolescents, and community norms. The data collection tools were pre-tested among some adolescents in the study area and necessary contextual adjustments were made before data collection. --- Recruitment and Data Collection Procedure Participants were purposively selected from two Senior and one Junior High School (20 girls), two adolescent health corners (10 girls), and three dressmaking parlors (8 girls) in the Kintampo Municipality and South District. Verbal announcements about the study were made in the recruitment centers. In the schools, we asked permission from the head teachers to talk with the girls in their classrooms. We shared information about the study, which comprised a summary of the study objectives (ie, identifying reasons for non-use of hormonal contraceptives among adolescent girls to inform interventions to promote hormonal contraceptive uptake and to prevent teenage pregnancy) and study procedures (ie, either taking part in a focus group discussion or in-depth interview), and we explained how to enroll into the study; by writing their names and phone numbers on a piece of paper that was left behind. Prospective respondents were given up to a day to rethink about participation, after they signed up for the study. Inclusion criteria were based on age (ie, between 15 and 19), educational background (primary, junior high and senior high schools and those without the education), and non-use of hormonal contraceptives. Any adolescent who reported ever having used hormonal contraceptives was not included in the study. The IDIs and FGDs were done face to face in either English or the local language (Twi), depending on the preference of the participants. The first FGD was held at a school premises in a designated room free from intrusion. The second FGD was held at a church premises. IDIs were held at school premises, youth health centers, and participant's homes. The discussions were facilitated by a female social scientist guided by an interview guide. Right before the start of the interview participants were again reminded of their rights given in the written informed consent forms. For participants less than 18 years, consent was provided by their teachers if interviews were done in school or parents if interviews were done at home, in addition to their individual assent. Participants received copies of their signed consent forms. On average, an IDI lasted between 25 and 35 minutes whilst an FGD lasted between 60 and 90minutes. All interviews were audio-recorded and transcribed verbatim, with those in Twi, further translated into the English language. The moderator sought the consent (through signed written informed consent) of respondents before recording and taking notes of all discussions. After conducting two FGDs and 15 IDIs, no new themes emerged and so data saturation was reached. Data collection ended after one more IDI was done. --- Data Management and Analysis ATLAS.Ti version 8.4.2 qualitative data analysis software was used in managing and analyzing data collected. All eighteen transcripts (2 FGDs and 16 IDIs) were exported from MS word into ATLAS.Ti and thematic analyses were done. Guided by the grounded theory technique, an inductive approach was used to identify major themes that emerged from the data. 41 Two members of the study team (first and second author) independently reviewed the first three transcripts and formulated preliminary codes, guided by the objectives of the study. Iterative reviews were done between the two team members to identify other sub-themes and discussion were held when coding differed until agreement was reached. Established codes were then applied to all transcripts for final analysis by the first author. All code summaries where again reviewed and discussed by both the first and the second author. For the transcripts review process, participant data related to their names were de-identified. Electronic files containing the audios and transcripts from the study have been stored in password-protected computers. --- Results Reasons for non-use of hormonal contraceptives are presented below structured by the different levels of the socioecological model. Quotes from both focus group discussions and interviews are included to illustrate major themes. The opinions expressed by adolescents on their perceived barriers to hormonal contraceptive use were not different for both in-depth interviews and focus group discussions, hence, results were merged. It is worthy to note that the adolescent girls used the terms family planning and contraceptives loosely to refer to hormonal methods such as the pill, injection and the implant. So even if the girls did not specifically refer to the word "hormonal" in the illustrative quotes, the methods they mentioned refer to what we consider as hormonal methods. --- Individual Level Factors of Influence Awareness and Knowledge of Hormonal Contraceptive Methods Almost all the girls had heard of hormonal contraceptive methods, which they also called family planning methods. The majority of them could mention at least one form of hormonal contraceptive method. The injection and the implant were the most common methods mentioned. However, even though most participants were aware that hormonal contraceptive methods exist and are used by women in their reproductive age to prevent pregnancy, they could not explain their exact mechanism of action. A typical misconception was that hormonal contraceptives destroy the man's sperm making it incapable of impregnating a woman. When you use it and you have sex, it destroys the man's sperm so that it cannot impregnate you (18 year old girl in FGD) Knowledge of Where to Get Hormonal Contraceptives Almost all the girls knew at least one source for obtaining a hormonal contraceptive method. Hospitals were the most frequently mentioned source and then clinics, pharmacy shops, and drugstores (when prompted). The preferred source of hormonal contraceptives was stated as the hospitals because hospitals are more equipped with personnel and equipment. How can someone obtain a hormonal contraceptive method if they want to?... through hospitals and some drugstores but going to the hospitals is more relevant than the drugstores. (IDI 16 year old girl) Few girls stated to not know where one could obtain the hormonal contraceptive method. --- Knowledge of the Cost of Hormonal Contraceptive Methods About half of the girls did not know how much it costs to get a hormonal contraceptive. Most of those who claimed to know only speculated that it was not expensive. R: Please it is not all that costly, it is not costly. Anyone who wants to do it the person can be able to afford and just do it straight. (IDI 19-year-old girl) Only one girl could attribute a price to the (removal of) the implant and few knew some organizations provide it for free. Madam it is free. If you want to go and take out the implant, they will take 30 Ghana Cedis from you. (18 a year-old girl in an FGD) A few of them mentioned that in their opinion, hormonal contraceptives are expensive and said they presumed the cost deterred people from accessing it. Attitude Toward Hormonal Contraceptive Use Most of the girls who were interviewed had positive attitudes toward the use of hormonal contraceptives in general but tended to be more negative when it was about adolescents using it. They said that it helped to prevent unplanned pregnancy, especially teenage pregnancy; therefore, users could work, have peace of mind, complete school, or finish a trade they were learning. Mostly among married women, they felt it is very useful for spacing their children. They indicated that hormonal contraceptives could be used by the married, unmarried women and young girls in relationships. It is good... people use it to prevent unwanted pregnancy. Some people had unplanned pregnancies so to plan for the next pregnancy they use the family planning methods. This is because if they are unable to space their birth, they find it difficult to take care of the children. (IDI with an 18-year-old girl) However, the use of hormonal contraceptives among married women was more acceptable to most girls compared to unmarried adults and young girls. They said that adolescents who used contraceptives did not think, or had no good morals; they liked sex, they had no self-control and were promiscuous. The girls were also of the opinion that adolescents who used hormonal contraceptives may become sick or infertile and so they hurt themselves by using the methods. These perceived side effects were also the most often mentioned disadvantages of hormonal contraceptive use.... I feel that they don't have good morals or they can't live a chaste life that is why they go for contraception... some people say that the contraceptives are not good, you can't have children after using it. So if I see them using it, I feel that it's is very bad for a young girl like me to use contraceptives. (IDI with a 16-year-old girl) Other respondents did not see anything wrong with adolescents using contraceptives. They said it is a way of securing their future. Using contraceptives would help them to prevent teenage pregnancy, to be able to complete their school or whatever trade they were learning. They also said it is always better than abortion and that some adolescents have already given birth and may like to prevent a second child from coming so it is good for those to use contraceptives. --- Self-Efficacy in Organizing and Using Hormonal Contraceptives A few of the adolescents expressed self-confidence in their ability to use hormonal contraceptives, should they want to. They claimed to know the benefits they would derive from using contraceptives and so if they decided to use it, they could. In contrast, most respondents said it would be very difficult for them to get a method if they wanted to. The adolescents indicated that they would have a negative feeling obtaining a hormonal contraceptive method from a pharmacy shop, clinic or hospital. They attributed this feeling to their perceived provider's negative reaction towards them. They all stated that providers would ask them a lot of questions including why they had come for a contraceptive method at this age, how old they were, what they were using "those things" for amongst others. They also felt the providers would think of them as bad girls and judge them because of their young age. As for me, I will feel very shy. They will ask you several questions. They will say you are too young. What are you using this pill for or why are you coming for this implant? (IDI with a 17-year-old girl) In addition, the girls feared providers would breach the confidentiality of their use of hormonal contraceptives. These negative feelings they said will make it very difficult to seek for hormonal contraceptive methods. The quotation below illustrates this feeling They will ask you what you have come there for and when you tell them and you leave the place, they will also tell other people. Maybe those people cannot also keep secrets so very soon people will start pointing their fingers at you when they see you passing. When that happens, I will not do it. (IDI with 17 year-old girl) However, most of these responses were based on the girls' expectations. Only one girl confirmed to have experienced such responses from a provider. Besides all these worries, one girl stated it would only be difficult the first time attending a clinic. After that, the people would know why she comes and stops asking the questions. --- Fear of Perceived Hormonal Contraceptive Side Effects Almost all adolescents had some form of misconceptions about contraceptives. They described several negative effects attributable to contraceptive use including infertility, sickness, extreme weight gain or weight loss (ie, you gain weight if the methods fit you or lose a lot of weight if it does not fit you), changes in the menstrual cycle and colour of blood, heavy bleeding, spotting, constant bleeding, amenorrhea, dysmenorrhea, amongst others. Other issues mentioned include body weakness, dizziness, fainting, blood clots during menstruation, miscarriages, and becoming epileptic.... I have heard that someone went to insert one (the implant) and when she came back to work with it, she collapsed and since that, she is been epileptic. (18-year-old girl in an FGD) Specifically, for the implant, they said it could dislodge to other parts of the body. I know one lady who was using the implant. When it was time for her to get married, the thing had made her grow so fat so they went to the hospital to get the thing out but they could not find everything. One of them was missing and they could not find it. (17-year-old girl in an FGD) Moreover, some of the girls expressed a strong fear of the side effects of hormonal contraceptives. This fear emanates from unpleasant experiences other people have had from the use of hormonal contraceptives. The thought of these perceived side effects deterred them from using the methods. I had a friend who was using it (implant) but it was worrying her so she took it out and then later she became pregnant but she had a miscarriage. So, when we went to the hospital, they said it was because she was using the hormonal contraceptive method that was why she lost the baby. The implant got mixed in her blood. (18-year-old girl in an FGD) In line with this, it came out strongly that adolescents were better off using short-term methods, to prevent risks related to using long-term methods.... It is just that I think we should not use the long term methods like the one for five years. At least you can take the monthly injections. (17-year-old girl in an FGD) However, one girl stated the need to switch between methods if one experienced an unpleasant effect. A friend of mine said when she did it initially (took the injection), it was good but later her bleeding pattern changed from one week to days... and she grew very fat. After some time, she had severe lower abdominal pain. Then later, she lost weight and began to faint... she said it is the injection. So, she stopped and she is now using the pills and all those effects stopped. (18 year old girl in an FGD) https://doi.org/10.2147/OAJC.S320038 --- DovePress Open Access Journal of Contraception 2021:12 Anticipated Disclosure of Hormonal Contraceptive Use The girls had divergent views about openly disclosing their use of hormonal contraceptive methods. Most of them expressed lack of willingness to disclose their hormonal contraceptive use. They would be worried for people, including their friends, to find out they used hormonal contraceptives. They feared people who would find them using hormonal contraceptives would perceive them to be bad girls, hence spreading rumours about them. This they indicated would make them feel bad, shy and embarrassed. Oooh...! in my school when they saw someone using contraceptive they started gossiping about that person. They said the girl can't live a chaste life. They even think that she is a prostitute. So, I will not like to use it so that people will talk bad about me. (IDI with a 16-yearold girl) However, for some girls, it would not be a problem if people close to them (mothers or sisters) got to know about their hormonal contraceptive use because they could trust them to keep it as a secret. --- Interpersonal Factors Peer Influence Participants "learn" a lot about hormonal contraceptives from chatting with their friends and the opinions and stories (whether true or false/gossiping) told by these friends appeared to have quite some influence on their decision to use, considering examples they provided. The often mentioned negative opinions of friends had a lot of overlap with the misconceptions about the side effects of hormonal contraceptive use (eg, it harms you, causes health problems, etc.). For me it is because of the lady who went to do it and the thing got missing in her arm. I hear it makes you so fat and the thing can get lost in the body. That is why I have decided not to use it. (FGD with 15 to 19-year-old girls) The positive opinions expressed by friends were that hormonal contraceptive is good, protective, helpful, gives you good curvy shape, helps in finishing school, and shows you take responsibility. However, on the other hand, when asked about the influence their friends had on them, they tended to strongly state they did not care and some gave examples of how their opinion was contrary to those of friends. --- Parents' Influence Almost all the adolescents reiterated that their parents would be very displeased if they found them using hormonal contraceptive methods. They anticipated their parents would think of them as very bad girls mostly because they are not of age to have sex in the first place. It is perceived as sinful behavior and being disrespectful towards the parents. Their parents would be disappointed in them, they would nag, scold them, may refuse to pay their school fees or even drive them away from home. These reactions from their parents would, in turn, make the girls feel shy and embarrassed. I think they will drive me away from home... they will say I am a bad girl. They will think that you have sex and you have a boyfriend. They will insult you and you won't feel happy. They will embarrass you and they will refuse to pay your school fees. They will ask you to let your boyfriend pay for your fees. (IDI with an 18-year-old girl) However, a few of the girls were more positive (ie, it's better to use hormonal contraceptive than becoming pregnant) especially when they would first discuss it with their mothers before going for a method. Once they did that they were sure their mothers would not have a problem if they got to know. They, however, alluded to the point that if they did it without pre-informing their parents, the parents would be angry at them. --- Anticipated Response from Partner Some of the girls who were asked to anticipate the opinion of their boyfriends on their use of hormonal contraceptive methods had different responses. They mostly did not think that their boyfriends would react negatively towards them for protecting themselves. Indeed, some mentioned that they thought their boyfriends would be happy if they found that they were using hormonal contraceptive methods because they could have sex without worrying about pregnancy. Oh nowadays, as for the boys, they like girls who use it. Hahhahhaa... I think they will be happy because as you have sexual intercourse, they know that nothing will come out of it. (IDI with a 16-year-old girl) One girl stated that her boyfriend's displeasure about her using a hormonal contraceptive method did not matter to her. As illustrated below That means he will not touch me hahhaahaaa... I will tell him the reason why I did it and if he doesn't agree, then that means he won't touch me haha haha. (IDI with a 19year-old girl) One girl strongly stated that her boyfriend would not be happy, especially when she does not discuss it with him in advance. --- Community Factors --- Role of Religion The majority of the girls stated that (their) religion (Christianity or Islam) is against the use of hormonal contraceptive, especially for adolescent girls. It is considered a sin, against the will of God. It resembles an abortion and it is against God's planned number of children for you. Some Christians like "Gyidi" people, they cannot use it because they are always giving birth so they cannot use it... They say it is sinful... it is against their religion. They say that The Bible indicates that we should have as many children as the sea sand so assuming that God has given you eight children and you continue to use the family planning so that you give birth to only 3 children, it is sinful. (19year old girl in an FGD) I also know an Islamic lady who went to do it and her husband was angry with her. Because it is something they don't like, her arm began to rot. I don't think it is the method that resulted in her arm rotting but I think it is because her husband spoke against it... she went to take it off and the rotting stopped. (17-year-old girl in an FGD) Almost all of them indicated their religious leaders would be disappointed in them if they got to know they used contraceptive methods. They expected their Pastors and Imams would see them as very bad girls who refuse to abide by the teachings or rules and regulations of the religion on the abhorrence of early and pre-marital sex including contraceptive use. They will think that you are not religious and then as a child, they always advise us to live a chaste life before marriage so they won't be happy with you. They think that since you are using the family planning method you have a boyfriend. (IDI with a 16-year-old girl) One of the girl said she may miss out on an opportunity to get married because her Imam would not recommend her in case there was such an opportunity. They declared these responses will make them feel bad, sad, refuse to go to church or even put a stop to their contraceptive use. if a man is looking for someone to marry. he will say I am a bad girl so he won't recommend me. He will say that I am having sex that is why I am using contraceptives. I will miss opportunities because he will recommend another person. (IDI with an 18-year-old girl) --- Perceived Community Norms Almost all the girls perceived that the community would react negatively to their contraceptive use. They maintained that society sees contraceptive use as a preserve of only married adults therefore children are not supposed to use them. Consequently, children who use them are considered as bad girls and promiscuous and some of them may get insulted for that. They also professed that if people should see them using contraceptives, they would spread rumors about them in the community.... in the Ghanaian society when they see you using those things, they will say that ah this child, how can a child like you be using family planning? Hhaahaahaa you are a town helper (IDI 16-year-old girl) Only two girls seemed to be more resilient and stated that "we need to quit the shyness" (as getting pregnant is still worse) and "no please it (ie, their opinion) will not affect me". --- Discussion Using in-depth interviews and focus group discussions, we determined factors that negatively affect the use of hormonal contraceptives among adolescent girls in the Kintampo area of Ghana who reported that they had no experience in the use of hormonal contraceptives. Non-use of hormonal contraceptives among the adolescents was explained by a combination of individual-, interpersonal, community and institutional-level factors. At the individual level, poor knowledge of the different hormonal contraceptive types and their mode of action, negative attitudes towards adolescent hormonal contraceptive use, lack of selfefficacy to organise hormonal contraceptives, fear of real and perceived side effects of hormonal contraceptive use and fear of disclosure explained why the sexually active adolescents in this study did not use hormonal contraceptives. The interpersonal, community and institutional levels showed a strong association between social normative beliefs and hormonal contraceptive use amongst adolescents. Disapproval of hormonal contraceptive use, both expected and actual, by parents and peers, and societal disapproval and stigma toward pre-marital sex and contraceptive use by the community and religious groups, explained why adolescent girls in this study did not use hormonal contraceptive methods. Our results showed that adolescents in this study had superficial knowledge on hormonal contraceptives. Though they could mention some hormonal contraceptive methods, their knowledge on the mode of action of these hormonal contraceptive methods in preventing pregnancy was poor. Studies have generally reported in support of our study the low levels of detailed knowledge of hormonal contraceptive among adolescents from different parts of the world, 48 as well as the negative impact that lack of knowledge has on (hormonal) contraception use. 30,48. A lack of knowledge may be explained by the fact that young people are often not given clear, correct and full information regarding matters of sex and sexuality at home and at school. 48,49 In the Ghanaian context, issues related to sex are practically not discussed at home and are sketchily taught as part of a few core and elective subjects in school. 50 This may explain why the adolescents in this study did not have in-depth knowledge about the different hormonal contraceptive methods and consequently, did not use them. To improve adolescents knowledge on hormonal contraceptives, efforts should be geared towards provision of in-depth knowledge about hormonal contraceptive types, mode of action and side effects to adolescents when they visit the facility for contraceptives and also through mass media and school health programs. A negative attitude towards adolescent hormonal contraceptive use was another important finding associated with the non-use of hormonal contraceptives among adolescents in this study. Most adolescents in this study approved of hormonal contraceptive use among married adults, to help them space up their children while they work. However, young girls and unmarried adults using contraception were perceived to lack good sexual morals. This negative attitude is likely shaped by prevailing descriptive social norms, that discourage pre-marital sex in most African societies including Ghana 39,51. Sexual intercourse in most African societies is not an activity meant for "children" and society's disapproval of sexual intercourse among young people inherently prohibits contraceptive use amongst them. 39,51 Agha et al highlighted a strong negative association between contraceptive use and social norms that discourage pre-marital sex and contraceptive use among adolescents 39. This finding supports results from other similar studies. 51,52 Another barrier to hormonal contraceptive use reported in this study is the lack of self-efficacy to organise hormonal contraceptive methods. This finding is similarly reported in other studies where adolescent's refuse to go for contraceptives from health facilities and chemical seller shops, attributable to feelings of embarrassment and shyness associated with securing contraceptive methods from the various sources. 31,52,53 The feeling of embarrassment emanates from adolescent's anticipated negative reaction from providers, community gossip and labelling of promiscuity, as a response to early sexual activity among

Background: Adolescent pregnancy remains a public health concern globally. The use of hormonal contraceptive methods are proven ways of preventing pregnancies and in turn unsafe abortions. However, research shows that use of hormonal contraceptive methods is rather low among African adolescent girls, of which Ghana is no exception. Objective: This manuscript uses the socio-ecological model to guide our understanding of the factors associated with non-use of hormonal contraceptives among adolescent girls in Ghana. Methods: An explorative study was done using qualitative data collection methods. Two focus group discussions and sixteen in-depth interviews were conducted among adolescent girls aged 15-19 years (N = 38) in the Kintampo area of Ghana to determine factors affecting uptake of hormonal contraceptives. Results: Adolescents showed a lack of in-depth knowledge related to the different hormonal contraceptive types. Negative attitudes towards adolescent hormonal contraceptive use, fear of real and perceived side effects of hormonal contraceptives, lack of self-efficacy to use contraceptives, fear of disclosure of use and fear of societal stigma related to sexual intercourse and its related issues among adolescents may explain why adolescent girls in this context do not use hormonal contraceptive methods.To promote hormonal contraceptives among adolescent girls, a combination of multifaceted social-psychological, personal and community level interventions are needed.

that discourage pre-marital sex in most African societies including Ghana 39,51. Sexual intercourse in most African societies is not an activity meant for "children" and society's disapproval of sexual intercourse among young people inherently prohibits contraceptive use amongst them. 39,51 Agha et al highlighted a strong negative association between contraceptive use and social norms that discourage pre-marital sex and contraceptive use among adolescents 39. This finding supports results from other similar studies. 51,52 Another barrier to hormonal contraceptive use reported in this study is the lack of self-efficacy to organise hormonal contraceptive methods. This finding is similarly reported in other studies where adolescent's refuse to go for contraceptives from health facilities and chemical seller shops, attributable to feelings of embarrassment and shyness associated with securing contraceptive methods from the various sources. 31,52,53 The feeling of embarrassment emanates from adolescent's anticipated negative reaction from providers, community gossip and labelling of promiscuity, as a response to early sexual activity amongst them. Programs aimed at building decision-making skills, assertiveness and self-confidence in adolescent girls could be an effective way of shaping their self-efficacy and hence, improving their hormonal contraceptive use decision making and subsequent uptake. An additional significant finding that explains the nonuse of hormonal contraceptives is the girls' strong perception and fear of side effects of hormonal contraceptives, similar to findings from other studies 29,52,53. Popular among the perceived side effects was future infertility. Some of the girls expressed the fear that the substance injected or implanted into the body could get mixed in the blood and stay in the system for long periods, which could cause miscarriages or lead to future infertility. In most African countries, childlessness is stigmatized, making childbirth a very important accomplishment. Indeed, one's success in life and social status is highly associated with the ability to bear children and sometimes the number of children one has. 29 Therefore, the use of anything with the potential to interfere with one's child bearing ability will be highly feared and avoided. In addition to the fear of future infertility, adolescents also expressed worry about specific side effects related to using the implant. Though dysmenorrhea, amenorrhea, headache and dizziness are supported by literature as side effects of using implants, 54 the popular belief that the implant could get missing in the body and also cause epilepsy is misconstrued. These misconceptions may have been fueled by ignorance and or misinformation from friends and other community members. However, the notion of dislodging implants appears to be common among Ghanaian youth as well as adults. 55 It is imperative therefore to direct interventions to disabuse adolescents' minds of their negative perceptions and misconstrued ideas about the side effects of hormonal contraception use. Out-reach to schools, places of worship and market centres could be very useful for sensitizing adolescents by health workers. Furthermore, fear for disclosure of contraceptive use emanating from societal disapproval of hormonal contraceptive use amongst adolescents was reported as a key deterrent to hormonal contraceptive use reported in this study. Whether actively, or passively, adolescents in this study would be unwilling to disclose contraceptive use to their important others. They feared that if these people became aware of their hormonal contraceptive use, it would be disapproved of and consequently result in stigmatization or even aggressive responses. 52,56 Such disclosure issues which are rarely reported in hormonal contraceptive use literature are often seen within the context of a set of social norms which sanction "immoral sexual practices". 57 Research on treatment adherence have shown that lack of disclosure can negatively influence adherence which in turn results in all kind of health issues. [58][59][60] Adolescents' ability to disclose their hormonal contraceptive use or intentions to use especially to experienced adults such as parents and health workers may potentially expose them to the right information about the different contraceptives and their mode of action, to disabuse their minds of some of their misconceptions and take away their fears to promote use. Interventions targeting parents' and improving parent-child communication on sexuality-related matters may be a solution. Lastly, adolescent's religious beliefs which prohibit the use of hormonal contraceptive prevent them from using hormonal contraceptives. Some Christians and Muslims believe that children are gifts from God and trying to stop them from coming by whichever means including the use of contraceptives is sinful as reported in other studies. 57,61,62 In Nnalwada's study, adolescent's reported that contraceptive use was viewed as murder in religious circles. 62 The phenomenon may explain why some religious leaders oppose contraceptive use. Religion is a very important component of the Ghanaian society. Christian and Islamic religions are highly practiced. Most of the religious laws and beliefs are consistent with, and reinforce societal norms, compounding adolescents' dilemma to use hormonal contraceptives. Societal norms are very difficult to change, 63 however, parents, religious leaders, teachers and community opinion leaders are very important agents in promoting change. It is important to educate them on the need for adolescents to have access to contraceptive use information and services and the risks to adolescent's wellbeing if these needs are not met. To conclude, non-use of hormonal contraceptives among adolescents in this study was explained by a combination of individual, interpersonal, community and institutional-based factors, shaped by social normative beliefs. Generally, the reasons for non-contraceptive use reported in other studies are similar to what we found as reasons for non-hormonal contraceptive use in this study. However, in addition to these reasons, fear of real and perceived side effects of hormonal contraceptives in general and perceived side effects of specific hormonal contraceptive methods, and disclosure issues are very strong reasons for non-use. A quantitative study to test the relative significance of the identified determinants of hormonal contraceptive use, to inform the content of interventions to promote hormonal contraceptive use, in order to reduce the occurrence of adolescent pregnancy in the Kintampo area of Ghana is desirable, so we plan to embark on one. It is worth to mention some limitations. Our study findings represent opinions from a few adolescent girls in the study area and make the study findings not generalizable to all other Ghanaian adolescents and, for that matter, other adolescents in general. The strength of this paper is that, though the adolescents' expressed opinions, believes and values were the same in both the focus group discussions and in-depth interviews, using both data collection methods was very useful. In the in-depth interviews, adolescents provided sensitive information that they may have avoided had it been in a focus group discussion. In the focus group discussions, discussants portrayed divergent ideas where necessary, made the point and gave examples to back their claim. This generated very rich diverse group data. during recruitment that data collection would be anonymous and that participation was voluntary. We also explained that participants had the right to decline participation or withdraw their consent at any stage of the study, or decline to answer any question they did not feel comfortable about and that one was free to stop the interview without having to offer any explanation. Finally, the prospective participants were assured of strict confidentiality regarding information collected; that only aggregated data will be made available as part of scientific and public dissemination. Written informed consent was obtained from the [individual(s) and/or minor-(s)' legal guardian/next of kin] for the publication of aggregated study results and any potentially identifiable images or data included in this article. --- Data Sharing Statement Data supporting the results reported in this manuscript is available upon request. Interested persons may contact the corresponding author. --- Ethics Approval and Informed Consent Ethical approvals were obtained from the Kintampo Health Research Centre Institutional Ethics Review Committee (FWA number 00011103) and the Ethical Review Committee, Psychology and Neuroscience at Maastricht University (Reference number ECP_04_09_2012_S23). Also, permission was sought from the management of the youth facilities and schools where participants were recruited. We explained to the prospective study participants https://doi.org/10.2147/OAJC.S320038 --- DovePress Open Access Journal of Contraception 2021:12 --- Author Contributions All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. --- Disclosure All authors declare no conflict of interests, be it financial or otherwise in this work. --- Open Access Journal of Contraception --- Dovepress --- Publish your work in this journal Open Access Journal of Contraception is an international, peerreviewed, open access, online journal, publishing original research, reports, reviews and commentaries on all areas of contraception. In addition to clinical research, demographics and health-related aspects, the journal welcomes new findings in animal and preclinical studies relating to understanding the biological mechanisms and practical development of new contraceptive agents. The manuscript management system is completely online and includes a very quick and fair peer-review system. Visit http://www.dovepress.com/testimonials. php to read real quotes from published authors.

Background: Adolescent pregnancy remains a public health concern globally. The use of hormonal contraceptive methods are proven ways of preventing pregnancies and in turn unsafe abortions. However, research shows that use of hormonal contraceptive methods is rather low among African adolescent girls, of which Ghana is no exception. Objective: This manuscript uses the socio-ecological model to guide our understanding of the factors associated with non-use of hormonal contraceptives among adolescent girls in Ghana. Methods: An explorative study was done using qualitative data collection methods. Two focus group discussions and sixteen in-depth interviews were conducted among adolescent girls aged 15-19 years (N = 38) in the Kintampo area of Ghana to determine factors affecting uptake of hormonal contraceptives. Results: Adolescents showed a lack of in-depth knowledge related to the different hormonal contraceptive types. Negative attitudes towards adolescent hormonal contraceptive use, fear of real and perceived side effects of hormonal contraceptives, lack of self-efficacy to use contraceptives, fear of disclosure of use and fear of societal stigma related to sexual intercourse and its related issues among adolescents may explain why adolescent girls in this context do not use hormonal contraceptive methods.To promote hormonal contraceptives among adolescent girls, a combination of multifaceted social-psychological, personal and community level interventions are needed.

Nationally, there are actually several forms of policies and regulations aimed at resolving and preventing cases of child marriage. First, at the end of 2019, the government issued the Undang-Undang Nomor 16 Tahun 2019 concerning Amendments to the Undang-Undang Nomor 1 Tahun 1974. In the new regulation, changes have been made to the minimum age for marriage. If the previous regulation states that a person is allowed to marry when he is 16 years old for women and 19 years for men. Meanwhile, the new regulation states that a person is allowed to marry when he is 19 years old for both men and women. Second, the government, through the Badan Koordinasi Keluarga Berencana Nasional/BKKN (National Population and Family Planning Agency), has in recent years intensively carried out campaigns for maturing the age of marriage. The substance of the program is to encourage people to get married when they are 21 years old for both men and women. Related to the national policy and local policy in Dompu district, the researcher views that all of these policies and regulations have the same orientation, which is equally oriented towards strengthening public understanding of the risks of early marriage. In addition, the researcher views that local policies in Dompu district are derived policies from national policies. Because as explained earlier that all policies, both national and local, are policies for maturing the marriage age of the community. Based on this explanation, the researcher is interested in conducting research with the aim of knowing the results of the evaluation of the implementation of the policy on preventing child marriage in Dompu Regency in the 2016-2021 Period. Prevention policies referred to in this study are several forms of policies implemented by the local government of Dompu which are oriented to prevent the increasing number of cases of child marriage. What becomes the urgency of this research is that in recent years Dompu Regency has become one of the regencies in West Nusa Tenggara Province with the highest number of child marriage cases. However, one of the interesting things is the decrease in the number of cases from year to year. This shows that there are good implications from the implementation of several policies and programs by the regional government. So that the results of this research will later be able to become a policy reference that can be continued by policy makers in the next few years to overcome the problem of child marriage. It can even be a policy reference for governments in other regions. --- B. LITERATURE REVIEW Policy As we know the policy is any form of decision or choice taken by the government. Policy is not only understood as a form of government action, but policy is also intended as an attitude taken by the government, including when the government chooses to remain silent and does nothing (Thomas R. Dye in Syafiie, 2006). The policy implemented by the government is a step that has clear objectives. A policy does not only come in the form of a statement, but is also carried out in a directed manner in order to achieve the desired goals (Dye in Harbani Pasolong, 2008). Referring to the explanation of the theory, the efforts made by the local government of Dompu district in preventing the increase in the number of cases of child marriage can be regarded as a form of policy, because these actions are carried out by policy makers as parties who have the authority to formulate and implement policies. In addition, these actions are forms of action that have clear goals and are carried out in a directed and systematic manner. --- Policy Evaluation Policy evaluation can be understood as a form of action to evaluate a policy. There are many things that are assessed, such as how the process of implementing the policy, what the results are, and what are the strengths and weaknesses of the policy. So that the final result of the implementation of a policy evaluation is to obtain an overview of the entire series of policies. This description then becomes a reference for policy makers to consider whether the policy is still appropriate to be implemented or not (Dunn, 1999). There are several policy evaluation models that can be used as a research analysis knife. The policy model is as follows (Farida Yusuf Tayibnapis, 2000): 1) Content, Input, Process, and Product (CIPP) evaluation model. This policy evaluation model consists of several types of policy models that can be used all or only some that are adapted to the research context. Several types of evaluation models are (1) Contect evaluation to serve planning decisions; (2) Input evaluation structuring decision; (3) Process evaluation to serve implementing decision; and (4) Product evaluation to serve recycling decision. 2) Evaluation of Stake Model or Countenance Model. This policy evaluation model consists of several stages or evaluation aspects, namely the stages of input, process, and results. Of the two proposed policy evaluation models, the researcher uses both of them as the analytical knife of this research. In the Stake evaluation model, researchers used the last two stages, namely the process and outcome stages. The researcher considers that the two stages are in accordance with the research context. While in the CIPP evaluation model, the researcher uses the Product evaluation to serve recycling decision model. By using this model, researchers will evaluate policy products that include several aspects of the advantages and disadvantages of the policy. --- Children Marriage As it is understood that child marriage is a marriage carried out by someone who is not yet 18 (eighteen) years old. This is based on the understanding of children according to WHO and child protection laws. These regulations and organizations both explain that what is called a child is someone aged 0 (zero) to 18 (eighteen) years, including those who are still in the womb. --- Prevention of Children Marriage As we know prevention is an effort or a group of efforts made by certain parties that aim to make something impossible. Prevention in this study relates to the efforts made by the government in preventing or avoiding society, in this case people who are still children are involved in marriage. Child marriage is a problem because child marriage poses a high risk for children involved in marriage and has a negative impact on the development process of an area. Maybe it will be a different story when child marriage is not a problem. On the basis of the existence of child marriage as a problem that prompted the presence of this research. --- C. METHOD This research is an analytical descriptive research using a qualitative approach. This research was conducted in Dompu Regency which was determined purposively based on the background of this research problem, namely the Dinas Perlindungan Pemberdayaan Perempuan dan Anak/DP3A (Office for the Protection of Women and Children Empowerment) Dompu Regency. This research conducted in May 2021. Data collection techniques used interview and documentation techniques using research instruments such as researchers, interview guidelines, and cellular phones. The subjects and informants of this study consisted of Mrs. Daryati Kustilawati as the Head of the DP3A Dompu Regency; Hairil and Sukma as parties involved in child marriage; and Mrs. Kalisom as the community. In carrying out this qualitative research, the researcher uses three components of analysis, namely data reduction, data presentation, and drawing conclusions with verification. --- D. RESULT AND DISCUSSION The Process of Implementing Child Marriage Prevention Policies in Dompu Regency in the 2016-2021 Period Dompu district is one of the districts with the highest number of child marriage cases in the province of West Nusa Tenggara. In 2017, Dompu district ranked third as the district with the highest number of child marriage cases in the province. The first and second ranks are occupied by the districts of East Lombok and West Lombok. The case of child marriage in Dompu district is caused by several things. The first causative factor is pregnancy out of wedlock. Marriage is used as the only way out to cover the shame of the family. Pregnancy outside of marriage is caused by many things, including promiscuity and juvenile delinquency as well as the influence of the spread of pornographic videos/photos. In 2011, through a survey of the influence of technological developments on child marriage by the the Forum Anak Dompu (Children's Forum), it was found that 62% of teenage boys and girls admitted to having watched pornographic videos. It was also found that 27% of teenage girls (aged 14 to 17 years) claimed to have had sex. The first causal factor is in accordance with what is explained by Suryowati (2018), that pregnancy outside of marriage is the most common factor causing child marriage in Indonesia. For reasons of their own volition or parental coercion into something that is hardly found. This means that when asked the children about whether they want to get married at a very young age, the children did not answer that they wanted to. In fact, marriage at a very early age is the least desired by them. However, when they are already involved in promiscuity and they experience pregnancy before marriage, then like it or not they have to be married off. The second causative factor is the education factor. The low understanding of the community and children about the risk of marriage is a fundamental factor in the occurrence of child marriage in Dompu district. Ignorance of children about the risks of child marriage in various aspects occurs because at school they are never given education about it. Children are also very rarely included in various socialization activities held by the relevant government. The second causal factor is in accordance with the study results of the Pusat Studi Kebijakan Kependudukan, UGM (2019), which shows that there is a relationship between the educational status of parents and cases of child marriage. Parents with low educational background are assumed to be parents with minimal knowledge about the risks of child marriage. With this limited knowledge, it makes parents more free to marry off their children because for these parents that marrying their children is the best way to reduce the family's economic burden. Even though this thought is very wrong considering the bad risks when marrying a very young child. The third factor is the economic factor. Based on research data, it can be understood that most cases of child marriage in Dompu occur in rural areas where the average community has low educational background and works as farmers and laborers. For these people, marrying off children is the best way to reduce the family's economic burden. Even though the facts show that marrying off children actually adds to the family's economic burden. The researcher views that this idea is a misleading thought that still lives on the outskirts of society. The third causal factor is in accordance with the research results of the Pusat Studi Kebijakan Kependudukan, UGM (2019), which shows that poor families tend to have a strong desire to immediately marry off their children even though their children are still children. This happens because there is still an assumption that marrying off children means reducing the family's economic burden, even though this assumption is clearly wrong. The fourth causative factor is the issue of the minimum age limit for marriage. Before the Undang-Undang Nomor 16 Tahun 2019 concerning amendments to the Undang-Undang Nomor 1 Tahun 1974, the regulation that becomes a reference related to the minimum age limit for marriage is the Undang-Undang Nomor 1 Tahun 1974. The regulation states that a woman is allowed to marry when she is 16 years old. The age limit for marriage is considered to provide opportunities for child marriage in Indonesia, including in Dompu. People think it is not a mistake to marry a child who is still 16 years old, because the regulations allow it. Even though the facts on the ground show that let alone someone who is 16 years old, someone who has just entered the age of 19 or 20 is still not ready to get married. This unpreparedness is intended for economic, mental, and physical aspects. The fourth causal factor has similarities with what is described by Alfafan (2017) in his research that the conflict of regulation and policy is one of the factors that influence the occurrence of child marriage cases. In Indonesia, previously the law used as the basis for marriage was the Undang-Undang Nomor 1 Tahun 1974 concerning marriage. In the regulation, it is stated that a person is allowed to marry when he is 16 years old for women, and 19 years old for men. Then in 2019, the regulation was amended by the signing of the Law concerning amendments to the 1974 Marriage Law. In the latest regulation, the age limit for marriage was changed, namely for both women and men, the minimum age for marriage is 19 years. However, even though there have been changes to regulations and limits on the age of marriage, these regulations are still not in line with government policies that encourage maturation of the age of marriage. The government through the BKKN in recent years has intensively carried out a campaign to mature the marriage age. The essence of the movement is to encourage people to get married when they are 21 years old for both women and men. With the conflict and discrepancy between these regulations and policies, it is possible to create public ambiguity. The fifth causal factor is the tradition factor. In Dompu Regency, there are immigrant communities who occupy several areas in the Manggelewa and Pekat sub-districts. The immigrant community comes from the island of Lombok who is of the Sasak ethnic group. So that the tradition that applies to the community is the tradition of origin. In the Sasak community, there is a tradition called the Merarik Kodeq tradition. This tradition is a marriage tradition because it is selarian. When a girl is taken away by a man and the girl is not brought home until 12 o'clock at night, it is obligatory for both partners to marry. It doesn't matter what age. As a result of this tradition, one of the factors in the occurrence of child marriage cases in Dompu district is the tradition factor of the Sasak community. The fifth causal factor is in accordance with the research results of the Pusat Studi Kebijakan Kependudukan UGM (2019), that there is a relationship between the existence of traditions in a region to the occurrence of child marriage cases. Of these several factors, the tradition factor is the most common cause of child marriage cases in Dompu district. This is evidenced by data showing that the highest number of cases of child marriage in Dompu Regency occurred in the Manggelewa and Pekat sub-districts, where both sub-districts were mostly inhabited by Sasak people. In addressing these public issues, the Dompu district government, through the DP3A implemented several policies to resolve and prevent the increasing number of child marriage cases in the area. The first policy is the establishment of the KPAD (Village Child Protection Commission). This program was designed and included in the Dompu Regency DP3A Work Plan and Budget at the end of 2015 and began to be implemented in early 2012. The task of the KPAD is to disseminate information to the community about the risks of child marriage. The socialization was carried out either through visiting community associations or inviting the community to attend meetings held by the KPAD. Each KPAD in each village has one community complaint post as well as a secretariat. The second policy is the Simultaneous Motion Module Program. This program was agreed upon and carried out together with the Dinas Kesehatan Dompu (Health Office). The Simultaneous Motion Module is a module that contains complete material on the risks of child marriage, adolescent reproductive health, and the dangers of drugs. This module is socialized in the village community by making children and young couples the main targets. The third policy is to make the KRR (Adolescent Reproductive Health Education) for each SMP/MTs and SMA/MA/SMK level schools in Dompu district. This program was implemented on the basis of an agreement between Plan Internasional and the DP3A, the Dinas Pendidikan Dompu and NTB (Education Offices). In implementing this policy, all junior high and high school levels in Dompu Regency were instructed by the Education Office to make KRR education a local content. Each school allocates 2 (two) hours of lessons per class once a week. The teachers who are in charge of local content are teachers who provide the BK (Counseling Guidance) who were sent by their respective schools to attend training facilitated by Plan International and the DP3A. The facilitators presented were facilitators from Plan Internasional Indonesia in Jakarta who handled the Child Protection program. The training is not only held once, but once every quarter, which is located in Dompu, where one event is held for 3 to 4 days. The fourth policy is the selection of peer counselors. Peer counselors are selected students from each junior and senior high school who are trained by Plan International Dompu and the DP3A Dompu facilitators. One school has 2 (two) peer counselors. The peer counselors are given training so that they have the skills to become counselors who are able to provide counseling to their peers both in the school environment and in the social environment. Based on the explanation related to the process of implementing the policy to prevent child marriage, the researcher has several conclusions. First, Dompu district is one of the districts with the highest number of child marriage cases in the province of West Nusa Tenggara. For researchers, of course this is not an achievement to be proud of. This is one of the sad and serious problems that requires a policy resolution by the policy makers in Dompu district. Second, there are several factors that cause child marriage cases. These causes are factors of pregnancy outside of marriage, education, economy, regulation and tradition. From these several factors, it is concluded that the traditional factor is the most common cause of child marriage cases in Dompu. Actually, there is no concrete data that mentions this, but according to the researcher, the reason that makes the tradition factor the most frequent factor in the presence of child marriages in Dompu is because based on the data on the distribution of child marriage cases in the area, it was found that the most cases occurred in the Manggelewa district and Concentrated. Based on the data, it is known that there are quite a lot of Sasak people as immigrant communities who occupy the two sub-districts. As it is known that the Sasak people have a tradition of "merarik kodeq", which is a tradition that marries someone who is still a child when the child is known to have been taken away by his partner. For the Sasak people, when a young girl is taken away by her partner, then the action is considered an act that violates the norms and tarnishes the Islamic religious values that are embraced by most of the Sasak community, so the steps that must be taken are the family is marry off his son. Related to this issue, in this case the researcher assumes that this tradition cannot be fully justified considering the greater bad risk when forcing the child to marry. According to researchers, marrying children has a greater bad risk than not marrying children even if they are considered to break tradition. Researchers believe that this tradition can still be compromised. The courage of the researcher to make such an argument is based on the facts and knowledge of the researcher related to the tradition. For researchers, it is perceived that a girl has been taken away by her partner and does not return home after 12 o'clock in the evening, does not mean that the child should be married off. Because it is not necessarily the girl who has committed adultery and things that are considered to violate the norms and values of the Islamic religion, in response to this, community leaders and families should sit down together and discuss solving problems without making marriage the only solution. The public must understand that marrying a young woman will be a very big risk. Their children cannot go to school, the risk of maternal and child mortality is high, and they tend to become unemployed after marriage, which has implications for the increasing number of unemployed and poor people. Third, to solve the problem of child marriage, nationally there are several policies, such as the enactment of the latest marriage law. In the regulation, it is stated that a person is only allowed to get married when someone is 19 years old for women and men. In addition, there is also a marriage age maturation program carried out by the BKKBN (National Population and Family Planning Agency). In addition to national policies, the Dompu district government has also formulated and implemented several policies to prevent the increasing number of cases of child marriage. Related to this, the researcher views that the Dompu district government does not only focus on implementing national policies, but chooses to be more proactive. If we look at several existing policies, both national policies and policies at the regional level, all of these policies are oriented to instilling public understanding about the risks of marriage. According to the researcher, when some of these policies are policies that target the strengthening of public understanding, it can be said that some of these policies are appropriate. Because almost all problems in society stem from a lack of understanding, so is the case with the issue of child marriage. When the community's understanding is strong about the risks of child marriage, the community will have a more vigilant attitude towards child marriage. Parents will be more closely supervised children. Children will also think twice about doing things that allow them to be involved in marriage. In fact, according to the researcher, the best way to solve the problem of child marriage due to traditional factors is to strengthen public understanding of the risks of child marriage. A traditionalist society is a society that has a traditional understanding and is less advanced. So the best way to change tradition is to change people's perspective. When the community already has an advanced understanding of child marriage, then the community will be more responsive and ready to take an attitude to prevent child marriage in their environment. --- Results of the Implementation of the Policy on Prevention of Child Marriage in Dompu Regency in the 2016-2021 Period There are several results from the implementation of several forms of policy or child prevention programs in the Dompu district which were carried out by the Dompu district government, in this case the Dompu district DP3A in partnership with several parties in the 2016-2021 period. First, it has been able to provide good results in preventing the continued increase in cases of child marriage in Dompu district in the last few years in the 2016-2021 Period. This is evidenced by the data on the number of child marriage cases released by the Ministry of Religion of Dompu Regency, where from year to year there has been a significant decrease in the number of child marriage cases in Dompu Regency. In 2017, the number of cases of child marriage in Dompu Regency was 234 cases. In 2019, there were 186 cases of child marriage. Based on these data, it can be understood that from year to year, the number of cases of child marriage in Dompu Regency has decreased. Second, some of these policies were adopted or maintained by the current government, namely for one period in the future. This is based on the consideration that currently Dompu district is still an area with a high number of child marriage cases. Then the policy makers consider that several forms of policies implemented in the previous period are considered appropriate to continue to reduce the number of cases of child marriage in Dompu district. Third, people are increasingly aware of the risks of child marriage. Parties who were married at the age of children admitted that they had regrets when they were already involved in cases of child marriage. After getting married, he is faced with the real reality of life that life after marriage, especially in conditions that are not ready and mature, is very difficult. He was faced with economic problems. He had to think about what to do to earn money to support his wife and child. In the past, the reason that made the party married was the juvenile delinquency factor and pregnancy out of wedlock, so that the two families inevitably have to marry both of them who are still students in high school. After marriage, the party admitted that married life was very difficult. With limited work skills and still being unemployed, the lives of the two people are really destitute. They are still living in their parents' house. Minimal source of income, eating is really tough, there is no money to buy milk, the wife's body is getting thinner, conflict with wife almost every day, not to mention the addition of the neighbor's gift, because someone who gets married at the age of a child will definitely become a victim of gossip from society. In addition, parents increasingly understand the risks of child marriage and decide to be strict in educating and supervising their children so that they are not free to socialize. For parents, it becomes something that is very embarrassing when their child gets married at a very early age. Moreover, the marriage was caused because her child was pregnant out of wedlock. Sometimes in these conditions, parents and families are in a dilemma. Her child is already pregnant but the only solution is to get married. What parents want is that it is possible to marry off their child at the age of the child, not to be a burden of shame too heavy as long as the reason is that the child is not pregnant out of wedlock. It was as if he had fallen and was hit by a ladder. Between her child being pregnant and getting married, there are two things that must be accepted or not. For the Dompu community, there is no other way to do it when their child is found to be pregnant outside of marriage other than having their child married off, so as a conclusion that the existence of policies or programs to prevent child marriage by the local government makes the public more aware of the risks of child marriage. Parents should be strict in educating and supervising their children. Based on the results of the implementation of these policies, the researcher concludes that the policies implemented have gotten quite good results. The good result is that the number of cases of child marriage has decreased significantly from year to year. In addition, the implementation of these policies has had a good impact on public awareness and understanding of the risks of child marriage. Departing from this awareness and understanding so that a public perspective will be formed in order to avoid child marriage. Related to this explanation, when referring to what was explained by Nugroho (2014), that the main purpose of conducting a policy evaluation is to find out the results of implementing the policy. A policy, of course, starts from the formulation stage. This means that from the beginning a policy has been designed many things, one of which is the goal to be achieved. So the reason why a policy is evaluated is to see whether the goals set from the start have been achieved or not. So, policy evaluation must be understood as something positive, so the researcher considers that when in this study one of the things to do is to evaluate policies, namely to find out how much achievement and expectations a policy has, it can be judged that the policies implemented by DP3A Dompu district has received quite good achievements. Likewise, it is hoped that the implementation of some of these policies has been quite successful in preventing the number of cases from increasing from year to year and having a good impact on public understanding. --- Evaluation of the Implementation of Child Marriage Prevention Policies in Dompu Regency in the 2016-2021 Period Even though the implementation of several forms of policies or programs to prevent child marriage has succeeded in reducing or preventing the number of cases of child marriage from increasing significantly from year to year, understanding the public about the risks of child marriage, and making the current government adopt some of these policies, there are several This is the result of an important evaluation of some of these policies. The things that become the material for evaluation of the implementation of some of these policies can be explained as follows. In the policy of establishing the KPAD (Village Child Protection Commission), several things that need to be evaluated are: First, the KPAD is only formed in a few priority villages based on the number of cases per village in Dompu district. Villages with the highest number of cases become priority villages. The existence of such a policy makes efforts to prevent child marriage in Dompu district uneven, considering that almost every village in Dompu district, especially in sub-districts other than Dompu sub-district for cases of child marriage, is almost evenly distributed. This means that when KPADs are only formed in a few priority villages, it is considered an effort that is carried out unequally. This makes child marriage cases continue to occur in areas where KPADs are not established. Second, there is a limited budget in the implementation of the KPAD program. The policy for the formation of the KPAD is a program that does not only reach the establishment and ratification of the parties who are the administrators, but the most important thing is that the administrators carry out a comprehensive education program to the community on a regular and ongoing basis. The available budget is not sufficient to accommodate all the programs planned by the management. This budget limitation is also related to the number of KPADs that have been successfully established. When sufficient budget is available, it is possible that KPADs will not only be formed in a few priority villages. In addition, the limited budget also makes the KPAD only last 2 years after it was first conceived and implemented. In the Simultaneous Module Movement policy, several things that need to be evaluated are: First, the Simultaneous Module Movement Program is actually the Dinas Kesehatan Dompu (Health Office) that is more dominant in its implementation. The reason why the DP3A Dompu can also join in the implementation is because of the similarity of orientation and targets for program implementation, where one of the orientations for implementing the program is to understand the community about the risks of child marriage and the target of the program is children. With these conditions, in the process of implementing the program, parties from DP3A are rarely involved. DP3A's involvement was only intense in the early stages of communication and coordination. The facilitators are midwives who work in health centers in each sub-district and village. Not even a facilitator was found from DP3A. However, with these conditions, does not make the DP3A feel any kind of jealousy organizationally. Because for DP3A, the most important thing is that the program is one of the programs that is claimed to be one of the programs that is also implemented by DP3A. Second, the implementation of the program is also faced with budget constraints. Implementation of the program requires a large budget. Starting from paying incentives to the facilitators, which are quite a lot. The implication is that the program is only phased in one year since it was first implemented. In the Peer Counselor election policy, several things that need to be evaluated are that from the beginning the background for this program was based on the assumption that "Children will be more open and willing to compromise with their peers", hence the birth of a peer counselor program in which children Children who become peer counselors are tasked with providing education to their peers. However, in practice, perhaps because it is influenced by the still weak ability of peer counselors, it has implications for how these peer counselors carry out their duties where the implementation of their duties is still very less than optimal. The peer counselors who have been selected are placed in each high school. Each school has at least two students who become peer counselors. At the beginning after being selected, the peer counselors were given training and a certain period of time by facilitators from DP3A and Plan Internasional. In front of peer counselors, the facilitators explain the tasks and functions, the form of the program that must be carried out, and the targets to be achieved. Each peer counselor has a monthly and annual work program in which the program is prepared based on the recommendations of the facilitators. Peer counselors are also trained on how to do counseling to their peers in their respective scopes of work, both at school and in social circles. However, in the implementation process in the field, it was found that peer counselors actually seemed to ignore their duties and responsibilities, so that in the end this program was considered a program that put forward sensations and was limited to mere formalities, where the program did not have a significant impact on efforts to reduce or prevent its increase, number of cases of child marriage. This is evidenced by the lack of intensity of peer counselors carrying out their main task, namely counseling their peers. The less than optimal implementation of these tasks can be caused by the status of peer counselors as high school students, where their job is to study and do various tasks, and the peer counselors are not professionals. With this status, their main task is to study in class and they have already been stressed with various school assignments, so it is not surprising that the implementation of their duties as peer counselors is not optimal. In addition, the program is also considered a program that costs money. There are approximately 50 students selected as peer counselors. Every month peer counselors are given incentives. Every month peer counselors are also given regular training. With all the efforts and costs incurred, it is considered quite futile without maximum results. However, the interesting thing is that of the four forms of policies or programs to prevent child marriage, the peer counselor program is the program that is actually being adopted by the current government. According to the researcher, with reference to the results of the study, the form of a policy or program to prevent child marriage in Dompu Regency which has a very broad and comprehensive impact and brings positive results is the policy of making the KRR (Adolescent Reproductive Health) education a Local Content in SMP and SMA in Dompu Regency. These good results were obtained because with the program, all junior and senior high school students received the same educational materials about the risks of child marriage. The program is considered a rational program to be implemented, because it only relies on maximum communication and coordination between agencies and the budget issued is not too heavy, but the effect of its implementation is very positive. However, based on considerations based on developing conditions, the program was discontinued in the current government era. This is due to several things, one of which is where there are the latest regulations and policies governing educational institutions. For now, all high school and equivalent have become not the domain of the district government, but have become the domain of the provincial government. At the time when the program was passed, at that time all high school and equivalent levels were still the domain of the local government. Based on the explanation of the evaluation of the implementation of some of these policies, the researcher understands that some of the policies implemented are considered as policies that only prioritize formality and mere sensation, and only cost money. Some policies are also considered as policies whose implementation is less targeted, less effective and efficient, and the impact is not comprehensive. The researcher also understands that there are policies that are actually very positive, namely the policy of making KRR education a local content in junior and senior high schools, only with communication and coordination it can become an effective, efficient, targeted policy, and have a comprehensive impact. In fact, this policy is considered as the policy that has the most significant contribution in preventing the increase in the number of cases of child marriage in Dompu district in recent years. However, this policy is not being continued by the current local government because it is constrained by regulations. --- E. CONCLUSSION 1. In recent years, Dompu Regency has become the district with the highest number of child marriage cases in the province of West Nusa Tenggara. Even in 2017, Dompu Regency ranked third as the district with the highest number of child marriage cases in the province. Of the several factors that cause child marriage cases, the traditional factor is the most common factor in the occurrence of these cases. Responding to this problem, the Dompu district government through DP3A implemented several policies, such as the selection of peer counselors, the formation of KPADs, simultaneous module movements, and making KRR education a local content in junior and senior high schools. 2. The policies implemented have succeeded in preventing the increase in the number of cases of child marriage in Dompu district in recent years. In addition, the implementation of these policies has had a good impact on public awareness and understanding of the risks of child marriage and there are policies adopted by the current government (2016-2021 period). 3. Some policies to prevent child marriage are considered as programs that only prioritize sensation and formality, cost quite a lot, the impact and targets are not comprehensive, faced with difficult regulatory conditions, so that some of these programs cannot be implemented optimally and bring more positive impact.

Dompu Regency is one of the regencies in West Nusa Tenggara Province with the highest number of child marriage cases. There has been a decrease in the number of cases from year to year. This is a good implication of the implementation of local government policies. The study aims to describe and analyze the process and results of the implementation of the policy to prevent child marriage in Dompu Regency for the 2016-2021 period. The study use descriptive analytical method with a qualitative approach. Conducted at the Kantor Perlindungan Pemberdayaan Perempuan dan Anak (DP3A) Kab. Dompu in May 2021. Data collection techniques used interview, observation, and documentation techniques. The data analysis technique used was qualitative consisting of data reduction, data presentation, and drawing conclusions by applying inductive logic. The results showed (1) DP3A Dompu Regency implemented several policies to overcome the problem of child marriage. In the period 2016-2021, policies have been implemented to establish the Komisi Perlindungan Anak Desa (KPAD), the Simultaneous Movement Module Program, the creation of Adolescent Reproductive Health Education for each SMP/MTs and SMA/MA/SMK, and the selection of peer counselors. Some of these policies are the result of the formulation and agreement process and are implemented by the Dompu Regency DP3A together with local NGOs and NGOs. (2) The implementation of the policy to prevent child marriage is considered successful in preventing an increase in cases of child marriage; Dompu local government policies currently have an impact on public understanding of the risks of child marriage. (3) the policy becomes a program that only prioritizes sensation and mere formality, costs a lot of money, has incomplete impacts and targets, is faced with difficult regulatory conditions, so that some programs cannot be implemented optimally and have a more positive impact.

preventing the increase in the number of cases of child marriage in Dompu district in recent years. In addition, the implementation of these policies has had a good impact on public awareness and understanding of the risks of child marriage and there are policies adopted by the current government (2016-2021 period). 3. Some policies to prevent child marriage are considered as programs that only prioritize sensation and formality, cost quite a lot, the impact and targets are not comprehensive, faced with difficult regulatory conditions, so that some of these programs cannot be implemented optimally and bring more positive impact.

Dompu Regency is one of the regencies in West Nusa Tenggara Province with the highest number of child marriage cases. There has been a decrease in the number of cases from year to year. This is a good implication of the implementation of local government policies. The study aims to describe and analyze the process and results of the implementation of the policy to prevent child marriage in Dompu Regency for the 2016-2021 period. The study use descriptive analytical method with a qualitative approach. Conducted at the Kantor Perlindungan Pemberdayaan Perempuan dan Anak (DP3A) Kab. Dompu in May 2021. Data collection techniques used interview, observation, and documentation techniques. The data analysis technique used was qualitative consisting of data reduction, data presentation, and drawing conclusions by applying inductive logic. The results showed (1) DP3A Dompu Regency implemented several policies to overcome the problem of child marriage. In the period 2016-2021, policies have been implemented to establish the Komisi Perlindungan Anak Desa (KPAD), the Simultaneous Movement Module Program, the creation of Adolescent Reproductive Health Education for each SMP/MTs and SMA/MA/SMK, and the selection of peer counselors. Some of these policies are the result of the formulation and agreement process and are implemented by the Dompu Regency DP3A together with local NGOs and NGOs. (2) The implementation of the policy to prevent child marriage is considered successful in preventing an increase in cases of child marriage; Dompu local government policies currently have an impact on public understanding of the risks of child marriage. (3) the policy becomes a program that only prioritizes sensation and mere formality, costs a lot of money, has incomplete impacts and targets, is faced with difficult regulatory conditions, so that some programs cannot be implemented optimally and have a more positive impact.

Introduction UNESCO estimates that there are some 3,000 endangered languages in the world (Moseley, 2010). Many of these are undergoing language shift as speakers cease using a minority language and use the majority language in its place (Fishman, 1991). Whilst intergenerational transmission is typically seen as the key factor in language maintenance, there are many factors which may influence transmission in a particular context, including economic benefit, perceived status, educational provision and so on (Clyne, 2004;Grin, 2007;Williams & Morris, 2000). The impact of the internet is not well understood and is to some extent contested. Thus, while Crystal postulates that 'An endangered language will progress if its speakers can make use of electronic technology' (Crystal, 2000, p. 141), UNESCO suggests that 'new media, including broadcast media and the Internet, usually serve only to expand the scope and power of the dominant language at the expense of endangered languages' (UNESCO, 2003, p. 11). This paper explores the relationship between a particular technology, social networking sites, and a particular language, Welsh, from the perspective of young speakers. Offline social networks are recognized as an important site for the development of language practice (Morris, 2007;<unk> Riagáin et al., 2008) and of language norms, particularly in opposition to the standard (majority) norms (Wei, 2000). There is a broad agreement among researchers that social networks have a role to play in language shift (de Bot & Stoessel, 2002). It has been suggested that networks of strong ties might help minority language speakers resist pressures towards language shift (Wei, 2000;Milroy, 2001). It is further claimed that visible and vibrant networks make membership of a minority language community appear more attractive, as well as providing more opportunity for language use (Lee, 2006), and enhancing ethnic identity based around that language (Lanza & Svendsen, 2007). Where the speakers of a minority language are ageing and isolated, fostering social networks may enable those speakers to maintain fluency and provide the opportunity for them to pass on the language to others (Sallabank, 2010). While online social networking sites (SNS) have been the focus of a significant body of research (boyd & Ellison, 2007), there has been little work specifically on language (though see Fragoso, 2006;Herring et al., 2007;Carroll, 2008;Honeycutt & Cunliffe, 2010), and there appear to be no studies directly investigating whether online social networks play a role in language shift similar to that played by offline social networks. Research has claimed that the availability of electronic media can be a powerful motivator for young people, and act as a stimulus to their use of a minority language within their social networks (Edwards, 2002). On the other hand, there are concerns that English or another majority language may be considered to be the language of electronic social networking even when the minority language is used face-to-face in offline social networks (Fleming & Debski, 2007). It does not seem unreasonable to suggest that SNS might play some role in language shift, in some language contexts. The remainder of this paper is structured as follows. First the specific context of Wales and the Welsh language is introduced. Secondly the methodology is outlined. Next some general results are presented, followed by a more in-depth examination of Facebook, considering language behaviours and influences on that behaviour. Both quantitative and qualitative data are reported. Finally conclusions and implications for future work are drawn. --- The Welsh context Wales is a country of around 3 million people, situated in the west of the United Kingdom. The Welsh language (Cymraeg) was the only language of the majority of the population of Wales until the mid 1800s (Morgan, 2001). There has been significant language shift towards English since that time (for perspectives on the social history of the language in the 20 th century, see Jenkins and Williams, 2000). The most recent census, in 2001, showed there were 582,000 Welsh speakers (aged 3+), some 20.8 per cent of the population and the figures have been interpreted as showing that the language has stabilised (Aitchison & Carter, 2004). UNESCO considers the language to be ''vulnerable'' (Moseley, 2010). The concentration of Welsh speakers varies considerably across the Welsh Local Authorities, with greater concentrations in the North and West; the highest being Gwynedd where 68.7% of the population are Welsh-speaking. Lower concentrations are found in the South and East, with the lowest being Monmouthshire where 9.0% of the population speak Welsh (Aitchison & Carter, 2004). In recent years the education system has played a major part in rejuvenating the language and the main growth area of the language has been the under 16s. The 2001 census showed that 31.2% of Welsh speakers were aged 3-15, and 32.3% were aged 16-44 (Aitchison & Carter, 2004). Young Welsh speakers are seen as being particularly significant for the future of the language. Iaith Pawb, the Welsh Assembly Government's Action Plan for a Bilingual Wales (Welsh Assembly Government, 2003, 4.38), states, ''The Assembly Government is acutely aware that if Welsh is to flourish young people in particular need to develop a sense of ownership for the language and to see it as their language and not simply the language of school and culture. The Assembly Government will work to ensure that we maximize the opportunities for our young people and teenagers to use the language in everyday leisure and social situations''. One of the Welsh Language Board's six strategic priorities is to ''Increase the use of Welsh among young people and give them the opportunity to use Welsh socially, for example, through sports and contemporary music'' (Welsh Language Board, n.d.). It is widely accepted that the teenage years are a critical period in the development of young people's attitudes towards a minority language ( <unk> Riagáin, 1997;Mac Giolla Chriost, 2005;<unk> Riagáin et al., 2008). The use young people make of their minority language during this period can affect their continued use in later stages of their life and the choices they make regarding intergenerational transmission. The role of offline social networks is recognised as being of crucial importance as regards the use of a minority language by young people ( <unk> Riagáin et al., 2008). Morris (2007) observes that the greater the density of Welsh-speakers in the offline social network of young Welsh-speakers, the greater the opportunity and tendency for members of that network to use Welsh. While young Welsh speakers' offline social networks have traditionally been maintained by faceto-face contact and the telephone, Information Technology (IT) is playing an increasing role. Figures from 2009 show that 68% of children aged 5-15 in Wales have access to the internet at home, the lowest percentage in the UK. However, 49% of these children visit SNS at least weekly, more than the percentage across UK children. Children aged 8-15 in Wales are also more likely to have set up a profile on a social networking site, with 58% of them saying they have done so (Ofcom, 2010). The Welsh language has been used online since at least the late 1980s (Jones, 2010) and is used to some degree across a number of different online domains (Cunliffe, 2009). The research presented in this paper is a preliminary examination of the way in which young Welsh speakers are using SNS and in particular their use of language within these sites. The main focus is on Facebook as this was by far the most popular SNS among the study group. Language choice and behaviour, factors influencing that behaviour and attitudes towards the Welsh language and IT among young people are explored. The study group were pupils in Welsh-medium education. Attendance at a Welsh-medium school is by parental opt-in. Depending on the area of Wales, these children may be more or less likely to come from Welsh-speaking homes. Non Welsh-speaking parents send their children to Welsh-medium education for a variety of reasons, principally cultural, but also because it is perceived to be a better quality of education (Hodges & Morris, 2010). While these pupils receive the majority of their education through the medium of Welsh, given the wider societal context they typically are also fluent English speakers. --- Methodology This paper reports a selection of results from a one year exploratory, mixed method study into language behaviour within the social networks of young Welsh speakers. In particular the question of any effect of modality on language use was of interest, following the results of Fleming and Debski (2007). The purpose of the study was to gather initial data that would provide both insight and direction for future research. This paper focuses on the part of the data relating to the use of Welsh online and particularly the use of Welsh on Facebook. The data relating to the offline use of Welsh and the relationship between the use of Welsh in online and offline social networks has been published elsewhere (Morris et al., 2012). Due to the lack of any existing data which could have guided the informed formation of testable hypotheses, the study focussed on data that would reveal whether or not there was a phenomenon to be studied (there was no existing evidence that proved that young Welsh speakers actually used SNS, for example) and what patterns, if any, appeared to exist in young Welsh speakers' language behaviour that would merit further study. From the data presented in this paper a number research questions emerge which could be investigated through a more targeted future study. The study, conducted in 2010, focussed on four Welsh-medium secondary schools, two in North West Wales and two in the South East. The schools were selected to represent the different language contexts in these two parts of Wales. Schools were selected at random and contacted via letter and subsequently by telephone. Schools were provided with information regarding the nature of the research being undertaken. Head Teachers of the schools were given the opportunity to ask questions regarding the research prior to agreeing. Several schools declined the invitation due to time constraints, in which case another school was selected at random until the four school sample was complete. Bilingual consent forms were sent to the parents of the pupils in the appropriate school years. A sample of 50 pupils from each school, for whom consent had been given, was selected at random, 10 from each school year (Year 9 to Year 13, aged 13-18). These 200 pupils were asked to complete an online questionnaire, hosted on Survey Monkey. The questionnaire was anonymous and was available in both Welsh and English versions. Questions examined the language used with teachers and friends at primary and secondary school; the language used in out-of-school clubs, such as sports clubs; first language orientation and written language confidence; the language used in the home and with specific family members; the use of SNS and language use on those sites; and the online and offline language used to communicate with three friends. The data was analysed using SPSS. This establishes a baseline of information about Welsh language use in both areas and provides the quantitative data reported in this paper. The questionnaire was followed-up by a series of focus groups which explored the issues raised in the questionnaire in greater depth. Two groups, typically of eight pupils, were selected at random from the respondents who had completed the questionnaire at each school, one group aged 13-15 (Years 9 to 11) and one aged 16-18 (Years 12 and 13). The size of the focus groups varied between six and ten pupils, with a total of 64 pupils taking part in the focus groups overall. The focus group discussions lasted 40-50 minutes (in order to fit in with the school timetable). The focus group discussions were semi-structured and made use of a set of eleven prompting questions. The questions covered their use of SNS, their use of Welsh and English on SNS and the web generally, barriers to the use of English and Welsh and the use of the Welsh-language interface on Facebook. All focus group discussions were conducted in Welsh. The discussions were recorded for subsequent transcription and analysis using Weft QDA. This more in-depth study of language attitudes and behaviour provides the qualitative data reported in this paper. This paper presents a selection and analysis of the quantitative results along with excerpts from the transcripts to provide additional context and texture. Due to the small sample sizes, it is necessary to present a descriptive analysis of the cross tabulations in the quantitative results rather than a statistical one. Both the quantitative and qualitative data presented in this paper are self reported data, rather than data based on observed language behaviour. Thus the reliability of some of the responses may be questioned due to respondents' inaccurate recall or estimation, or deliberate misrepresentation. However for the quantitative data, the sample size should minimise the impact of any individual misreporting. In terms of gaining a more complete and nuanced understanding of language behaviour in SNS, direct observation of actual language behaviour would clearly be a useful addition to the type of study presented in this paper. There is however, significant ethical and methodological complexity involved in conducting such a study; we are dealing with young people and with essentially personal communications. While these issues may be overcome through careful study design and such as study was considered, it was decided that a simpler approach was preferred for this initial exploratory study, given relatively limited resources. --- Results To protect the anonymity of the schools and their pupils, the schools in the North West of Wales are referred to as NW1 and NW2, and the schools in the South East as SE1 and SE2. In reporting the results of the focus groups, Year 9 to 11 are denoted as (9-11), while Year 12 to 13 are denoted as (12-13). Fn and Mn are used to denote individual female and male respondents where conversations are reported, otherwise quotations are attributed only to the School and Year. --- First language The overall split between those pupils who considered themselves to be first language English speakers and those who considered themselves to be first language Welsh speakers was fairly even (see Table 1). However there is a marked difference between the proportions when comparing the NW with the SE. The majority of the pupils in both the NW schools considered themselves to be first language Welsh speakers, whilst in the SE the situation was reversed. This may be explained to some extent by the wider use of Welsh as a home and community language in the NW and the fact that the majority of the pupils in the SE schools come from non Welsh-speaking homes. --- Internet use It was clear from the focus groups that the internet was playing a significant role in the lives of young people in both areas. All participants reported having broadband access at home and several also had internet access on their mobile phones or on their personal media players. For many of the participants the internet was an important source of entertainment and information in the home; used for social networking, gaming, homework, shopping and viewing television programs. Dwi'n neud y ddoi ar yr un pryd. Soffa, teledu, laptop, cup of tea. Perfect! (I do both the same time. Sofa, TV, laptop, cup of tea. Perfect!) [SE1/12-13] The focus groups also revealed that the pupils' broad experience of the internet was one in which the English language was the norm in terms of availability of provision, but perhaps also in terms of the choices that individual pupils would make. M1 Ond am Facebook, nid oes nifer o websites sydd gyda Cymraeg. F1 Mae MSN a hotmail yn Saesneg, mae Twitter yn Saesneg... F2 On os fydde nhw yna fydde ti ddim yn defnyddio nhw, na fydde ti. Mae Facebook ar gael yn Gymraeg ond ti ddim yn defnyddio fe! M1 Mae Wikipedia Cymraeg a fi'n defnyddio hwna! (M1 Apart from Facebook, there aren't a lot of websites that have Welsh. F1 MSN and hotmail are in English, Twitter is in English... --- F2 But if they were there you wouldn't use them, would you. Facebook is available in Welsh and you don't use that! M1 There is a Welsh Wikipedia and I use that!) [SE1/12-13] In addition to the perceived language norms, language behaviour appeared to be influenced by availability, context and the accessibility of the language used. Fyddai'n defnyddio Cymraeg weithiau ar y we, os ydw i'n cael opsiwn Cymraeg, yn yr ysgol i ddarllen rhywbeth, ond heblaw hynny, fi'n defnyddio Saesneg. --- (I'd sometimes use Welsh on the web, if I get a Welsh option, in school to read something, but apart from that, I use English.) [SE1/9-11] The issue of the accessibility of the Welsh used on websites and interfaces was raised in a number of contexts. Mae o'n haws defnyddio fo'n Saesneg oherwydd bod chi'n gwybod y geiriau i gyd... fel arfer mae pob website yn Saesneg felly chi'n gwybod beth mae nhw yn siarad amdano. Oherwydd mae o'n Gymraeg mae o'n eithaf anodd, oherwydd mae nhw yn defnyddio geiriau anodd, geiriau fydde chi ddim yn ei defnyddio yn y Gymraeg. --- (It's easier to use it in English because you know all the words... usually all the websites are English so you know what they are talking about. Because it's Welsh it's quite difficult, because they use difficult words, words you wouldn't use in Welsh.) [SE2/9-11] While this type of comment may be reflecting individual difficulties in comprehension, they may also be revealing weaknesses in the way that IT is taught, or in the design of the websites and interfaces themselves. --- The use of social networking sites The use of SNS was pervasive, with only six of the 200 pupils reporting that they didn't use any SNS at all. As Table 2 shows, Facebook, YouTube and MSN dominate and presumably fulfil different, complementary communication functions for the pupils. The majority of Facebook users had used Bebo before switching to Facebook as Bebo became unfashionable, with the perception that it was for 'children' or 'little kids'. The use of the word 'adults' (oedolion) in this context should probably not be taken to include parents and teachers, but as meaning something more along the lines of'mature young adults like us', distinguishing between their generation and both the younger and older generations. Thus being on Facebook would appear to be a desirable badge of maturity even among pupils as young as 9. The high levels of SNS use suggest that such sites are both popular and important for these young people. It also suggests that they might play a role in the formation of attitudes towards the Welsh and English languages, as well as providing an opportunity for language use. --- Language use and modality Part of the questionnaire asked pupils to identify three friends, note whether they were Welsh-speaking, the language they would use orally with each friend and the language they would use to communicate with them electronically in a SNS, MSN message, text, or email. Overall the vast majority of the friends identified spoke Welsh (94%), a small number could not (4.8%) and in a very small number of cases the Welsh speaking ability was not known (1.2%). The school with the highest percentage of Welsh speakers in the respondents' selected friends was NW2 with 97.3%; the school with the lowest percentage was SE1 with 88.4%. However, it is worth noting that both these percentages are significantly higher than the percentage of Welsh-speakers in the general population in those areas. This might be explained by the pupils selecting friends from school in this activity (though they were not directed to do so). This would suggest that Welsh-medium schools are particularly important for establishing social networks with a high density of Welsh-speakers when this density may not be reflected in the wider local community (particularly in the South East). While comparing language used orally and in electronic communications, the main finding is that language behaviour does not generally appear to change significantly with the modality. As Table 3 shows, the vast majority of pupils who use a single language with a particular friend would use the same language in electronic communications as they would use orally. However, respondents who used both Welsh and English orally with a particular friend were much more likely to use English with them in electronic communications. This is an interesting finding as it suggests that the respondents who use both languages orally with their friends (possibly due to having to use Welsh in school) would change to using English in this important, and often more personal, form of communication. The same trend is apparent in all four schools, both in the North West and South East. The trend of using English in electronic communications when they would use both languages orally suggests that the relationship between the languages is not equal. --- Facebook Facebook appears to be particularly significant for these young Welsh speakers, given its popularity, the perception that it is a website where Welsh is used and the status associated with Facebook use as a badge of maturity and achievement of adulthood. Because of this significance, the remainder of this paper will focus specifically on Facebook. The popularity of Facebook among the pupils reflects the popularity of Facebook generally in the UK. Facebook is the most visited SNS in the UK, with 56.53% of all visits to SNS, and the second most visited site in the UK after Google UK, with 7.78% of all website visits (Experian Hitwise, 2011). From the focus groups it appeared that Facebook was an essential element of many young people's social lives, playing a central role in the maintenance of their social networks. Ymchwilydd -Pan ti'n dod adref o'r ysgol, be ydi'r website cyntaf ti'n mynd i? Pawb -Facebook! Rhaid i fi checo Facebook rhag ofn bod rhywbeth wedi newid, rhag ofn bod rhywbeth wedi digwydd. Bod hwn a hwn wedi sblito lan, neu bod so and so ddim yn siarad bellach, neu i checo pryd mae'r parti chweched yn dod lan. --- (Researcher -When you arrive home from school, what's the first website you go to? Everyone -Facebook! I have to check Facebook in case something has changed, in case something has happened. So and so have split up, or so and so don't speak any more, or to check when the next sixth form party is coming up.) [SE1/12-13] The percentage of pupils using Facebook was consistently high across the four schools (Table 4), and across the different Years (Table 5). In common with other studies (e.g., Ellison et al., 2007), Facebook was mainly used to keep in touch with people in the pupils' offline social networks, particularly their fellow pupils. Swni'n deud, er ein bod ni yn yr ysgol efo'n gilydd drwy'r dydd, da ni just yn siarad efo ni! Mae ganddo ni ffrindiau eraill da ni'n nabod, dros y blynyddoedd, ond rhan fwyaf o'r amser, da ni'n cadw mewn cysylltiad efo'n ffrindiau agosaf. The fact that fellow school pupils play a significant role in the online social network may be important in establishing language norms within Facebook. Pan nesi ymuno a Facebook, roedd chydig o ffrindiau Cymraeg fi yna, a dim ond nhw oedd yna, felly roni'n siarad Cymraeg efo nhw, a mae o wedi dal ymlaen. (When I joined Facebook, some of my Welsh friends were there, and only they were there, so I spoke Welsh with them and it's carried on.) Table 6 shows that overall the main language used on Facebook by pupils was English. However, the point of interest in this paper, given that these pupils are bilingual, is the use or non-use of Welsh, rather than the use or non-use of English. Comparing the percentage for English only (those whose language behaviour on Facebook would not normally include Welsh) with the combined percentage for those who would use both equally or mainly use Welsh (those whose language behaviour would normally include Welsh) gives a more even split of 55.7% to 44.2% -but still in favour of English use. In order to understand the reasons behind this high percentage of bilingual pupils in Welsh-medium education not usually using Welsh, a more detailed analysis of the data was conducted. Four main aspects were considered; the community language; the language of the pupils social network; language confidence; and the influence of Facebook itself. The community language Table 7 presents a more detailed breakdown of languages used on Facebook according to the different schools. The two schools in the more anglicised South East show high levels of English use on Facebook. Given the percentages of pupils considering themselves first language English speakers (Table 1) this is perhaps unsurprising. However in the more Welsh-speaking areas of the North West, while the percentages of pupils using Welsh on Facebook (including those using it equally with English) is higher than the two SE schools, only in NW2 is Welsh alone the main language used. In NW1 more than twice as many pupils mainly use only English on Facebook than mainly use only Welsh. For the majority of pupils in NW1, Welsh would not feature in their main language use on Facebook. It appears that living in an area in which the English language is dominant is a good predictor of English language use on Facebook, but that living in an area where the Welsh language is stronger is not such a good predictor of Welsh language use on Facebook. This suggests that there may be different factors influencing the use or non-use of Welsh than English, or that the same set of factors has different outcomes for the two languages. Table 8 shows that the large majority of pupils who self identify as first language English speakers use English as their main language on Facebook. The majority of those who self identify as first language Welsh also use English as the main language, though the distribution across the Facebook language categories is far more even for first language Welsh, than first language English. Again, comparing the percentage of those whose language behaviour on Facebook would not normally include Welsh with those whose language behaviour would normally include Welsh gives a split of 74.1 to 25.9 among first language English speakers, but 39.8 to 60.2 among first language Welsh speakers. There appears to be a relationship between self identified first language and main language used on Facebook. It is possible that the linguistic make-up of the pupil's offline social networks contributes to their self-identification as a first language speaker and that overlaps between their offline and online social networks then influence their language use on Facebook. Table 9 appears to show a similar relationship between language of the home and the main language used on Facebook. However, where both languages are used at home, the large majority of pupils mainly used English on Facebook. Considering those pupils whose home language is Welsh, comparing the percentage of those whose language behaviour on Facebook would not normally include Welsh with those whose language behaviour would normally include Welsh gives a split of 25.8 to 74.2 -therefore the language of a pupils home appears to have a slightly stronger relationship with their normal use of Welsh on Facebook, than their self identification as a first language Welsh speaker. The results in this section suggest a relationship between language use on Facebook and language use in the real world. While the existence of a Welsh speaking offline community context seems to be linked to the use of Welsh on Facebook, the existence of an English or bilingual community context appears to be more strongly linked to the use of English on Facebook. Thus language use on Facebook reflects the wider language context and the likely make-up of offline social networks which are then reflected in online social networks. The language behaviour in online social networks cannot be understood in isolation from the offline context. --- The language of the social network Tables 10 and11 suggest that there is a relationship between the language used with friends outside school and the language used on Facebook. This is unsurprising as Facebook networks are known to recreate offline social networks (e.g., Ellison et al., 2007). In terms of the strength of the relationship, it appears that the use of English in offline social networks is more strongly related to the use of English on Facebook than the use of Welsh in offline social networks is related to the use of Welsh on Facebook. This is a similar pattern to that observed when considering the community language. It is interesting to note that there are a small number of pupils who use mainly Welsh on Facebook even though in their offline social networks they use English. This may perhaps be reflecting differences in the membership of these pupils online and offline social networks. Nearly a third of those who use more Welsh than English in their offline social networks use mainly English on Facebook. Even of those pupils who use more Welsh than English or Welsh only in their offline social networks, more than 30% use both languages equally on Facebook. This may reflect their concern not to exclude members of their online social network who are not Welsh-speaking -demonstrating one possible effect of audience. Mae mwy o bobl yn gwybod Saesneg na sy'n gwybod Cymraeg. Tishe pawb i ddeall e. (More people know English than Welsh. You want everyone to understand it.) [SE2/12-13] However, the effect of audience is not always straightforward and doesn't necessarily always result in the use of the language that is mostly widely understood by the entire network of friends. Os ni'n gwybod mai ffrindiau ni, sydd yn yr ysgol, fyddai yn rhoi nodyn bach i nhw achos fi'n gwybod bod nhw yn siarad Cymraeg -oherwydd bod neb arall yn gallu neud e, ni'n teimlo'n fawr i neud e. Fel ''Yea, ni'n gallu siarad Cymraeg i ti!'' Ti'n teimlo'n reit chuffed bod ti'n gallu neud e. --- (If we know our friends, who are in school with us, I'd give them a small note because I know they can speak Welsh -because nobody else can do it we feel big to do it. Like ''Yea, I can speak Welsh with you!'' You feel quite chuffed that you can do it). [SE1/9-11] Bilinguals who are effectively fluent in two languages, such as those in this study, have a choice of which language to use. Their language choice appears to be complex and influenced by conscious and possibly subconscious factors. Thus the choice of language for a particular message may be influenced by the sender, the intended audience and the message itself. While there were characteristics of Facebook which appeared to influence this choice (e.g. all Friends see status updates), it did not appear that Facebook per se was influencing this choice. It seems plausible to suggest that there might be strong similarities between the choice and use of language on Facebook and oral language choice and use offline. However, there may also be some language behaviours that are specific to written environments, such as the use of ''text talk'' (Jones, 2007). --- Language confidence While the language register used on Facebook tends to be very informal, and attitudes towards spelling and grammar relaxed, it is possible that confidence in writing Welsh and English may have an influence on language behaviour. The vast majority of pupils (85.8%) were either very confident or fairly confident in writing English. As Table 12 shows, English was the main language used on Facebook, regardless of confidence in writing English. The percentages of those who use English on Facebook and those who use Welsh appear very similar with regards to confidence in writing English (Table 13). This indicates that those pupils who mainly use Welsh on Facebook are not doing so because they lack confidence in their written English. The vast majority of pupils (81.0%) were either very confident or fairly confident in writing Welsh. As Table 14 shows, English was the main language used on Facebook, regardless of confidence in writing Welsh. Comparing Tables 12 and14 shows similarities in terms of the use of language on Facebook, regardless of which language confidence is being examined. The percentages of those who use English on Facebook and those who use Welsh appear very similar with regards to confidence in writing English (Table 13), but there appear to be some differences when considering confidence in writing Welsh (Table 15). Pupils who use Welsh as their main language on Facebook appear to be slightly more likely to be very confident in writing Welsh. However, this is not to necessarily suggest direct causality; it may be the case that confidence in writing Welsh and the use of Welsh as the main language on Facebook are both influenced by greater exposure to Welsh as the language of the community or the language of the home. 13.4 (13) 14.3 (6) 02.9 (1) Not very confident % (n) 08.2 (8) 00.0 (0) 00.0 (0) Not confident at all % (n) 05.2 (5) 00.0 (0) 00.0 (0) Comparing Table 13 and Table 15, those pupils who use Welsh on Facebook appear more likely to be confident in their written Welsh, than those using English on Facebook are likely to have confidence in their written English. There are no pupils who are unconfident in Welsh who use Welsh on Facebook (Table 15), whereas 5.6% of pupils who use English on Facebook lack confidence in their written English (Table 13). This difference in behaviours relative to confidence suggests that the use of English on Facebook is determined by more than simply confidence in the language. It may be that these pupils have generally weak writing skills, or strong writing skills in another language, and that English is their strongest language. It is possible that audience is an influence, perhaps pupils consider it a more effective communication strategy to write badly in English than well in Welsh on Facebook. Another possibility is that as Welsh is the language of instruction, pupils may consider it more important to write well in Welsh than to write well in English and that this is reflected in their language use on Facebook. While there appears to be a slight relationship between written Welsh language confidence and the use of Welsh on Facebook, there does not appear to be such a relationship for English. --- The influence of Facebook The influence the characteristics of Facebook itself on language behaviour was considered from two aspects. Firstly, whether the language used varied between different Facebook elements. Secondly, whether the

Social networking sites feature significantly in the lives of many young people. Where these young people are bilingual, social networking sites may have an important role to play in terms of minority language use and in shaping perceptions of that language. Through a quantitative and qualitative study, this paper investigates the use of language in social networking sites by young Welsh speakers, focussing particularly on Facebook. Language choice and behaviour, factors influencing that behaviour, and attitudes towards use of the Welsh language in Information Technology are explored. The data suggests that there are a number of different factors at play, and that it is necessary to consider language behaviour in social networking sites in the context of offline language behaviour.

on Facebook are likely to have confidence in their written English. There are no pupils who are unconfident in Welsh who use Welsh on Facebook (Table 15), whereas 5.6% of pupils who use English on Facebook lack confidence in their written English (Table 13). This difference in behaviours relative to confidence suggests that the use of English on Facebook is determined by more than simply confidence in the language. It may be that these pupils have generally weak writing skills, or strong writing skills in another language, and that English is their strongest language. It is possible that audience is an influence, perhaps pupils consider it a more effective communication strategy to write badly in English than well in Welsh on Facebook. Another possibility is that as Welsh is the language of instruction, pupils may consider it more important to write well in Welsh than to write well in English and that this is reflected in their language use on Facebook. While there appears to be a slight relationship between written Welsh language confidence and the use of Welsh on Facebook, there does not appear to be such a relationship for English. --- The influence of Facebook The influence the characteristics of Facebook itself on language behaviour was considered from two aspects. Firstly, whether the language used varied between different Facebook elements. Secondly, whether the availability of a Welsh language interface was having any effect. A study of the use of Puerto Rican Spanish on MySpace (Carroll, 2008) suggested that language use might vary according to the nature of the text, e.g. profile information versus comments. Further questions in the study therefore examined language use specifically on Facebook status and on personal profile information. Tables 16 and17 show the main language used on Facebook against the language used specifically for status updates. There appears to be a relationship, suggesting that typically pupils' general language use on Facebook is the same as the specific language used for status updates. Though as can be seen in Table 16, those pupils who mainly use Welsh on Facebook are less likely to only use Welsh for status updates (19.4%), whereas most pupils who mainly use English, use only English for status updates (54.2%). It should be noted that the language used for status updates forms part of a pupils general language use on Facebook, so there is some degree of overlap between these dimensions that would naturally suggest a relationship. It is curious to note that two pupils, who mainly use English on Facebook, claim to only use Welsh in their status updates. Unfortunately, the current methodology does not allow the veracity of these claims to be investigated, or the reasons to be understood. Tables 18 and19 show main language used against language used on Facebook profile. Comparing Table 18 with Table 16 appears to show a broadly similar pattern of a weak relationship. However it is Tables 20 and21 compare the language of profile information and language of status updates directly. There appears to be a relationship between the two, though once again the correlation for English appears to be stronger, 70.1% of pupils who only use English on their profile also only use English on their status updates, and 77.0% of pupils who only use English on their status updates also only use English on their profile. For Welsh, the figures are 41.2% and 63.6% respectively, again suggesting that Welsh language use in status updates is different to that in profile information. Even in status updates the effect of audience on language choice can be seen, as status updates are not necessarily directed to the entire online social network. The use of Welsh for status updates to online social networks which included non Welsh speakers did not appear to be viewed as an exclusion of these people, but more as a by-product of the fact that the online social network included multiple offline social networks. Os ydi o yn rhywbeth i wneud efo gwaith ysgol nai neud o'n Gymraeg, achos mai Cymraeg ydi gwaith ysgol fi. Os ydi o yn rhywbeth i wneud efo mynd allan, nai neud o'n Saesneg, achos Saesneg ydi iaith ffrindiau dwi'n mynd allan efo. --- Welsh-language interface on Facebook Since the autumn of 2008, Facebook has been one of a small number of applications which provide a Welsh-language interface and it is the only widely used SNS to do so. Carroll's (2008) study of the use of Puerto Rican Spanish on MySpace observed that the English-language interface lead to the adoption of English terminology, therefore it might be suggested that the availability of an interface in Welsh may help to normalise Welsh-language terminology within Facebook and possibly in the wider domain of IT. In the focus groups, pupils expressed a variety of views about the Welsh language interface, mostly relating to the style of language used. This may be revealing issues of terminology (particularly uncommon terms referring to interface elements), regional dialectal variation and register. Comments such as these perhaps suggest that the effectiveness of crowd-sourced interface translations (and Welsh language interface design more generally) bears further examination. There was little evidence to suggest that the Welsh language interface was a positive influence to use Welsh, but there was also no evidence to suggest that the use of the English language interface was consciously perceived of as a negative influence. As the pupils are bilinguals, the use of English in the interface is unlikely to prove any sort of barrier to use, but it is interesting to speculate whether the existence of a Welsh language interface, or a Welsh language interface that is perceived of as being poor quality, might have an influence on the pupils' perception of the status of Welsh both as a language of IT and more widely. --- Conclusions and implications for future work It is clear from the data that SNS generally, and Facebook in particular, are playing a significant role in the lives of young Welsh speakers. The extent to which these young speakers use the language on Facebook varies. The data suggests that there are a number of different factors at play, but due to the small sample sizes a rigorous statistical analysis is not possible. However the data indicate that it is necessary to consider language behaviour in online social networks in the context of language use in offline social networks and that in some ways this behaviour is best considered as an extension of language behaviour in offline networks, just through a different medium. The specific medium of Facebook did not seem to directly influence their language behaviour, though there appears to be some indirect influence related to specific Facebook elements, such as status updates. In common with Fleming and Debski's (2007) study of Irish schoolchildren (aged 10-12 and 16-18), young Welsh speakers appear to see English as the language of the internet. However, their study showed that English was also the language of networked (electronic) communications; among pupils from Irish-medium and Gaeltacht schools more than 60% wrote no emails in Irish; among pupils from Irish-medium schools more than 90% rarely or never sent SMS messages in Irish and the same was true for more than 65% of pupils from Gaeltacht schools. While Fleming and Debski's study did not explicitly consider SNS, it seems plausible that similarly low levels of Irish use might have been observed. In contrast, the use of Welsh online and in electronic communications appears to be normalised to a much greater extent than Irish. Fleming and Debski do note an apparent relationship between the amount of Irish used in face-to-face conversations and in text message based conversations, a similar relationship between offline and online use appears to be true of Welsh. There are difficulties in making meaningful comparisons with previous studies, largely due to the lack of them, but also because of differences in the methodology, the SNS, or the focus of study within the SNS. The study by Carroll (2008) supports the general finding that the language behaviour of bilinguals within SNS is complex and influenced by a range of factors. His observation that different language behaviours occur in different elements within a SNS (such as the profile, the status updates etc.) is also echoed in the data presented here. A previous study of the use of Welsh on Facebook (Honeycutt & Cunliffe, 2010) found that there were a number of Groups where Welsh was used and that Welsh was also being used on personal profiles. This data, combined with the data presented in this paper shows that Facebook provides an online venue in which Welsh is an everyday language of communication. It is interesting to note that the average declared age of those identified as Welsh speakers in that study was 26.36 and the youngest was 18 (based on a sample of 85 profiles). Given the popularity of Facebook among young Welsh speakers, their apparent relative lack of presence in Facebook Groups might indicate that they are mainly using Facebook to engage with their own social networks rather than to engage with the wider Welsh speaking population in the communal spaces on Facebook. The initial study presented in this paper suggests a number of relationships and raises a number of questions. Future work needs to address the issue of small sample size in order to facilitate rigorous statistical analysis, in particular to verify and quantify the strength of the relationships which are suggested by the current data. The apparent imbalances in the use of the two languages and the causes of this imbalance need to be investigated. Among the wider questions raised by the data are: Which websites do young Welsh speakers typically use, which languages are they available in and which languages are they used in? To what extent is the Welsh IT terminology understood and used by young Welsh speakers? Which SNS, if any, are used by younger Welsh speakers? Do patterns of language use change over time (individually; as a population of speakers)? Are different patterns of language use observed in different SNS and if so, why? Are there quantifiable effects either in terms of perceived status or use of Welsh, due to the Welsh language having a presence in IT? The study presented in this paper relies on self reported data, rather than direct observation. Future work could directly examine the actual language behaviour of young Welsh speakers in SNS, coupled with a mapping of the languages of contacts in their online network using traditional social network analysis techniques. While this approach is likely to provide a rich source of data, the methodological and ethical issues require careful consideration. In addition to validating and exploring the general findings of the present paper, two events in the lives of young people merit particular scrutiny as they potentially involve radical reconfiguration of their offline social networks; moving from primary to secondary school (when some pupils may move from Welsh-medium to English-medium education); and the end of school education (when young people may move into employment or go on to university). Both these events may disconnect young Welsh speakers from their existing offline social networks and the Welsh speakers in those networks. speakers to continue using Welsh both outside school and when they leave school, and to foster a sense of ownership of the language among those who do not come from Welsh-speaking families or communities. Does yna ddim byd yn stopio ni rhag defnyddio'r Gymraeg ar y we, ni just yn ddiog. Ni'n methu bod yn bothered i siarad Cymraeg. (There isn't anything stopping us from using Welsh on the web, we're just lazy. We can't be bothered to speak Welsh.) [SE1/12-13] Perhaps the most potent force for change would be the desire among young people for online content and services in Welsh. Heightened desire and expectation leading to increased demand could broaden the range of online domains in which Welsh can be used. Unless the expectations of young Welsh speakers with regards to the role of Welsh in IT can be raised it is difficult to see how their future use of Welsh in IT can ever extend much beyond the social domain. --- As noted previously, the choice of language for a particular message may be influenced by the sender, the intended audience and the message itself. While there is nothing in the data to suggest that Facebook itself is directly influencing language behaviour, there is some evidence to suggest that language behaviour may differ between different Facebook elements, perhaps because they fulfil different communicative functions or are perceived of as being addressed to different audiences. However, this effect of audience may not be as great as might have been anticipated as pupils appear not to treat the audience for status updates, for example, as being homogenous. Rather messages may be addressed to only part of that audience, and it is the language of that part of the audience which influences language choice, even if this excludes some of the wider audience who will receive the message. Online social networks may have a role to play in maintaining contact with those Welsh speakers and with the language. The need for a critical mass of Welsh speakers in a social network and the possibility of there being a ''tipping point'' when the proportion (or number, or importance) of Welsh speakers falls below a threshold and the use of the language diminishes rapidly or ceases all together also needs to be examined. Comparative studies of other minority language contexts may help to shed light on the wider factors influencing language use, such as prestige, official status, or economic benefit. The study presented in this paper needs to be seen in the broader context of young Welsh speakers experience and practice of using Welsh in IT. This includes the language used to teach the subject in school, the availability of Welsh-language software, and the extent to which IT is discussed in the Welsh-language media. While it was not a particular focus of the current study, it appears that English is perceived to be the language of IT, in terms of the availability of content and services, but also in terms of actual use of IT. ''Dwi ddim yn meddwl bydd e'n syniad da, oherwydd ar ôl i ni adael yr ysgol bydd pob cyfrifiadur ni'n gweld yn y Saesneg. Os i ni'n dysgu sut i wneud pethau yn Cymraeg bydd e'n fwy anodd i wneud pethau yn y Saesneg, oherwydd bydde ni ddim yn deall beth mai geiriau yn dweud.'' ([Regarding the use of Welsh language Windows] I don't think it's a good idea, because after we leave school every computer we see will be in English. If we learn how to do things in Welsh it will be more difficult to do things in English, because we wouldn't understand what the words say.) [SE2/9-11] Mae Wikipedia Saesneg efo fel chwech tudalen ar rhywbeth, a mae'r un Cymraeg efo un paragraff. (English Wikipedia has six pages on something, the Welsh one has one paragraph.) Considered against this wider context, it could be suggested that the use of Welsh on Facebook, limited as it is, is a relative success story for the language. Mae ganddoch chi grwpiau Cymraeg, a ti'n cael dy annog i siarad Cymraeg wedyn dwyt. Mae yna lot mwy o bobl Cymraeg arna fo dwi'n meddwl. (You have Welsh groups, so you are encouraged to speak Welsh. I think there are a lot more Welsh people on it.) [NW2/12-13] Mae ein Facebook ni yn ddarn Cymraeg o'r rhyngrwyd, lle mae'n ffrindiau ni yn siarad Cymraeg. (Our Facebook is a Welsh section of the Internet, where our friends speak Welsh.) [NW1/12-13] However, it could also be argued that this is yet another example of the language being restricted to the social domain and perhaps failing to establish itself across the wide variety of domains supported by IT. I siarad efo pobl dwi'n nabod, dwi'n siarad Cymraeg o hyd, ond Saesneg ydi bob dim arall. ([Regarding the language of the web] To speak with people I know, I speak Welsh all the time, but everything else is English.) [NW1/9-11] Many of the challenges facing the use of Welsh in IT are the same as those facing the use of Welsh generally. Fundamental challenges still exist in providing opportunities and incentives for young Welsh

Social networking sites feature significantly in the lives of many young people. Where these young people are bilingual, social networking sites may have an important role to play in terms of minority language use and in shaping perceptions of that language. Through a quantitative and qualitative study, this paper investigates the use of language in social networking sites by young Welsh speakers, focussing particularly on Facebook. Language choice and behaviour, factors influencing that behaviour, and attitudes towards use of the Welsh language in Information Technology are explored. The data suggests that there are a number of different factors at play, and that it is necessary to consider language behaviour in social networking sites in the context of offline language behaviour.

Introduction I took note of the gray cubicles and the non-ergonomic workstations, curious about how they influenced productivity. Watching the employees, while focusing on my own experience, I noticed the discomfort as we unconnectedly shifted in rigid chairs and contended with unforgiving desks, with our body language mutually signaling a struggle to adapt to the unyielding furniture. My back hurts, and there is no real alternative to move myself elsewhere or a manager around to complain to. The lack of fresh air, sealed windows, and an insufficient air conditioning system contributed to a sense of stagnation in the atmosphere. While I felt unmotivated and rather dire, I wondered how this stale environment affected their physical and mental well-being. The open layout amplified distractions, with loud conversations and various office sounds easily traversing the space, creating a symphony of disruption for the workers trying to concentrate. How can this office play with my organizational settings and with contemporary places of work, with especially one form being based on focusing researcher's experience within an organizational context. Organizational autoethnography, a progressive subfield of autoethnographic research, illuminates the complexities and diversities inherent within workplace experiences. Grounded in the fusion of self and culture, this methodology has been extensively applied across diverse sectors (Doloriert and Sambrook, 2012;Herrmann, 2020). The approach has been efficaciously employed to investigate a broad spectrum of experiences and positionalities within organizational settings as it can be a tool for gaining a deeper understanding of specific organizational phenomena, such as a process, occurrence or specific situation in a contemporary place of work. Notable instances include Hunniecutt's (2017) exploration of gender dynamics through the lens of a female soldier in boot camp, Denker's (2017) critical dissection of exploitation within the bartending industry and Sambrook and Herrmann's (2018) examination of Australian construction organization from within. However, despite the growth and development of organizational autoethnography, its adoption as a primary mode of data inquiry within the academic realm remains limited. While several studies have incorporated this approach within their research frameworks, its adoption within academia has been comparatively slower. Yet, those studies that have integrated this approach have yielded insightful results. Numerous studies have served as pivotal examples in our discussion, further contextualizing the diverse applications of autoethnography in workplace research. Miller (2002) focused on the emotional labor of academic professionals, while Riad (2007) explored the complex intersections of motherhood and an academic career. Cohen et al. (2009) critically engaged with the prevailing metaphor of work-life balance in an autoethnographic conversation between three scholars, whereas Kempster and Stewart (2010) delved into leadership dynamics within academia. Cullen (2011) broached the topic of workplace spiritualization, Sobre-Denton (2012) examined systematic discrimination and workplace bullying and Van Amsterdam (2015) highlighted the oft-ignored intersection of motherhood and academic work. Further expanding the scope of autoethnographic workplace research, Sambrook et al. (2014) deviated from traditional methodologies to examine employee engagement from a more interpretive angle. Pheko (2018) probed into the darker aspects of academia, studying the experiences of academic mobbing within the power structures of academic institutions. Popova (2018) conducted an autoethnographic reflection on her sexuality and decade-long employment in an LGBT-inclusive organization, offering insights into the role of inclusive practices in organizational culture. Bohonos (2021) used "nightmarish' autoethnography to prompt discussions about racially abusive language in the workplace, capturing the propagation of hateful language and its impact on creating hostile environments for people of color. Working under a pseudonym, Van de Berg (2022) utilized autoethnography to grapple with the trauma of her husband's infidelity and its impact on her emotional recovery and academic identity, shedding light on the significant role of the academic workplace in her recovery process. The breadth of studies covering various focus areas, from aspects of gender and sexuality to nuances of leadership and power dynamics, illuminates the potential of autoethnography to provide nuanced and deeply personal perspectives on contemporary workplaces. These studies, whether opting for an analytical stance or leaning toward a more evocative narrative, underscore the predilection toward the organizational dimension of autoethnography when exploring workplace-related phenomena. That said, it is somewhat vital to recognize that autoethnography, when employed in an organizational context, may not universally fit all research questions or environments. Therefore, it is incumbent upon researchers to critically appraise its appropriateness for their line of investigation. Given this complexity, it is worth noting that autoethnography can manifest in multiple forms, namely realist, expressionist, impressionist and conceptualist. --- JOE The diversification of autoethnography into distinct subsets and methodologies equips scholars with the versatility and adaptability to address specific workplace-related concerns differently. Various autoethnographic approaches become imperative, especially when contemplating contemporary workspaces, which often manifest as organizational and spatial hybrids. These varied methodological forms allow for the nuanced exploration of the dynamics within these spaces, understanding the interplay between their unique structural and cultural elements and their subsequent impact on occupants' experiences. This paves the way for a more comprehensive grasp of modern workplaces' organizational and spatial peculiarities, offering deeper, contextually grounded insights. --- Typology of autoethnographic representation The profound work of Adams et al. (2015) provides a comprehensive delineation of the variegated forms of autoethnographic representation. These are meticulously classified into four distinct yet interconnected categories: realist, impressionist, expressionist and conceptualist autoethnographic methodological forms. Each category reflects a unique perspective and representation mode, enriching autoethnographic research's overall breadth and depth. To start, realist autoethnographies are fundamentally rooted in the concept of verisimilitude, striving to create a convincing illusion of reality. This approach leverages personal experiences as a gateway into the realm of cultural understanding, aiming to describe the cultural milieu as evocatively as possible. The resultant narrative, often rich in detail and depth, is known as a "thick description" of cultural life, something that Geertz (1973, pp. 5) would define as "essentially a rendering of what goes on, what it is like from the native's point of view, or how they experience his or her world." The inherent realism of these autoethnographies imbues them with a sense of authenticity and groundedness, enabling readers to connect with the experiences depicted in a deeply personal manner, with the thick description underlining the detailed and nuanced representation of the (cultural) phenomenon. At the core of the realist autoethnographic approach is the intricate coupling of theoretical frameworks with documented personal narrativesa process that heavily leans on individual experiences to clarify and understand theoretical precepts (Lofland, 1995;Anderson, 2006). The practice around the latter fosters an enriched understanding of theoretical paradigms and offers a potent means to communicate scholarly findings to a wider audience (Doloriert and Sambrook, 2012). Therefore, the subsets of organizational and analytic autoethnography, previously discussed briefly in the backdrop of exemplifying past scholarly work that employed autoethnography to comprehend the workplace, can be aptly categorized under the ambit of realist autoethnography. On the other hand, we have impressionistic autoethnographies predicated on capturing an overall experience in its fullest essence. This approach strives to portray detailed representations of the researcher's surroundings or the examined context. The autoethnographer seeks to immerse readers in the experience presented by crafting impressionist text, aiming to foster an enriched understanding of the phenomenon at hand. This immersion engenders a sense of shared experience, blurring the boundaries between the reader and the researched. Several key characteristics distinguish impressionistic autoethnography from realist and other autoethnographic methodological approaches, which we will discuss shortly. First, impressionistic autoethnographers employ their personal experiences as the primary data source (Ellis, 2004). They construct a narrative of their lived experience by drawing from their memories, thoughts and emotions. Second, impressionistic autoethnographers harness literary devices to generate a sense of immediacy and engagement for the reader (Chang, 2008). Autoethnographers tend to infuse their experiences with life and dynamism by employing methodological forms such as metaphor, smile and vivid, lively imagery. Last but not least, impressionistic autoethnographers emphasize the subjective, personal and emotional aspects of their experiences (Jones et al., 2016). Rather than aiming for a detached, objective account of their experiences, these researchers endeavor to share their stories authentically and evocatively. Next, expressionistic autoethnographies deviate from the objective, factual stance commonly associated with traditional research methodologies. Instead, they lean heavily toward evoking moods and expressing the researcher's internal feelings and emotions (Adams et al., 2015). The expressionistic approach validates the essential role of personal and subjective experience mainly by deviating from traditional objectivity and detachment and by its innovative use of language, paired with crafting imagery and symbolism. Using the latter enables the autoethnographer to construct a more robust and nuanced depiction of human experiences (Sughrua, 2020). For example, in a recent work by Rafi (2021), the author uses expressionistic autoethnography to process and define the personal spiritual beliefs of researcher's religious journey from Islam, through atheism, to religious mysticism. With that in mind, expressionistic autoethnographies serve as a conduit for the visceral, emotional aspects of experience, offering a unique and deeply personal insight into the culture or the cultural situation being studied. Conceptualist autoethnographies, the fourth category identified by Adams et al. (2015), represent a distinct form of research method that sets out to contest widely accepted norms and assumptions. With it, autoethnographers seek to navigate and question the taken-forgranted constructs within societal and cultural life, inviting critical discourse into the research process. Here, personal narratives are positioned as more than just episodic anecdotes. These narratives, replete with authentic experiences and memories, transform into tools of potent conveyance, highlighting cultural experiences and breaking down the barriers of silence that often surround the intricacies of cultural existence. Personal stories are leveraged to illuminate and expose, often challenging the silence enveloping controversial, unexplored or misunderstood aspects of our shared cultural life (Wall, 2006;Ellis et al., 2011). Conceptualist autoethnographers engage in a nuanced dance of interpretation and comprehension. They unveil the intricate intersections and interactions between the personal and the cultural, emphasizing how individuals are shaped by the culture they inhabit and, reciprocally, how their actions mold that very culture (Ellis et al., 2011). In its audacious challenge to assumptions and its boundary-pushing nature, conceptualist autoethnography reveals the elaborate network of connections linking individual experiences with broader cultural dynamics, providing a unique lens to perceive the complexities of human cultural life. The latter is predominantly done through critical autoethnographic representation, emphasizing identifying and addressing biases, power imbalances and injustices inherent in these experiences (Adams, 2017). The paper's representative examples have been meticulously chosen based on criteria ensuring their alignment with the methodological approaches presented. Emphasizing relevance and clarity, each example illuminates the methodology in question while showcasing both its common and unique facets, selected for robustness, diversity and comprehensive explanatory ability. This systematic selection not only guarantees validity but also enriches our understanding. As we articulate these interconnected autoethnographic approaches, it becomes evident how these varied methodological approaches offer a more nuanced perspective on the workplace. Therefore, we will further explore these sub-forms of autoethnography and their profound implications within workplace research. --- Autoethnographic forms for workplace exploration 4.1 Realist autoethnographic forms for workplace research With a focus on workplace environments and the very nature of work, we delve into specific autoethnographic subtypes that prove exceptionally valuable for such inquiries. --- JOE Within the realm of realist autoethnography, three distinct subtypes surface as particularly pertinent for examining the workplace. Among them, analytic autoethnography, originally proposed as an adjunct to the more traditional evocative approach, espouses a realist or analytic tradition that proves beneficial to researchers (Pace, 2012). This approach provides an avenue for weaving personal experiences into broader sociocultural and political narratives, enabling researchers to critique and dissect prevalent discourses within cultural contexts in the quest for transformative change in a manner that Wall (2016) would call doing a "moderate" autoethnography. The application of ethnographic strategies within this framework requires a meticulous research approach, often involving the researcher as a full-fledged member of the study group or setting, transparency about this role in the resulting publications and a profound commitment to evolving theoretical comprehension of broader phenomena (Anderson, 2006). As applied to the workplace, analytic autoethnography allows researchers to plumb their personal experiences and observations within an organization, offering novel insights into the cultural underpinnings, power dynamics and social constructs of the workplace, and the researcher's unique position within these structures (O'Neil, 2018). To illustrate, a researcher may leverage analytic autoethnography to unpack their experiences as budding employees within a large corporation, exploring how the company's culture and power dynamics shaped their work and colleague interactions. This perspective promotes a deeper understanding of overarching social phenomena within the organization, such as the ramifications of corporate culture on employee well-being and productivity. It expands the theoretical comprehension of the phenomena under study. Two other types of realist autoethnographies described by Adams et al. (2015) could be deemed highly suitable for workplace researchboth exhibit suitability when studying workplace environments and dynamics. Reflexive interviews empower researchers to document and explore their personal experiences, facilitating a rich augmentation of fieldwork, particularly valuable for capturing the researcher's unique perspective, thereby leading to a deeper understanding of cultural phenomena within a given context. Applying this approach to workplace research permits a thorough exploration of interviewees' experiences and perceptions, illuminating the organizational culture, power dynamics and societal structures underpinning the workplace. For instance, a researcher may delve into employees' experiences within a specific workplace through reflexive interviews, concentrating on their views of the organization's culture and dynamics. This methodology enhances the understanding of individual workers' experiences within the organization and unravels how larger societal phenomena influence these experiences. Reflexive interviews also pave the way for critical self-analysis, yielding a more self-aware research approach (Lear et al., 2018). With that, this approach can empower researchers to engage with interviewees as reflective subjects, thereby fostering a more collaborative and ethical research process. In contrast, layered accounts illuminate the interplay between personal experiences and collated data's ensuing interpretation and analysis. This method acknowledges the strata of consciousness and reflexivity that pervade a researcher's account of personal experiences contextualized within a cultural milieu (Esgalhado, 2003). Layered accounts encapsulate the researcher's personal experiences, reflections on overarching social and cultural contexts shaping these experiences and, significantly, the perspectives and experiences of others involved, such as colleagues or community members (Ellis et al., 2018). Applying layered accounts to workplace research, a researcher could weave together personal experiences as an employee with reflections on the organizational culture, power dynamics and societal structures of the workplace, thereby providing a more multifaceted and nuanced narrative. The inclusion of colleagues' perspectives and experiences further enriches the account, yielding a broader, more comprehensive view of the workplace experience. See Table 1 for the summary of realist autoethnographies. --- Impressionistic autoethnographic forms for workplace research Impressionistic autoethnography blends vivid descriptive language with an artistic writing approach to artistically convey the researcher's subjective experiences, emotions and sensory nuances, rooted in personal storytelling and detailed narrative representations of their observations, memories and emotions (Islam, 2015). Within this context, Adams et al. (2015) highlight three sub-forums that are especially advantageous for researching workplace settings. First, collaborative autoethnography arises as a valuable method for examining personal experiences and perspectives through a collaborative, reflexive lens to generate a shared narrative encompassing group members' myriad perspectives and experiences. This approach underscores collaboration, reflexivity and dialogue, endeavoring to create a comprehensive account that faithfully mirrors the heterogeneity of group members' perspectives and experiences (Lapadat, 2017). With that being said, collaborative autoethnography shows promise in dissecting complex and sensitive issues, facilitating a more nuanced, layered understanding of personal experiences embedded within culture (Malorni et al., 2023). To illustrate, a cadre of researchers might employ collaborative autoethnography to delve into their collective experiences within a specific organization, giving special attention to the organizational culture, power dynamics and social constructs shaping the workplace. This approach can cultivate a more comprehensive and diverse understanding of the workplace and illuminate how personal experiences are situated within broader sociocultural contexts (Doloriert and Sambrook, 2012). In doing so, the research group could, for instance, unearth the unspoken norms shaping team dynamics or shed light on systemic issues impacting worker well-being, thereby contributing significantly to the body of knowledge surrounding organizational culture and behavior. Two additional sub-forums come to the fore when facilitating a deeper understanding of the workplace, whether as a physical entity or an organizational body. On one side, sensory and physical accounts offer a unique perspective in autoethnographic research, enabling the exploration of personal and cultural experiences through the prism of sensory perception, physical embodiment and the passage of time (Adams et al., 2015). Such an approach entails a --- JOE heightened awareness of sensory and physical facets of personal experiences, encompassing visual impressions, auditory cues, olfactory stimuli, gustatory experiences and corporeal sensations linked to the researched phenomenon (McLlveen, 2008;Uotinen, 2011). For instance, in a workplace-focused autoethnographic study, sensory and physical accounts could capture the researcher's interactions with the physical environment, such as the spatial layout, ambient lighting and thermal conditions. The sensory undercurrents of work could also be delved into, for example, documenting the sounds and scents characteristic of a specific working environment. Second, impressionistic narratives of space and place offer invaluable insight into how spaces and places imprint upon and shape identities. Essentially, these narratives are woven from the impressions that chosen spaces and places leave on the researcher (Adams et al., 2015). Through these accounts, researchers can scrutinize how their personal experiences are molded by the physical and social milieus within which they unfold and the reciprocal influence they exert on these environments (Olmos-L opez and Tusting, 2020). In the context of a workplace-focused study, this could entail exploring the researcher's personal experiences of their workplace's physical and social terrain. Complementing this, the researcher could attain a more tangible and experiential understanding of their workplace and elucidate the contextual factors that frame personal experiences. For example, Winkler's (2018) work serves as an instructive exemplar of this approach, where he weaves a compelling autoethnographic narrative elucidating the relationship between his personal journey of learning Danish and his workplace's physical and social context. As projected in Table 2, these impressionistic narratives of space and place can illuminate a more nuanced and layered understanding of personal experiences within a cultural context, particularly within a workplace environment. However, fully engaging with these experiences' emotive dimensions requires shifting toward expressionistic autoethnographies. --- Expressionistic autoethnographic forms for workplace research Navigating further into expressionistic autoethnographies, we encounter sub-forms that emphasize the creation of aesthetic and evocative narratives. These narratives are designed to vividly represent the thoughts, emotions and actions of the individuals involved, enabling readers to resonate with, or gain an empathetic understanding of, the depicted experiences. Distinguished by its accent on evoking emotions and fostering active reader engagement, evocative autoethnography is less about imparting information and instigating a dialogue. The narrative, written predominantly in the first-person, is intended to provoke an emotional response, often unveiling intimate aspects of personal life, and foregrounding emotive experiences. Presented in various formats such as poetry, short stories, fiction, novels or photographic essays, evocative autoethnography can facilitate a comprehensive exploration of varied facets of a researched workplace, especially from an insider's perspective (Faulkner, 2017). The first exemplar of this expressionistic approach that would fit the context of workplace research is the sub-form of emotional renderings, which zeroes in on the researcher's exploration and articulation of their emotional responses and affective experiences in connection with their personal journey situated within a cultural milieu. Emotional renderings can foster a nuanced, multifaceted understanding of personal experiences and how they are enmeshed within broader social and cultural constructs (Adams et al., 2015;Lee, 2022;Akehurst and Scott, 2023). For instance, in an autoethnographic study centered around a workplace, emotional renderings could encapsulate the researcher's experiences of workinduced stress, anxiety or fulfillment. The researcher could introspect on their work environment's emotional toll or boon on their overall well-being and the influence exerted by the workplace's organizational culture and power dynamics on their emotional landscape. Through this lens, the researcher could attain a more embodied, experiential understanding of their workplace, and the contextual factors that embed personal experiences within broader social and cultural realms. As we venture further into the domain of expressionistic autoethnographies, we come across the realm of confessional research accounts. These accounts, a characteristic of autoethnographic research, encompass the researcher's exploration and articulation of their deeply personal experiences and emotions in a profoundly intimate and candid manner (Kennedy, 2020). This modality involves the researcher divulging private aspects of their personal experiences, often adopting a confessional or cathartic style, intending to expand understanding of a specific culture, discipline or phenomenon (Merchant and Garza, 2015). Take, for example, an autoethnographic study of a workplace. Here, confessional research accounts could encompass the researcher's experiences of stress, anxiety or satisfaction tied to their professional roles and their struggles navigating power dynamics or organizational culture within the workplace. This approach allows the researcher to attain a more embodied and experiential comprehension of their professional environment and insight into how personal experiences are positioned within broader social and cultural contexts. Through this lens, the researcher is a participant and a narrator, providing a human dimension and emotional depth to the portrayal of the workplace environment. The researcher allows readers to empathize with their journey by revealing the raw nerves of their experiences, fostering empathy, understanding and a feeling of our common humanity. Third, there is the approach of producing devotional texts. Devotional texts encompass the researcher's exploration and articulation of personal experiences and emotions connected to their spiritual or religious beliefs and practices. The implementation of this approach includes the researcher divulging intimate aspects of their spiritual or religious experiences, often adopting a confessional or cathartic style, to expand understanding of a specific culture, discipline or phenomenon (Zubko, 2006;Milner-Thornton, 2007). Picture, for instance, an autoethnographic study conducted within a religious or spiritual community. In this setting, devotional texts may detail the researcher's experiences with prayer, meditation or other spiritual practices, and their personal struggles with faith or belief within the community. This approach empowers the researcher to attain a more embodied and experiential comprehension of their spiritual or religious community and insight into how personal experiences are situated within broader social and cultural contexts. In the workplace context, devotional texts may be particularly insightful if religious or spiritual values influence the place of work, or if the researcher's religious or spiritual beliefs influence their perceptions and experiences of the workplace. For example, a researcher could explore how their religious beliefs influence their perceptions of teamwork and leadership within their organization, or how a Catholic hospital's mission and values influence the practices and interactions within the workplace. This evocative approach, thus, provides a rich and multilayered understanding of the workplace, shedding light on often unexplored spiritual or religious dimensions. Lastly, we delve into the realm of collaborative witnessing. This approach paves the way for researchers to place their focus on the lives of others, recounting them in an evocative manner through shared storytelling and conversation. Collaborative witnessing intertwines the roles of the storyteller and the listener, fostering a joint narrative in which both parties participate equally, reciprocally engaged in an enduring relationship and dialogic exchange (Adams et al., 2015). In workplace research, collaborative witnessing invites multiple researchers (or individuals who are not necessarily researchers) to share their experiences and interpretations of the collective autoethnographic data (Ellis and Rawicki, 2013). This strategy can unfold a nuanced and multifaceted understanding of personal experiences in the workplace culture and how broader social and cultural contexts shape these experiences. Collaborative witnessing could prove particularly insightful in examining the collaborative nature of knowledge-based work. Imagine, for instance, a group of researchers working in a technology startup. They can weave together their individual experiences and perceptions of the company's dynamic and fast-paced work environment, shedding light on the challenges and triumphs of innovation and team synergy. Collaborative witnessing can be used when individuals share their past experiences with the clear aim of developing committed relationships with one another. This approach could also elucidate the importance of the physical and spatial aspects of the workplace in supporting collaboration performance. For instance, the researchers could reflect on how the open-plan design of the office, the availability of shared workspaces and the use of technology-enabled meeting rooms affect them personally and subsequently shape their collaboration and communication practices. In this manner, collaborative witnessing can provide a rich, multilayered and collaborative understanding of the workplace environment. See Table 3 --- Conceptualist autoethnographic forms for workplace research Transitioning to the final cluster and informed by the categorization by Adams et al. (2015), we examine the types of conceptualist autoethnographies that can be of value when researching workspaces. Leading off with critical autoethnography, this approach emphasizes the critical analysis of personal experiences in conjunction with the social and cultural construction of identities. It involves researchers introspectively engaging with their personal experiences, and then using the lens of critical theory to scrutinize and interpret these experiences in the wider backdrop of social and cultural contexts. The goal of critical autoethnography is to act as a catalyst for personal and societal emancipatory changes by pinpointing and challenging deeply entrenched power dynamics, inequities and social injustices (Jensen-Hart and Williams, 2010;Marx et al., 2017). When applied to the exploration of work environments, critical autoethnography can be an impactful tool for deep understanding of personal experiences nested in cultural contexts, especially within the intricacies of multidisciplinary teams or complex sociocultural settings. Here, critical autoethnography hones in on the thorough analysis of personal experiences and the social and cultural development of identities within the workplace. It may be used to identify and address power disparities, injustices and inequities intricately woven within organizational culture. Another instance of how critical autoethnography may illuminate underrepresented or vulnerable groups in a particular environment is the experiences of women, people of color and LGBTQIA<unk> persons (e.g. Lynch et al., 2022;Moosavi, 2022). To set an example; a researcher might critically explore their experiences as a member of a marginalized group in the workplace, focusing on the challenges they face and the strategies they employ to navigate them. Through this approach, the researcher can offer insights into the lived experiences of marginalized groups, providing a foundation for more inclusive and equitable workplace practices. Advancing to the next conceptualistic approach, we encounter "insider texts." This method leverages personal experiences and insider knowledge of marginalized groups to shed light on power dynamics, often revealing inaccuracies and harms of past research, thus casting fresh perspectives on cultural practices and experiences (Adams et al., 2015). For instance, insider texts can provide valuable insights into phenomena such as workplace bullying, exploring its prevalence, consequences and mechanisms. What is more, these texts could offer an enriched perspective on the influence of managerial coaching on the well-being of subordinates within the workplace. Last, but certainly not least, are community autoethnographies. This approach invites researchers to collaborate with community members to investigate and address specific issues. These autoethnographies provide a platform for narratives often silenced or overlooked, illuminating life's everyday neglected and distorted aspects (Toyosaki et al., 2009). They also open avenues for cooperative research in selected organizational settings, mainly to uncover workplace-related issues that would otherwise remain uncovered. Take, for instance, the environment of a coworking space. Here, researchers could partner with community members to delve into the dynamics of the work community, unveiling issues like subtle bullying or systemic racism that might lurk beneath the surface. Researchers can delve deeper into organizational contexts through such a collaborative and co-produced autoethnographic approach, shedding light on intricate dynamics that inform the broader workplace culture. See Table 4 for the summarized examples. --- Concluding debate: Autoethnography's role in workplace research This paper accentuates the potential of autoethnography as a methodological paradigm for deciphering the complexities of workplace dynamics and organizational cultures. Recognizing autoethnography's immersive perspectiverooted in the lived experiences of individuals within their professional realmsthis methodological paradigm moves beyond mere personal narratives. This paper delves into various autoethnographic methodologies structured around Adams et al.'s (2015) framework, each offering distinctive attributes that collectively paint a comprehensive picture of organizational landscapes and the varied ways individuals traverse these realms. Engaging in a lively debate about applying autoethnography in workplace research unveils its exceptional aptitude to bring subtle and often concealed facets of organizational life to light. Elements like the sensory, physical and emotional dimensions, the nuanced influence of spaces and places on identities, the dynamics of power and even spiritual experiences within the workplace are not usually the subject of conventional organizational studies. Autoethnography, emphasizing subjective experiences and narratives, invites these elements to take center stage, thus endowing a more comprehensive and nuanced understanding of professional life. Consequently, this exploration underscores autoethnography's capability to penetrate the depths of contemporary workplaces, enriching our understanding of these multifaceted, ever-evolving spaces. However, exploring such personal and intimate experiences also raises important ethical considerations. Exposing personal and potentially sensitive information requires rigorous attention to consent, confidentiality and potential harm. Furthermore, the inherent subjectivity of autoethnography prompts debates around reliability, validity and generalizability. Can personal narratives be accepted as valid insights into broader organizational dynamics? How can these narratives' inherently unique and contextual nature be reconciled with the scientific pursuit of generalizable knowledge? Rather than undermining the value of autoethnography, these debates can be viewed as an invitation for researchers to continue innovating in this field. For instance, strategies such as collaborative autoethnography, insider texts and community autoethnographies help address these issues by incorporating multiple perspectives and deeply involving those being studied in the research process. Finally, using autoethnography in workplace research is more than just a methodological choice; it is a commitment to humanize the workplace, validate workers' lived experiences and stimulate conversations that could lead to more inclusive, empathetic and effective organizations. The further exploration, adaptation and integration of these approaches in organizational studies promise a future of research that is not just about organizations, but also for them and the people within them.

Purpose -This conceptual paper seeks to critically evaluate and illuminate the diverse autoethnographic methodologies that are pivotal for understanding the dynamics of contemporary workspaces. The objective is to contribute to the ongoing scholarly debate on the value of autoethnography in workplace research and explore how it can shed light on complex organizational phenomena. Design/methodology/approach -The paper adopts a narrative literature review approach, focusing on four main forms of autoethnography: realist, impressionistic, expressionistic and conceptualistic autoethnographies. Each form is discussed and dissected, emphasizing their specific sub-forms and illustrating their application through representative examples. The paper engages in a critical debate on utilizing autoethnography in workplace research. Findings -The findings illuminate how autoethnographic methods can be used to gain nuanced and complex understandings of personal experiences situated in workplace culture, as well as how broader social and cultural contexts shape these experiences. The study also highlights the potential of these methods to explore marginalized and silenced stories within workplaces and contribute to the knowledge on power dynamics, inequalities and injustices embedded in the organizational culture. Practical implications -The following contribution discusses approaches for conducting autoethnographic explorations of selected work environments, offering researchers valuable insights into these methods' application. Through better comprehension and application of these methodologies, researchers can enhance their contribution toward cultivating more inclusive and equitable workplace environments. Originality/value -The paper stands out in its extensive review and critical discussion of the autoethnographic methods as applied in workplace research. It expands upon individual autoethnographic studies by providing a comprehensive, multifaceted perspective, delving into the merits and limitations of these approaches in particular context of researching contemporary places of work.

Introduction The coronavirus SARS-CoV-2 that causes the disease COVID-19 has caused significant disruption in everyday life on a global scale. Several public health measures have been put in place to reduce the transmission of the virus and to minimize the impact of the disease [1,2]. These measures include isolation of those who have acquired the infection and quarantine of their close contacts [3]. Quarantine refers to separating and restricting the movement of people who are exposed to a contagious disease to see if they become sick whereas isolation means separating infected people from those who are not known to be infected [4]. The effect of various public health measures to contain the COVID-19 pandemic is not yet fully understood [3]. However, recent studies increasingly support quarantine measures as an effective precaution to curb transmission of the virus [5][6][7]. Moreover, quarantine appeared to be an effective virus mitigation measure in several countries during previous SARS outbreaks in 2003 including Singapore, Canada and China [8][9][10]. There are various kinds of isolation and quarantine measures as well as systems to follow up on the implementation of these measures worldwide [11]. In Finland, isolation and quarantine measures are home based with an official notification about the measures and regular phone-based follow up by health officials. Quarantined persons without symptoms are usually not tested. Persons in quarantine are allowed to go out in public as long as they are not in contact with other people. However, going to work, school, or shopping is not permitted during quarantine [12]. This is based on the Communicable Diseases Act Infectious Disease Law that stipulates that both quarantine and isolation are obligatory [13]. Breach of the law is punishable by up to three months of imprisonment. However, follow up on the adherence of the law is not systematic. Those in quarantine found themselves isolated at home without their usual routines. This rise in unstructured time, combined with the enormous stress of the pandemic and its farreaching consequences on both health and the economy, has led to widespread concerns including worry about social stigma [14]. Stigma is a well-documented global barrier to health-seeking behavior, engagement in care, and adherence to treatment across a range of health conditions including infectious diseases [15][16][17][18]. It may also occur due to patient isolation and quarantine procedures [19,20]. Stigma operates across different levels including in the public sphere through public policies, in organizations, and in communities through cultural values, norm, and attitudes in communities. Stigma also operates in interpersonal relations related to family and friends, and on an individual level related to the knowledge and skills of individuals to manage stigma [21][22][23][24]. Although previous studies indicate many similarities regarding stigma across countries, stigma is also known to be context-specific which necessitates understanding stigma in the given context [25]. Coronavirus and COVID-19-related stigma has been reported in number of countries such as in India, Ethiopia, Japan and Uganda [26][27][28][29][30][31]. Stigma against healthcare workers associated with the care of coronavirus patients has been reported widely as well [32]. However, little is known about the nature of coronavirus and COVID-19-related stigma, which is paramount for developing effective stigma reduction strategies. Several studies have investigated the psychological experience of quarantined individuals during major infectious disease outbreaks [33][34][35], but less focus has been given to social and behavioral research that is necessary to develop meaningful support strategies for those isolated or quarantined [36]. This study aims to review the forms, drivers, outcomes, and impact of social stigma towards those with coronavirus and COVID-19 and their family members, and to shed light on their quarantine experiences in order to develop operational recommendations for public health officials in Finland and other similar cultural settings to better support people during and after quarantine or isolation. --- Materials and methods This study is comprised of in-depth interviews with people from households that experienced coronavirus and were in home quarantine or in isolation for a period of time. The interviews were conducted between April and May 2020 by a researcher (A-LL) trained and experienced in qualitative data collection and analysis methods. Those eligible to join the study were people from households located in the capital area of Helsinki in Finland with at least one COVID-19 PCR confirmed case and at least one additional person living in the household. Respondents included children defined as over the age of 12, youth ages 13 to 17 and adults over the age of 18. Any number of household members could participate in the study. --- Recruitment The study was part of a larger COVID-19 household transmission protocol that explored the extent of household transmission [37]. Individuals who were recruited for the transmission study, which included a series of household visits to test for the virus and antibodies, could also participate in the qualitative interview study during the final household visit. Recruitment took place through the Finnish Institute for Health and Welfare website or via an SMS message that was sent to PCR confirmed cases in the capital area. The study coordinator contacted those interested in joining the study by phone to assess eligibility and to schedule a series of home visits. A qualitative interview was conducted 28+ days after the household index's PCR confirmation when they were expected to have recovered from the virus. To protect the interviewer from potential transmission of the virus, a phone call was made to each household before the visit to ensure household members were free of symptoms. All but one interview was conducted in Finnish. --- Sampling The sampling was based on maximum variation in which the overarching principle was to engage respondents from different types of households including couples without children, families with children, and families with teens so that their aggregate answers could be considered to reflect those of close to the whole population [38]. Interviews were conducted until no new information was generated and accordingly data saturation was reached [39]. --- Conceptual framework and tools The conceptual framework of health stigma informed the development of the stigma question guide. It included drivers and facilitators, manifestations, outcomes, and impacts of stigma. The drivers and facilitators are factors that encourage stigma. Drivers are conceptualized as inherently negative. Conversely, facilitators may be positive or negative influences. Drivers and facilitators determine whether stigma "marking" occurs, meaning stigma is applied to people or groups. Once a stigma is applied, it manifests in a range of stigma experiences and practices [25]. Stigma manifestations influence a number of outcomes for affected populations as well as for organizations and institutions, which then together influence longer term impacts of stigma. The study explored "self-stigma," which is defined as a stigmatized group member's own adoption of negative societal beliefs and feelings associated with their health status [25]. In this study, self-stigma explored negative feeling towards self among confirmed coronavirus individuals and their household members. The study also explored perceived stigma, which are the perceptions of a stigmatized group regarding how people treat them. In this study, perceived stigma explored how laboratory confirmed coronavirus cases and their household members perceived treatment by others. This framework was selected as it is not only theoretical, but facilitates an understanding of the factors that facilitate and mediate the stigmatization process for individuals and also informs intervention development [25]. Participants were asked to describe any negative experiences with people during their quarantine or isolation to record their experiences of stigma. The question guides also included a set of open-ended questions that explored their experiences in quarantine or isolation, such as: Tell me about your time in quarantine? How did quarantine influence your life? What was difficult for you during quarantine?. --- Interviews Interviews ranged from 20 to 60 minutes and were conducted in a private room or space in the homes of the respondents. Interviews were conducted individually to allow for the exchange of sensitive or confidential information. All interviews were conducted in Finnish except one that was conducted in English. They were audio recorded and transcribed. Approximately 5% of completed interview transcripts (n = 3) were cross checked by another transcriber to ensure accuracy and the level of detail. --- Analysis The analysis was based on a thematic analysis conducted by the first author (AL) [40]. The analysis of stigma followed the health stigma framework [25] that included identifying codes and categories within each construct of the framework (drivers, facilitators, manifestations, outcomes, and impacts of stigma). Analysis of the quarantine experiences were based on an inductive coding process. The process started with a data familiarization process during which the analyst read the transcripts multiple times to get an overall idea of the dataset and to create an initial set of codes that resulted in a codebook. Coding was conducted for each interview using the codebooks, emerging new codes were also included using NVIVO12, followed by refining and expanding codes and developing categories. The initial analysis was shared with the study team (HN, TD, and LH) to get consensus on the emerging categories and the ways to explore relationships and patterns across the interviews. In the final stage, the analyst developed the interpretation. The syntheses of the results served as the foundation for operational recommendations to support people in quarantine and isolation. --- Ethics The Finnish Communicable Diseases Law and the law on the duties of the Finnish Institute for Health and Welfare allowed the implementation of this research without seeking further institutional ethical review. Written informed consent was obtained from all cases and contacts willing to participate in the investigation, before each interview. A written consent for children under the legal age of consent (15 years) was obtained from a parent or legal guardian as well as from children under the age of 15. --- Results --- Participant characteristics The study included 64 participants from 24 households in the capital area of Helsinki in Finland. Each household included at least one PCR-confirmed SARS-CoV-2 positive individual and 1-4 family members. Almost half of the households (42%) had children (0-12 years old), one-quarter of the families (25%) had teenagers (13-17 years old), one household was a single parent household, and the remaining households (29%) were couples without children or households where children no longer lived with their parents. The sample included 14 teenagers or children and four households included healthcare workers (nurses or doctors). Most adult participants were in the age range of 30-49 (75%). The sample included approximately an equal number of female and male respondents. The PCR confirmed cases occurred in households during February-April 2020. The majority were confirmed in week 11 (50%) and week 12 (34%), while the remaining cases were confirmed in week 9, week 10 and week 13. Among PCR confirmed cases there was one teenager and three children who were confirmed positive. Household members who did not have symptoms were not PCR tested. --- Perceived stigma This section describes drivers, manifestations, outcomes and impact of perceived stigma. See Fig 1 Framework for perceived stigma. Most adult respondents had experienced stigma, while stigmatizing experiences among children and teenagers were less common. All stigma experiences of teen and child respondents included parent involvement, such as informing their friends or their families about their coronavirus status on behalf of the child or teenager. Respondents explained that most experiences of stigma occurred after quarantine because during quarantine their social contacts were minimal and accordingly there were few opportunities for stigmatizing experiences. Perceived stigma did not differ between respondents who experienced the infection during different periods of time nor between people who had wide social support networks or narrow social networks with whom to communicate. Stigmatizing experiences did not vary between respondents from different types of families or between those who were COVID-19 PCR confirmed cases, those who tested negative and those did not know of their coronavirus status, or between those with severe symptoms and those with mild symptoms, or among different types of families. Those who did not report perceived stigma explained they had not thought of coronavirus as something stigmatizing. They included households with teens and children and in many of these households the infected individuals had experienced only mild symptoms. --- Drivers of perceived stigma Respondents believed that they were stigmatized because of fear of getting infected with SARS-CoV-2 or because they were blamed for contracting the virus. Some respondents also believed that people were angry with them for putting others, especially children, at risk of infection. A number of respondents highlighted that fear of contracting the virus was prominent because people were unsure how long individuals stayed infectious and whether the infection was followed by immunity and if so, for how long. Healthcare workers experienced particular blame for contracting the virus. "People think that we should not have any other life but being nurses or doctors. We should not be allowed to go out and contract the virus." (Female healthcare worker respondent from a family with teenagers) --- Perpetrators and manifestations of perceived stigma Respondents identified four types of stigma perpetrators linked with different types of social networks. The most distant social network of stigma perpetrators included those who had no personal relationship with the respondents but who communicated by posting comments on social media and traditional media sites. Stigma manifested in blame for being irresponsible and careless. --- "After talking to media I got so many negative comments. I could not believe the reactions of people. They blamed us for being reckless. It felt really bad. I decided not to speak up again." (Female respondent from a family with children) The second network of stigma perpetrators were those who had an indirect link to the social networks of the respondents such as being parents at the same school as the respondents' children or living in the same neighborhood, but not having a personal relationship with respondents. They stigmatized respondents by blaming them for contracting the virus, gossiping, and by being overly interested in their coronavirus and COVID-19 experiences. --- "Yes we heard through friends that some people were accusing us of not informing everyone in the neighborhood about our infection. I am very sensitive about this kind of gossiping." (Female respondent from a family with children) The third network of stigma perpetrators included friends, acquaintances and colleagues with whom participants had not been in close contact before contracting the virus. Stigma manifested in the reluctance to interact with the respondents. "There are many friends who are very straight forward that they won't meet with us even outdoors." (Male respondent from a family with children) The fourth networks of stigma perpetrators were those who had been in close contact with the respondents before or during quarantine or isolation. Stigma manifested in being overly curious and continuously questioning them about coronavirus, the modes of transmission, and the ease of the transmission. --- "It was quite obvious that they (friends) were afraid of my infection. It was tiring to answer the same questions over and over again. They also wanted us to give them instructions how to protect others from the infection and they did not believe that we had not received any such instructions." (Male respondent from family with no children) --- Outcomes of perceived stigma Stigmatizing experiences resulted in respondents' reluctance to disclose their coronavirus status. Respondents frequently explained that disclosing their status to those that they had exposed was seen as a duty, but they disclosed to others only on a "need to know basis". Some respondents explained they did not hide their coronavirus status from others, but only talked about it if asked. --- "I still carefully consider every time I am in a situation in which I should tell about my COVID-19 status." (Female respondent from a family with teenagers) Outcomes of stigma among teenagers and children included insecurity about how to deal with friends and worry about the reaction of colleagues and friends at school. --- "I am bit nervous about going to school. I know that people know we had coronavirus at home." (Teenage respondent) --- Impact of perceived stigma Respondents highlighted that perceived stigma negatively impacted their social contacts in many ways and accordingly reduced their quality of life. --- "My life is not the same. There was more going on and more people around. It feels empty now." (A female respondent from a family with children) --- Self-stigma This section describes drivers, manifestations, outcomes and impacts of self-stigma. See Fig 2 Framework for self-stigma. Participants were asked to explain the kind of negative feelings they had towards self to better understand how they defined self-stigma. Participants explained that self-stigma meant feelings of being contagious or infectious and accordingly worry about infecting others, which was particularly common after the quarantine or isolation ended. Almost all adults had negative feelings towards self, whereas none of the children, youth or healthcare workers or their family members expressed self-stigma. Self-stigma did not differ between respondents experiencing the coronavirus during different periods of time nor between people who had wide social support networks and those who only had a few people with whom to communicate. Self-stigma did not vary between respondents from different types of families, between or between those who were COVID-19 PCR confirmed cases, those who tested negative and those did not know of their coronavirus status, or between those with severe symptoms and those with mild symptoms. --- Drivers of self-stigma Respondents highlighted that negative feeling towards self were driven by limited and changing information about the virus as well as limited and often contradicting information about quarantine procedures. Respondents also highlighted that information about quarantine did not include many concrete or practical instructions, which led to uncertainty about how to manage daily life during quarantine or isolation and how not to infect others. Some respondents worried that the health authorities had ended their quarantine time only because there were not enough workers to follow up with all positive coronavirus cases. Similarly, some COVID-19 PCR positive cases worried about being potentially infectious as their quarantine ended while they were still symptomatic. In addition, respondents expressed insecurity surrounding immunity as yet another reason that kept them worried about potentially still being infectious. "I had hoped that once I was done with quarantine that my life would return to normal but it did not. I continued to be worried about transmitting the infection to others." (Female respondent from a family without children) Some respondents who did not know about their coronavirus status often struggled for several weeks to get PCR-tested for SARS-CoV-2 during which continuous uncertainty played a central role in their lives. The same uncertainty continued after quarantine. --- Manifestations of self-stigma Adult respondents explained that self-stigma created stress when leaving the house and when in close proximity to others in shops, markets and even outdoor areas such as in parks. Meeting friends in the street and greeting people made some respondents tense; some worried about being blamed by others for being outside of their home. COVID-19 PCR respondents expressed greater stress about encounters with people outside of the house than others. --- "I was thinking that neighbors are watching and wondering why I'm going to do the shopping." (Female respondents from a family with children) Healthcare workers and their family members did not express fears about being infectious after quarantine. On the contrary, they were confident about having immunity that protects them and others. --- "It may come back [COVID-19] but I would be really surprised if no antibodies were detected in me." (Female respondent from a family with a healthcare worker) Children and teenage respondents did not explain situations in which they felt difficulty interacting with people outside their house. On the contrary, some of them claimed having breached quarantine to meet friends. --- "My sister told me not to go out but it was so frustrating to stay at home. I really missed my friends. So I met my girlfriend outside of the house a couple of times." (Male teenage respondent) --- Outcomes of self-stigma Adult respondents explained that self-stigma made them reluctant to meet people outside of their household, and in particular, with people who belonged to high-risk groups. Many of them expressed being devastated about not being able to meet elderly or sick parents in person and not knowing when they would able to do so. --- "I know I am no longer sick but I haven't been able to meet with my parents. I really do not dare to do that. This is a real tragedy for us, but I am too worried about infecting them." (Male respondent from a family with children) Adult respondents also prolonged their quarantine after the official quarantine time had ended by an additional one to even three weeks because of fear of infecting others "We just wanted to be on the safe side and continue our quarantine for an additional two weeks." (Female respondent from a couple without children) Two adult respondents expressed guilt about having infected people outside of their household who belonged to high-risk groups. Respondents did not express guilt about infecting members of their own household, which they saw as inevitable. "I felt so guilty for having infected my mother. I visited her every day. My isolation was all about worrying about my mother." (Female respondent from a family with children) --- Impact of self-stigma In general, respondents agreed that self-stigma was a burden that created psychological stress. --- "These negative feelings that I have towards myself are creating so much tension and stress in my life." (Male respondent from a couple without children) --- Coping mechanisms to manage stigma Respondents explained they managed stigma in multiple ways. Some of them felt that the best way to avoid stigma was to challenge the fear of being stigmatized by telling everyone with whom they had been in contact about their coronavirus status. However, not all respondents could overcome the fear of stigma to do so. --- "We told everyone so nobody will come later to blame us." (Male respondent from a family with children) Others explained that they avoided stigma by following the instructions for isolation or quarantine and ensured that everyone who knew about their coronavirus infection knew that they were doing the right thing to prevent the transmission of the virus. --- "We were always at home as they requested us to do. This was also a way to avoid conflicts and reduce the fear people had towards us." (Female respondent from a family without children) Some respondents reduced self-stigma by convincing themselves that they had done everything they could have to avoid contracting coronavirus. Others believed that increasing quarantine time by an additional week or two reduced self-stigma. --- "We took decisions based on the available information. There was nothing more we could have done at that time to avoid the infection." (Female respondent from a family with children) --- Quarantine and isolation experiences This section describes key characteristics linked with quarantine experiences (worry about health and boredom) as well as communication and everyday routines during quarantine and isolation. --- Worries about health Respondents from households with severe or prolonged coronavirus-related symptoms or from households where household members had difficulty accessing testing or being admitted to the hospital often described their quarantine experience as having revolved around symptom management and worry about escalating symptoms and even death. For some respondents this was an overwhelming experience. Respondents explained thinking about death in particular when a friend or someone they knew was hospitalized or when media reported about high infection rates and fatalities abroad. Respondents explained that they passed the time by analyzing their changing symptoms. --- "I was living in continuous worry and fear. No one was able to explain how the illness will develop." (Female respondent from a family with children) Some respondents found themselves caring for their sick household members, which consumed all of their time and energy. Many of them felt incapable of the task and therefore considered it a heavy responsibility. Some respondents felt sorry for their children who were ignored and forgotten while they managed the illness among other household members. --- "My life was revolving around my sick husband. I could not rest or think; I just kept going from one day to the next. I wanted him to be admitted to hospital as I did not want to carry all that responsibility myself." (Female respondent from a family with children) Children and teen respondents explained being worried when seeing one or both parents severely ill. Some of them worried about the condition of their parents and what they could do to help the situation, others were more worried about practical issues such as what to do if both parents ended up in the hospital. Neither children nor teenagers seemed worried about their own health. --- "I was scared when both of my parents were sick. I went through an emotional rollercoaster when my parents were ill." (A male teenager respondent) Some respondents were consumed with worry about the people they exposed to the coronavirus or who contracted the virus from them. --- "I had no time to think about myself or worry; I was so devastated about my mother. I felt so guilty for infecting her." (Female respondent from a family with children) Others worried about friends and family members in high-risk groups who may get sick or about not being able to socialize with them. --- "We haven't met with my parents since this all started. I am so worried and we are all so sad. I kept thinking of my parents a lot." (Female respondent from a family with no children) --- Boredom Some respondents from households with mild COVID-19 symptoms described quarantine as monotonous with the same daily routines. Some were irritated about their everyday lives. Teen and child respondents also frequently described quarantine as tiresome and dull. One of them explained that quarantine made him and his friends extremely passive. Respondents who used to meet with friends and had an outgoing and active lifestyle were particularly bothered about the restricted lifestyle in quarantine. --- "It is exhausting to be at home, all days are the same. Although I manage to work from home just fine, the days are the same." (Male respondent from a family without children) Others with mild symptoms did not consider that their everyday life had changed much since they contracted the virus. They explained spending a lot of time at home, working from home, or having little social contact outside of their home. --- "Our life is already like quarantine so this situation has brought us no major changes for us." (Male respondents from a family with teenage children) --- Communication Over half of the participants had at least one person in the household who was communicating regularly with others who had contracted the virus. The most common communication channel was a WhatsApp group that was established among people who attended an event during which they contracted the virus or a pre-existing WhatsApp group where friends who had contracted coronavirus were already communicating. --- "I don't know what I would have done without my group. I was talking to them daily. It helped me to ensure that I was going to manage this." (Female respondent from a couple without children) Those who did not belong to such peer support groups included participants who did not know the mode of transmission of their infection or those who were elderly. Respondents explained that regular communication with others, including listening to the illness episodes of others and finding similarities with their own experiences, reduced worry about their own health and the health of other coronavirus positive household members. Communication with peers also provided an opportunity to share their own experience with those who understood their situation. Respondents said that being part of a group empowered them: "Together we can make it." In addition, respondents mentioned that groups provided information about how to access testing and they helped them prepare for being positive for SARS--CoV-2. Communicating with others in the same situation was also important to healthcare workers. For some respondents participation in coronavirus-specific communication groups was a negative experience as continuous discussions about the topic made the illness highly present in their lives and a source of stress. One respondent felt that the active WhatsApp communication by his partner made him an outsider. For other respondents, active WhatsApp communication with other household members was a great source of information for the whole household. "It was a bit too much for after a while with all the information I received from the group. I felt that there was nothing else in my life than corona so I started distance myself from the group." (Female respondent from a family with children Some respondents discussed their infection in other personal WhatsApp groups to share coronavirus and COVID-19 information with others or to get attention. Some respondents explained that they had the role of "corona experts" in those groups whose advice friends sought through the group. --- "My friends who are worried about corona keep consulting me about their symptoms. I turned out to be corona expert." (Male respondent from a family with children) Teen and child respondents did not explain having established any coronavirus-specific groups. Some of them communicated with friends from time to time about their infection, but more often their discussions related to quarantine and the problems that it brought to their lives such as cancelled graduation parties, sports and travel. "We used to talk about corona in the beginning with friends but not so much anymore. Now we wonder when all this will end and we get back to our lives and our activities." (A male teenage respondent) Many respondents highlighted that they were cautious talking about worries and fears related to coronavirus with their own family members to avoid elevating problems. Some respondents clarified that talking about the infection might increase their fears or generate more serious situations. --- "I did not want to open up discussion about my fears with my family. They were worried enough. I thought it may upset them more." (Female respondent from a family with teenagers) Respondents explained that media coverage was exhausting and stressful and some of them had stopped actively following it. Other participants claimed following all news related to coronavirus on a daily basis. Several adolescent respondents felt that the media coverage irritated them and accordingly they no longer followed the coronavirus coverage regularly. --- "I stopped following news about coronavirus some time ago. It was making me depressed." (A female teenage respondent) Some respondents mentioned that following media coverage had been helpful as it allowed them to prepare themselves for the possibility of contracting the coronavirus. --- "I was not surprised about it. I knew what to expect. I had heard so much about it over the past weeks." (Female respondent from a family with teenagers) --- Everyday routines Not many respondents took precautions with their living arrangements to protect others in the household from coronavirus. Some considered their house too small to take any special precautions, others felt it unnecessary because they discovered the infection late and accordingly had been living together without precautions for a while. A few respondents had not thought of such precautions or they explained not having received any such instructions from the health authorities. Those who organized their everyday life to avoid transmission of the virus within the household slept in different rooms, lived on different floors or in other areas of the house, used separate kitchen utensils, separate toilets and bathroom, or undertook more intensive cleaning procedures. Leaving the house during quarantine varied from those who did not leave their house the entire time to those who took short walks and those who took a regular walks with their dog or children on a daily basis. Some participants were far too sick to leave their house, and others were unsure about what they were allowed to do and discussions in WhatsApp groups confused them further. "They said we can go to the backyard. But we do not have a backyard. We live in an apartment building in the middle of the city." (Female respondent from a couple without children) --- Family relations Some respondents believed that quarantine created tension at home between the household members. One respondent explained her child was having constant tantrums due to the shift from an active lifestyle to being at home. But several respondents saw some positive developments from quarantine, such as getting closer to their partner, having more time as a family, or time to relax. --- "We have gotten closer one another due to this experience that we shared." (Male respondent from a family with no children) --- Discussion To our knowledge, this is the first study in Finland exploring COVID-19-related social stigma and the quarantine and isolation experiences. The study indicated that social stigma poses a challenge by impacting social relations and by creating psychological distress, which is likely to affect quality of life particularly after the illness. Quarantine and isolation experiences were characterized by worry about health and boredom. Communicating with others who contracted coronavirus was common, but fears and worries were only cautiously communicated to family members. Living arrangements did not include specific precautions to prevent further transmission at home. Activities outside the home during quarantine were limited but varied. The study findings indicated that respondents did not feel a sense of closure after their isolation and quarantine had ended because of perceived stigma and self-stigma, and worry that they could still infect people around them. Stigma reduced their willingness to disclose their coronavirus status or any household association with it leading to psychological and social distress. Stigma is known to result in delayed health seeking behavior among symptomatic patients including testing which can speed the transmission of the virus rapidly [42,43]. This can be particularly problematic in countries where the focus of the national COVID-19 prevention strategy is testing and contact tracing followed by isolation and quarantine such as currently in Finland. The study findings also indicated that the way adults communicated about coronavirus in the social networks of their children created stigma. The public and, in particular, parents will benefit from guidance on how to communicate about coronavirus and COVID-19-related issues. Marketing of de-stigmatizing wording has been identified as helpful to reduce stigma elsewhere [44,45]. In addition, stigma has been successfully reduced by communicating the rationale behind potentially stigmatizing concepts of quarantine, isolation or suspect cases [11]. Fear and blame were drivers of coronavirus and COVID-19 stigma, which are also common drivers of infectious disease stigma worldwide [46][47][48]. In today's world, fear is easily generated by an overabundance of news, mixing facts, rumors, and fake news [49]. Misinformation about COVID-19 has also rapidly spread around the world through social media [50]. Accordingly, the provision of factual information about transmission and the nature of the virus have been found to be an effective strategy to reduce stigma [43,44,51]. Stigma reducing information should include expert information about the disease such as contagiousness, number of diagnosed people, fatality rate, and seroprevalence in the community. In addition, the information should also provide people with tools about how to prevent the infection to ensure that people feel confident about being able to protect themselves, which in turn will prompt their willingness to apply protective measures [43]. New and innovative ways to communicate about SARS-CoV-2 and COVID-19 should be considered [52]. Overall, provision of accurate information about COVID-19 is challenging as information is rapidly evolving. Therefore, health authorities should focus on ensuring that the public is aware of trustworthy and updated sources of information where they can look up continuously changing information about the virus as a means to help build public confidence to manage better their interactions with those who contracted the virus. Having a trusted source provide information to the public is crucial as demonstrated in an anti-stigma intervention in Sicily where trusted health experts engaged themselves with the public through an online platform and successfully reduced COVID-19-related stigma [43]. Blame for infection could be reduced through messaging that anyone can contract the virus and anyone is vulnerable [44]. Blame could be reduced by using emotions in the communication though symbols or metaphors [53]. Special attention should be given to address blame for the infection that is directed towards healthcare workers who are already likely to be under high pressure. Stigma towards healthcare workers caring for COVID-19 patients has been identified in a number of countries worldwide [31]. In particular, actions are needed to promote their well-being during and after the outbreak. The UK has developed a digital learning package for healthcare workers' well-being during and after COVID-19 that might be worthwhile to explore in Finland and in other settings [54]. As both traditional media and social media promoted stigmatizing attitudes. Stigma capacity building training could be organized for media representatives and social media influencers, such as raising awareness about how to recognize stigmatized groups and how stigmatization is enacted. The content of anti-stigma training often includes information about the ways to identify stigmatized persons, about responsibility for their condition, about the moral and physical peril linked to them, as well as labels for the stigmatized group [55]. The study discovered that perpetrators of stigma belonged to different types of social networks ranging from close friends to those who had no personal relationship with the respondents. Likely, those who stigmatize persons with coronavirus and their family members do not necessarily understand the harm they cause through their actions and words. Messages of empathy could be promoted to develop a more sensitive

The COVID-19 pandemic has intensely changed the everyday lives of people worldwide. This study explores the forms and outcomes of coronavirus and COVID-19-related social stigma and the experiences of people who were home quarantined or isolated in Finland during the spring 2020. The findings of this study can be used to improve support for those quarantined or isolated and to develop strategies to reduce the stigma associated with coronavirus and COVID-19.The study is based on qualitative one-to-one interviews with households with at least two members and at least one PCR confirmed COVID-19 case. Recruitment took place via website or SMS messages sent to PCR confirmed cases in the capital area of Helsinki. Sampling was based on maximum variation to acquire different types of respondents. The framework of health stigma was used to develop question guides and analyze stigma. Quarantine and isolation experiences were explored through open-ended questions. The analysis was based on thematic analysis.The study included 64 participants from 24 households. Perceived stigma among respondents was driven by fear and blame for infection, and it manifested in various ways leading to a reluctance to disclose their coronavirus status to others. Self-stigma developed from conflicting information and advice about coronavirus and COVID-19 led to difficulties interacting with others outside of the house and reluctance to meet people after quarantine and isolation. Quarantine and isolation experiences included uncertainty, health concerns, and boredom. Communication with others in similar situations was perceived vital, whereas discussions with family members about worries and fears related to coronavirus and COVID-19 was not preferred.

D-19 patients has been identified in a number of countries worldwide [31]. In particular, actions are needed to promote their well-being during and after the outbreak. The UK has developed a digital learning package for healthcare workers' well-being during and after COVID-19 that might be worthwhile to explore in Finland and in other settings [54]. As both traditional media and social media promoted stigmatizing attitudes. Stigma capacity building training could be organized for media representatives and social media influencers, such as raising awareness about how to recognize stigmatized groups and how stigmatization is enacted. The content of anti-stigma training often includes information about the ways to identify stigmatized persons, about responsibility for their condition, about the moral and physical peril linked to them, as well as labels for the stigmatized group [55]. The study discovered that perpetrators of stigma belonged to different types of social networks ranging from close friends to those who had no personal relationship with the respondents. Likely, those who stigmatize persons with coronavirus and their family members do not necessarily understand the harm they cause through their actions and words. Messages of empathy could be promoted to develop a more sensitive and caring atmosphere for those with coronavirus and their household members. Stigma reduction efforts that focus on promoting emotional approaches could be used as guidance such as contact interventions [52,55]. At the same time, those with coronavirus and their family members need to be empowered to manage dealings among the social networks of those with coronavirus during and after quarantine. Children and teenagers could be provided with special "back to school instructions" to reduce the worry about how to meet friends at school. Guidance about how to deal with members of high-risk groups after quarantine would be important as well. Due to changing and contradictory information received during the epidemic, uncertainty was central in the experiences of those quarantined and isolated as was similarly identified in recent study in China [11]. This highlights the need for a national communication strategy under which all authorities and academic institutions communicate at all levels to ensure that that all health personal disseminate the same information in the same way [56]. The findings showed that health officials left out a number of important audiences in communications about the virus. Firstly, those who cared for sick household members were usually not in touch with health officials. This left caretakers without critical information and opportunities to discuss and get advice. Many caretakers were overly stressed about the responsibility they were left to manage. Secondly, children and teenagers did not have a specific channel to communicate with health officials to gain information or share fears and concerns. Thirdly, asymptomatic household members or those who tested negative received less attention although they seemed to have equally pressing uncertainties compared to others. A recent study in China concluded that the close contacts of those with coronavirus suffered from physical and psychological problems that must be addressed [11]. There is a need to explore how to engage all household members in the communication with health authorities who follow up and provide assistance for families with coronavirus. Models for expanding communication to families instead of patients could be taken from countries that have a system of family doctors where communication is often also family based [57]. Digital platforms could be considered to reach all household members. Individual behavior is of central importance to control the spread of coronavirus [32]. The study showed that quarantine and isolation may be accepted interventions among the public in Finland. Although boredom among more social and active participants during quarantine and isolation was prevalent, there were also those who did not perceive quarantine particularly different from their everyday life as reported also in Canada [58]. Moreover, participants used physical activities as coping mechanisms to manage the boredom such as walking and jogging similar to a study in China that showed that quarantined individuals focused on physical health to manage the situation [11]. Communicating with other people with coronavirus via WhatsApp developed naturally based on the current communication culture in which WhatsApp groups are based on themes and or social networks and are a major channel to communicate with others [59]. Respondents noted that finding others in the same situation and having the opportunity to discuss the infection and related developments were of utmost importance as identified in a number of studies elsewhere [60]. Communicating with others with coronavirus provided information and reduced worries, however, communicating with peers did not reduce self-stigma or uncertainties around coronavirus and COVID-19. On the contrary, sometimes discussions in peer WhatsApp groups confused the situation further. Moreover, WhatsApp groups have also been identified as major channels of misinformation [61]. Communicating about coronavirus and COVID-19 within families was more problematic as household members feared they would elevate the problem by talking about it. Emotional support group communication for children and youth has been identified as a way to help participants express sorrow and worry [62]. There are limitations in our study that must be acknowledged. Sampling following maximum variation was fulfilled in terms of engaging different types of households. However, variation regarding the age group of participants and the time of onset of illness had only limited variation which may have been influenced by the mobile and web-based recruitment process that may have excluded elderly participants who are potentially less likely to communicate through those channels or less comfortable using the devices. In addition, the perceptions reported in interviews might have been influenced by social desirability bias given the potentially sensitive nature of topics such as feelings and family dynamics. --- Conclusion This study provided valuable information about how to support those in quarantine and isolation, which can be used to ensure health interventions are acceptable to the public. It resulted in a set of recommendations to reduce stigma including promotion of destigmatizing language, addressing fear of infection by promoting reliable sources of COVID-19 information, and addressing the blame of infection through messages that reinforce ideas that "anyone can get infected." In addition, recommendations include conducting stigma trainings for media and social media influencers, using emotions as a communication approach, empowering those with coronavirus and COVID-19 and their family members to manage stigma, and advocating for the creation of a national communication plan to ensure aligned messaging about coronavirus and COVID-19 across the country. To better manage quarantine and isolation, the study recommended ensuring the delivery of sufficient and practical information about coronavirus, COVID-19 and quarantine to all household members including children, teenagers, asymptomatic and SARS-CoV-2 negative individuals. The information should address practical matters related to everyday life and how to stay active in quarantine and isolation. --- All relevant data are within the paper and its Supporting Information files.

The COVID-19 pandemic has intensely changed the everyday lives of people worldwide. This study explores the forms and outcomes of coronavirus and COVID-19-related social stigma and the experiences of people who were home quarantined or isolated in Finland during the spring 2020. The findings of this study can be used to improve support for those quarantined or isolated and to develop strategies to reduce the stigma associated with coronavirus and COVID-19.The study is based on qualitative one-to-one interviews with households with at least two members and at least one PCR confirmed COVID-19 case. Recruitment took place via website or SMS messages sent to PCR confirmed cases in the capital area of Helsinki. Sampling was based on maximum variation to acquire different types of respondents. The framework of health stigma was used to develop question guides and analyze stigma. Quarantine and isolation experiences were explored through open-ended questions. The analysis was based on thematic analysis.The study included 64 participants from 24 households. Perceived stigma among respondents was driven by fear and blame for infection, and it manifested in various ways leading to a reluctance to disclose their coronavirus status to others. Self-stigma developed from conflicting information and advice about coronavirus and COVID-19 led to difficulties interacting with others outside of the house and reluctance to meet people after quarantine and isolation. Quarantine and isolation experiences included uncertainty, health concerns, and boredom. Communication with others in similar situations was perceived vital, whereas discussions with family members about worries and fears related to coronavirus and COVID-19 was not preferred.

Introduction Although symptoms of nonaffective psychotic disorders typically emerge during adolescence or early adulthood, 1 it has long been recognized that a subset of people experience their first episode of psychosis in old age, 2,3 defined in the context of very late-onset schizophrenia-like psychosis (VLOSLP) as after 60 years old. 3 The symptomatology underlying VLOSLP appears to be similar to psychosis in younger adults, although fewer negative symptoms are present. 4 Epidemiology has been less well characterized, 5 and while there is consistent evidence that VLOSLPs are more common in women than men, 4,6 whether rates vary by age, migration, or other potential social determinants of risk, such as traumatic life events or social isolation, remains largely unexplored. Previous findings with respect to age have been mixed, showing both increased 7 and decreased VLOSLP rates with advancing age. [8][9][10] It is also unclear whether these patterns differ between men and women. In line with the literature on psychosis incidence in younger adults, 11,12 several studies have also reported higher risk among migrants, 13,14 but this literature remains sparse, particularly outside of the United Kingdom. Indeed, in general, the VLOSLP literature has predominantly consisted of small-scale, cross-sectional studies. Although these have led to the identification of several potential risk factors, including sensory impairments, 15 social isolation, 16,17 premorbid schizotypal traits, 16 and traumatic life events, [18][19][20][21] results have not been consistently replicated. 22 Epidemiological investigation in large, population-based longitudinal studies is largely lacking, with limited exceptions. 10 Older people have consistently been omitted from studies that have elucidated a robust set of risk indicators for psychotic disorders at younger ages. [23][24][25][26] The principal aim of this study was to delineate the epidemiology of VLOSLP in a national, population-based cohort of people living in Sweden since 1920. We aimed Incidence of Nonaffective, Nonorganic Psychotic Disorders in Older People to examine variation in incidence rates by potential risk factors for VLOSLP, hypothesizing that advanced age, female sex, migrant status, lower socioeconomic status (SES), family history of psychotic disorders, sensory impairment, gestational exposure to World War II (WWII) (which could confer risk, in utero, via nutritional deficiencies or maternal trauma), social isolation, and death of a partner or child would increase risk. --- Methods --- Study Design and Setting In Sweden, all people granted residency are given a unique national identification number, allowing record linkage across national health and administrative registers. "Psychiatry Sweden" is a linkage of these national registers for the study of psychiatric disorders. Using this data, we established a longitudinal cohort of people born between 1920 and 1949, and living in, or who immigrated to, Sweden on or after their 60th birthday. Participants born before 1932 were enumerated and identified from the 1960 and 1965 censuses, whereas those born since 1932 have been followed prospectively through the registers. In our study, participants were followed from their 60th birthday (earliest: January 15, 1980) until the end of follow-up (December 30, 2011), emigration from Sweden, dementia diagnosis, death or psychotic disorder diagnosis, whichever came first. We excluded those who died before age 60 years (N = 291 568), emigrated from Sweden before age 60 without return (N = 202 325), or were diagnosed with dementia before diagnosis with a psychotic disorder (N = 2570) (supplementary table S1). --- Outcome We identified all participants recorded in the Swedish National Patient Register diagnosed with nonaffective psychotic disorder according to the International Classification of Diseases, Revisions 8-10 (ICD-8, -9, -10) since 1980 (supplementary table S1). The Swedish National Patient Register contains records of approximately 70% of all psychiatric admissions in the healthcare system (excluding primary care) from 1970, 83% by 1973, 97% from 1974 to 1983, 80%-95% from 1984 to 1986, and has been close to complete since 1987. 27 Recording of outpatient data began in 1997 and was close to complete from 2001. --- Covariates Data on age, sex, birth period, and region of birth were obtained from the Swedish Register of the Total Population. We categorized region of birth as Sweden, Africa, Asia, North America, Europe, Finland, South America, Oceania, Middle East, Russia-Baltic, and "Other." To investigate the possible role of gestational exposure to maternal stressors experienced during WWII (September 1, 1939-September 2, 1945), we categorized participants into the following birth periods, based on earliest likely gestational date (see supplementary methods): 1920-1924, 1925-1929, 1930-1933, 1934-August 1939, September 1939-May 1946 (WWII gestation), and June 1946-1949. We created a disposable income variable, grouped into quartiles, based on all cohort members with disposable income from all sources (employment, welfare receipts, savings, investments) at age 60 recorded in the same calendar year, using data from the Longitudinal Integration Database for Health Insurance and Labour Market Studies (LISA). Using administrative registers, the LISA collects information annually on work-related information such as income, employment, education, and insurance for the total Swedish population aged 16 years and older. We linked participants to their children via the Multigenerational Register to derive a measure of psychosis family history, based on whether their biological children had ever received a psychotic disorder diagnosis. We also linked this register to the Cause of Death Register to obtain data on death of a child (biological and adopted) before cohort exit, before child age 12 months or age 18 years. These exposures were grouped as follows: "Had children, no child death" (reference), "Had no children," and "Death of at least one child." We also created a variable on death of a partner in the 2 years preceding cohort exit, using Census data (before 1990) or the LISA database thereafter, linked to the Cause of Death Register (see supplementary methods). This variable was grouped as follows: "Had a partner, but did not experience partner death (reference)," "Death of one or more partners," and "Had no partner." We created binary hearing and visual impairment variables using diagnoses from the National Patient Register recorded before cohort exit (ICD codes: supplementary table S1). --- Missing Data Missing data were limited to income. For income, we included data at age 55-59 for those with missing data at age 60 years, where possible (N = 21 325; 0.72%). We conducted complete-case analyses, dropping those with remaining missing data on income from analyses (1.7%) (supplementary table S2). --- Statistical Analysis We used Cox proportional hazards regression to model survival in the context of time to VLOSLP diagnosis in relation to exposures of interest, reported using hazard ratios (HR) with 95% CIs. Initially, we examined univariable associations between each exposure and the outcome, recording overall fit of each model using Akaike's Information Criterion (AIC), where low scores indicated better fit. Using a forward-fitting modeling strategy, we added variables with the lowest AIC scores to a multivariable model with age, sex, and their interaction included as a priori confounders. Model building was tested via likelihood ratio test (LRT). Age was modeled as a timevarying covariate using Lexis expansion to examine age at-risk during follow-up, which was grouped into 5-year age bands between ages 60 and 90 years and older. In sensitivity analyses, we excluded migrants diagnosed with a psychotic disorder within 2 years of immigration to Sweden to mitigate the possibility of including prevalent cases in our sample. In addition, we conducted a sensitivity analysis to examine any differences in results after excluding those diagnosed with dementia within 2 years of diagnosis with VLOSLP, given that these individuals may be considered to be experiencing the dementia prodrome. We also tested our final model for violation of the proportional hazards assumption. Analyses were conducted using STATA, version 13. --- Results From 3 007 378 people contributing 39 764 686 person-years of follow-up time, we identified 14 977 cases diagnosed with VLOSLP during the follow-up period, corresponding to a crude incidence rate of 37.66 per 100 000 person-years at-risk (95% CI = 37.06-38.27). After excluding participants with missing income data (1.7%), 2 955 796 cohort members were retained, including 14 825 cases. Median age-at-first diagnosis of VLOSLP was 68 years for men (interquartile range [IQR] = 64-74) and 70 years for women (IQR = 65-77; Mann-Whitney P <unk>.001). Compared with the remainder of the population, people with VLOSLP were more likely to be women (60% vs 50%), from the lowest income quartile (39% vs 22%), have no children (33% vs 15%), have children with a psychotic disorder (5% vs 2%), have no partner in the 2 years before cohort exit (71% vs 44%), be born outside of Sweden (14% vs 11%), and be born in the youngest birth period (table 1; all Ps <unk>.001). --- Incidence by Age and Sex A significant interaction was observed between age and sex in crude and fully adjusted analyses (unadjusted model LRT: <unk> 2 (6) = 38.19, P <unk>.001; adjusted model LRT: <unk> 2 (6) = 31.56, P <unk>.001). This suggested that VLOSLP incidence increased with age for men and women, but at an accelerated rate for women after age 80 years (figure 1). --- Proportional Hazards Modeling After adjustment for age and sex, we observed strong associations between almost all variables of interest and risk (hazard) of being diagnosed with VLOSLP (Adjustment 1, table 2). Full adjustment following multivariable model building led to some attenuation in observed associations (table 2), but most risk factors remained associated with VLOSLP. For example, migrants from Africa (HR = 1.98, 95% CI = 1.44-2.72), North America (HR = 1.38, 95% CI = 1.02-1.87), and Europe (HR = 1.32, 95% CI = 1.24-1.40) were at elevated VLOSLP risk after adjusting for all other covariates, including income at age 60. Those born in later birth periods, particularly those with gestational exposure to WWII (HR = 2.35, 95% CI = 2.20-2.50) or born after WWII (HR = 3.09, 95% CI = 2.79-3.42) were more likely to receive a diagnosis of VLOSLP compared with those born 1920-1924. Lower income at age 60 years was strongly associated with future risk of VLOSLP, with the highest rates in those in the lowest income quartile (HR = 3.07, 95% CI = 2.89-3.25). Participants whose children had a history of psychotic disorder were over twice as likely to develop VLOSLP than those without such a family history (HR = 2.40; 95% CI = 2.23-2.58), as were those without children (HR = 2.41, 95% CI = 2.32-2.50). Participants without a partner 2 years before cohort exit (HR = 1.86, 95% CI = 1.78-1.93) or whose partner died (HR = 1.14, 95% CI = 1.02-1.27) were also at higher VLOSLP risk. There was weak evidence that people who lost a child in infancy were more likely to develop VLOSLP than those with children who did not die in infancy (HR = 1.20, 95% CI = 1.00-1.44, P =.050), although death of a child before age 18 years was not associated with VLOSLP risk in our final model. Interestingly, and contrary to our hypotheses, those with a history of sensory impairment were less likely to receive a diagnosis of VLOSLP (visual impairment HR = 0.24, 95% CI = 0.23-0.25, hearing impairment HR = 0.55, 95% CI = 0.50-0.60); this finding was independently present in the domains of visual impairment and hearing loss. --- Sensitivity Analyses Results from the sensitivity analysis, excluding migrants who presented for psychosis within 2 years of arrival to Sweden, and who may have been prevalent cases, did not substantially differ from results based on the full sample (supplementary table S3). Results from an additional sensitivity analysis excluding those diagnosed with dementia within 2 years of diagnosis with VLOSLP were also very similar to results involving the full sample (supplementary table S4). --- Proportional Hazards There was some evidence that the proportional hazard assumption was violated for several variables (supplementary table S5). Inspection of the data, stratified by time (supplementary table S6), suggested the effects of income and sensory impairments on VLOSLP risk weakened over time (ie, in the youngest cohort), whereas death of a partner was only associated with risk in the youngest cohort. --- Incidence of Nonaffective, Nonorganic Psychotic Disorders in Older People --- Discussion --- Summary of Findings In this nationwide cohort study investigating the epidemiology of VLOSLP, we found substantial incidence after age 60 years. The overall incidence rate of 37.66 per 100 000 person-years at-risk (95% CI = 37.06-38.27) was toward the higher end of previously reported rates of VLOSLP. In a recent systematic review, 5 the overall rate of nonaffective psychotic disorders in those aged 60 years and older was found to vary substantially across studies, ranging from 14.3 per 100 kpy in Northumberland (95% CI = 10.5-18.1) 28 to 39.9 per 100 kpy in Camberwell (95% CI = 31.1-51.3). 14 Rates increased with age beyond 80 years old and were generally higher in women than men; a disparity that widened with increased age. Rates were higher for those born later, including those with some gestational exposure to WWII. Consistent with epidemiological research in younger adult-onset samples, we found raised rates among some migrant groups, particularly from Africa and Europe. These findings were unlikely to be explained by prevalent cases among migrants, or by income, itself a strong predictor of VLOSLP. Unexpectedly, rates were lower in those with sensory impairments. Finally, we found higher rates among those without a partner or children, those whose children had a history of psychotic disorder, and those who had experienced the recent death of a partner or child in infancy. --- Strengths and Limitations This is the largest population-based cohort study to examine the incidence of VLOSLP. We used Swedish registry data, which are highly complete and reliable for research purposes. 29,30 This enabled us to include a relatively high number of cases and to obtain precise estimates for potential risk factors. We note several study limitations, including the need to consider whether reliance on register-based diagnoses could have biased results. On the one hand, we may have underestimated true incidence; as those with VLOSLP may be less likely to contact services due to higher levels of functioning, 16 and limited social contact. 31 By contrast, given that recording of psychiatric diagnoses in Swedish registers only began in 1973, we may have included some prevalent cases, which would have overestimated incidence. Nonetheless, our follow-up period began in 1980 and we excluded those with a recorded psychotic disorder in the 7 years prior. Register coverage improved over this washout period, during which most prevalent cases would be expected to present to services. We may have expected more prevalent cases among older birth cohorts, who were more likely to have experienced the major risk period for psychosis (late teens through to early 30s 32 ) before routine registration of psychiatric diagnoses began. By contrast, we found stronger VLOSLP risk in our younger birth cohorts. This may be explained by differential ascertainment bias over time, whereby younger cohorts were more likely to be diagnosed with VLOSLP after 60 years old, either because of more complete register coverage since 1987 or because of improved clinical awareness of VLOSLP as a distinct set of syndromes from dementias in later life. To mitigate the possibility of VLOSLP representing misclassified dementia with psychosis symptoms, we excluded those diagnosed with dementia before psychotic disorder (N = 2570). In general, when an older patient presents to services with psychotic symptoms, we would expect dementia to be assessed and ruled out before a psychotic disorder diagnosis was given. However, we cannot exclude the possibility of psychosis representing misdiagnosed dementia in some cases, or the reverse. It is also possible that, in some patients, VLOSLP represents a prodrome for future dementia. 33 Correspondingly, a Danish register-based study identified higher rates of subsequent dementia in those with VLOSLP compared with the general population and osteoarthritis patients. 34 To examine whether our findings were influenced by including those who may be experiencing the dementia prodrome, we conducted a sensitivity analysis excluding individuals diagnosed with dementia in the 2 years following diagnosis with VLOSLP. Results were very similar to those involving the full sample, suggesting that our findings are unlikely to be explained by the inclusion of this group. In this study, we could not link our cohort with their parents; hence we could not delineate second-generation migrants from the Swedish-born population. However, we would not expect a large number of second-generation migrants in this cohort given the birth periods covered. We were also, therefore, unable to investigate parental history of psychotic disorder; instead we used offspring psychotic illness as an indirect proxy. This will have overestimated the prevalence of psychosis family history, and our strong estimates for this variable may therefore be conservative. We also had to make some assumptions about coding death of a partner in the 2 years before cohort exit (supplementary methods). We do not consider this will have introduced any substantial biases in our data. In addition, we did not examine other mental health diagnoses such as depression, substance abuse, or bipolar disorder in this study. Future studies examining premorbid mental health conditions in those with VLOSLP could provide valuable insights into the mental health trajectories of this group throughout adult life, before the emergence of late-life psychosis. Finally, the proportional hazards assumption was violated for several exposures, warranting further exploration of potential reasons for variation in these effects over time in future studies. For example, the attenuation of a protective effect over time in those diagnosed with sensory impairments (supplementary table S6) may be attributable to better clinical awareness of physical health morbidities in people with psychosis. --- Meaning of Findings We have precisely delineated a substantial incidence of nonorganic psychotic disorder occurring in later life, which our results suggest is distinct from psychosis associated with dementia. There is already evidence that people with VLOSLP have greater preserved functioning compared with those with adult-onset psychosis, 16,17 but are more socially isolated. 31 This is consistent with our observations of greater risk with older age, particularly for women, 4,6,35,36 and given that this population were less likely to have children, or a partner in the 2 years before diagnosis. Together, these findings suggest that this group may harbor unrecognized psychiatric morbidity requiring clinical attention. Our findings also raise questions about the biological and/or social mechanisms underlying increased psychosis risk in older women, which may begin from the well-documented secondary peak in incidence in their late 40s. 32,37 We found higher rates in later birth cohorts, independent of age, with highest rates in people gestationally exposed to WWII or born thereafter. Although this may reflect greater exposure to malnutrition, or traumatic events occurring during or in the immediate aftermath of the war, we recommend interpreting these results with some caution, give that they could also represent a period effect related to changes in VLOSLP recognition and diagnostic trends occurring from the 1980s. Psychosis incidence was higher among migrants to Sweden from Africa, North America, Russian-Baltic regions, Europe, and Finland, corresponding with previous VLOSLP findings, 13,14,38 and those from the younger adult-onset literature. 11,12,39 Several potential explanations have been proposed, including stressors experienced preand post-migration and during migration itself. 11 Contrary to hypotheses, we found lower rates of VLOSLP in those with hearing and visual impairments. This contrasts several previous small-scale studies. 15,40 One possibility is that our population-based (rather than clinical) sample reflects under-detection and treatment of sensory impairments in older adults with psychosis at a national-level, as observed for other physical health problems, such as cardiovascular disease, in those with serious mental illness. 41,42 Such disparities may reflect reducedhelp seeking behavior, or provider-level factors, such as the separation of specialist physical and mental health services, 42 clinical uncertainty in providing suitable care for patients with psychosis, or "diagnostic overshadowing," where physical symptoms are misattributed to mental illness. 43 Participants with VLOSLP were more likely to experience a range of social disadvantages than the population at-risk, including lower income, greater social isolation, and adverse life events. One interpretation of these findings is that exposure to structural inequalities and social stressors may have long-lasting effects on psychosis risk into later life. In the younger adult onset literature, low SES has consistently been associated with psychosis risk. [44][45][46] Although our findings regarding income could be attributed to social drift during the prodromal phases of psychosis, this interpretation seems less readily applicable to VLOSLP patients, who would have had to maintain sufficient levels of functioning throughout their adult life (ie, survival) 47 to be at-risk of VLOSLP at cohort entry. Similarly, as suggested for younger adults with psychosis, our findings regarding social isolation could be interpreted causally 48,49 or may reflect premorbid impairments in social functioning, limiting one's ability to form and maintain stable intimate relationships; leading to reduced fecundity. [50][51][52] Our findings regarding the recent death of a partner, or loss of a child in infancy correspond with previous smallscale studies suggesting that traumatic life events could be associated with VLOSLP, [18][19][20][21] and with the wider epidemiological literature on psychosis in those aged 65 years and younger. [53][54][55] Our findings extend this research to suggest that the loss of a child in infancy might convey longstanding-albeit modest-increased risk of psychotic disorder several decades later. On the other hand, this finding may be another manifestation of the association between VLOSLP and long-term social disadvantage. That we did not observe similar effects for the loss of a child at other ages was somewhat surprising; further well-powered studies will be required to understand whether such stressors have more pernicious effects before age 60 years. Further research is now needed to replicate these findings and examine potential biological and psychological mechanisms underlying these associations, with the aim of identifying potential targets for intervention. --- Supplementary Material Supplementary data are available at Schizophrenia Bulletin online.

Background: There are limited data on the epidemiology of very late-onset schizophrenia-like psychosis (VLOSLP) and how this relates to potential risk factors including migration, sensory impairment, traumatic life events, and social isolation. Methods: We followed up a cohort of 3 007 378 people living in Sweden, born 1920-1949, from their 60th birthday (earliest: January 15, 1980) until December 30 2011, emigration, death, or first recorded diagnosis of nonaffective psychosis. We examined VLOSLP incidence by age, sex, region of origin, income, partner or child death, birth period, and sensory impairments. Results: We identified 14 977 cases and an overall incidence of 37.7 per 100 000 person-years at-risk (95% CI = 37.1-38.3), with evidence that rates increased more sharply with age for women (likelihood ratio test: χ 2 (6) = 31.56, P < .001). After adjustment for confounders, rates of VLOSLP were higher among migrants from Africa (hazard ratio [HR] = 2.0, 95% CI = 1.4-2.7), North America (HR = 1.4, 95% CI = 1.0-1.9, P = .04), Europe (HR = 1.3, 95% CI = 1.2-1.4), Russian-Baltic regions (HR = 1.6, 95% CI = 1.4-1.9), and Finland (HR = 1.6, 95% CI = 1.5-1.7). VLOSLP risk was highest for those in the lowest income quartile (HR = 3.1, 95% CI = 2.9-3.3). Rates were raised in those whose partner died 2 years before cohort exit (HR = 1.1, 95% CI = 1.0-1.3, P = .02) or whose child died in infancy (HR = 1.2, 95% CI = 1.0-1.4, P = .05), those without a partner (HR = 1.9, 95% CI = 1.8-1.9) or children (HR = 2.4, 95% CI = 2.3-2.5), and those whose child had a psychotic disorder (HR = 2.4, 95% CI = 2.2-2.6). Interpretation: We identified a substantial burden of psychosis incidence in old age, with a higher preponderance in women and most migrant groups. Life course exposure to environmental factors including markers of deprivation, isolation, and adversity were associated with VLOSLP risk.

A s the need for long-term care (LTC) increases with the steady growth in the number of older adults, relocations into residential settings will increase. About 70% of people older than age 65 will require time in LTC services, and 40% will require nursing home care for a period of time (Jones, Dwyer, Bercovitz, & Strahan, 2009). Relocation is a move from one permanent home to another permanent home, and it is considered a significant life event (Hertz, Rossetti, Koren, & Robertson, 2007). Skinner (1992) noted that a forced relocation can have disturbing effects on an older adult, including loss of social and community connections. Even with planned relocation, however, encountering a new and unfamiliar environment requires an older person to rethink ways in which life will differ. Adjustment can take a few weeks to several years (Brandburg, 2007;Krout & Pillemer, 2003). Many factors determine how this new life will evolve, including past adaptive strategies and life experiences, family support systems, socioeconomic resources, and cultural values. Moving from a familiar environment to an unfamiliar one involves adaptation. The concept of adaptation has appeared in the literature of many disciplines, in which it refers to relationships between creatures and their environments. In health services research, Lawton and Nahemow's (1973) classic theory of environmental press is based on the concept of adaptation and examination of relationships between people and their environmental contexts. Conceptually, adaptation has been used extensively in health care disciplines as a foundation for practice and research (Frank, 1996;Roy & Andrews, 1999;Schultz & Schkade, 1997). Indicators of successful adaptation to LTC have included developing a sense of identity and place, having care needs met, knowing and being known to other residents, maintaining or developing social networks, experiencing continuity of lifestyle, and maintaining control over life situations (Chao et al., 2008;Heliker & Scholler-Jaquish, 2006;Hersch et al., 2004;Iwasiw, Goldenberg, Bol, & MacMaster, 2003). In this study, we defined adaptation as a normal process by which a person encounters a perceived challenge in the environment and successfully manages that challenge, as measured by increased quality of life, activity engagement, and social participation. Related to adaptation is the cultural heritage that a person brings to the LTC facility on relocation. Evans, Crogan, and Schultz (2004) found in a study of the meaning of mealtimes in a nursing home that resident preferences were rooted in childhood and family. They suggested that dining experiences, such as a soul food day, that connect with residents' personal remembrances can increase quality of life. Because culture affects the learned beliefs, values, customs, actions, communication, and life ways of a person (Leininger, 1991;Office of Minority Health, 2001;Spector, 2004), it can be expected to permeate all aspects of life in an LTC facility. Lack of social support, chronic illness, and cognitive impairment are prompting older Americans of all cultural backgrounds to enter LTC facilities (Stanford & Schmidt, 1995). As with their White counterparts, minority older adults are entering these settings in greater numbers because they are part of the growing population of older adults. Attention to cultural differences has only begun to make inroads into daily life in these facilities. Quality of life (QOL) is a complex construct that has been used synonymously with terms such as well-being, life satisfaction, and functional health. Lawton (1991) asserted that QOL is a collection of dimensions consisting of objective and subjective factors that may include behavioral competence, objective environment, perceived QOL, psychological well-being, and health-related status. Other factors associated with QOL in an LTC facility include interaction with family and friends, personal qualities, room-and-board items, number of health problems, staff-patient ratios, and continuity of care (Coughlan & Ward, 2007;Guse & Masesar, 1999;Mitchell & Kemp, 2000). These factors attest to the importance of a personenvironment match when QOL issues for nursing home residents are considered. Incorporating meaningful activity and social connections into the lives of older adults whose occupational performance has been circumscribed by illness and disability is particularly important to residents' QOL. Engagement in activity involves the performance of a task, whether it is self-care, work, leisure, or instrumental activities of daily living (IADLs). Social participation is sometimes difficult to distinguish from activity engagement because both involve activity. Mosey's (1996) definition of social participation as "organized patterns of behavior that are characteristic and expected of an individual or a given position within a social system" (p. 340) highlighted the influence of social context on the individual. The gerontological literature has concentrated on personal care and IADLs and how they contribute to health and functional status (Horgas, Wilms, & Baltes, 1998). These obligatory tasks are essential to one's survival, but perhaps even more significant to an older adult's well-being are discretionary activities involving social and meaningful occupations. The findings of Kendig, Browning, and Young (2000) supported the proposition that activity and social support systems are important in mediating the impact of illness on well-being. On the basis of findings from previous studies (Hersch, Spencer, & Kapoor, 2003;Spencer, Hersch, Aldridge, Anderson, & Ulbrich, 2001;Spencer et al., 2002), we created an occupation-based cultural heritage intervention (OBCHI). Central to the intervention was that person and environment factors contribute to the resident's transition to an LTC facility. Implementing the OBCHI during this relocation period highlighted the resident's cultural heritage. The significance of the intervention lies in the potential for modifying relocation stress and facilitating a more meaningful transition into LTC facilities for older adults. This intervention aligns with the profession's mandate to facilitate productive aging in a variety of settings (American Occupational Therapy Association [AOTA], 2007). The intent of this study was to determine whether the OBCHI facilitated older adults' adaptation to their new home. We describe a 2-yr study funded by the National Institutes of Health and answer the following research questions: 1. What are the differences at baseline between groups on the measures of QOL, family support, physical and mental health, activity engagement, social participation, and environmental factors? 2. What relationships were found at baseline between these person and environment variables? 3. Does the intervention improve participants' QOL, activity engagement, and social participation? --- Method --- Design We used a quasi-experimental nonequivalent control-group design with pretests and posttests (Cook & Campbell, 1979). Site matching and randomization were initially proposed, but because of recruitment issues, adding four additional sites that were not randomized was necessary. However, we considered the mix of or predominant ethnic groups residing in each facility to keep to the original plan as much as possible. We compared residents who received the cultural intervention with those who received a typical activity group without culturally specific elements. We obtained institutional review board approval from Texas Woman's University for all sites and approval from another university's managed facility at the initiation of the study, and we renewed the approvals on a yearly basis. All participants gave written informed consent to participate. --- Sample Participants were recruited from 10 LTC facilitiesspecifically, skilled nursing units-in a southwestern metropolitan city; however, in three of those facilities the number of participants was insufficient to form a group, resulting in seven sites for the intervention and control groups. Residents who participated in the study met the following criteria: age 355 yr; relocation into the project site during the previous year; receiving licensed nursing care, but not in a hospice or locked unit; White or African-American; English speaking; and able to participate in interviews, as determined by a score of £5 on the Short Portable Mental Status Questionnaire (SPMSQ; Pfeiffer, 1975). --- Development and Implementation of the OBCHI and Control Groups We chose a group approach to intervention on the basis of support from the literature (O' Sullivan, 2004;Spilak, 1999;Voelkl, Fries, & Galecki, 1995). Structure and format for both control and intervention groups were identical: Each group consisted of eight 1-hr sessions that took place twice weekly for 4 wk. Protocols were structured to include specific guidelines, group names, expectations of group leaders and members, methods of delivery, equipment lists, and recommended scripts for facilitators (Howe & Schwartzberg, 2001). The group format consisted of an introduction, warm-up, activity, discussion, and closure. Control and intervention groups differed by content. The content for the control group consisted of the usual activities, determined by examining calendars of activities in the LTC facilities and by reviews of current literature. Protocols included structured activities of exercise, poetry writing, current events, and crafts. We derived content for the intervention protocols from qualitative interviews conducted with residents in six LTC facilities (the first aim of the study) that focused on people and cultural characteristics of older adults relocating to LTC facilities. The interviews generated themes of family traditions that shaped their lives, food as part of family roots, enjoyment of music, home, family, occupations of work and leisure, and spirituality (Hutchinson, Hersch, Davidson, Mastel-Smith, & Chu, 2011). For our second aim, we designed group protocols for the intervention incorporating these themes and based on principles delineated by Clark et al. (1996), Cole (2005), and Howe and Schwartzberg (2001). The protocols were reviewed by one expert each in the fields of nursing and occupational therapy to test content validity. Recommended changes were incorporated into the final protocol manual. Further information about the intervention can be obtained by contacting Gayle Hersch. Two certified occupational therapy assistants conducted the groups, assisted by a trained graduate research student. Both assistants were blinded to group assignment; one was trained in the intervention protocol, and the other was trained in the control protocol. A third certified occupational therapy assistant, trained in both intervention and control protocols, served as a substitute when needed. The initial series of eight sessions for both intervention and control groups was monitored by one of the investigators (G. Hersch, S. Hutchinson, or C. Wilson) to ensure that the protocol was followed. --- Instrumentation Pregroup tools included the Medical Outcome Studies Short Form 12 (SF-12; Jenkinson et al., 1997;Ware, Kosinski, & Keller, 1996), Duke Social Support and Stress Scale (DUSOCS; Parkerson et al., 1989), and Sheltered Care Environment Scale (SCES; Moos & Lemke, 1984). The Yesterday Interview (YI; Moss & Lawton, 1982) and Quality of Life Index: Nursing Home Version (QLI; Ferrans & Powers, 1985, 1992) were administered before and after the intervention and served as outcome measures. SF-12. We used the SF-12 to assess physical and mental health status. It has excellent reliability and validity, with the physical and mental function component scores being highly predictive of the scores obtained from the full SF-36 (Ware & Sherbourne, 1992). DUSOCS. The DUSOCS was developed to measure covariates of family and nonfamily support and stress. This 24-item self-report instrument has the respondent rate, on a 3-point scale, the extent to which types of family members or nonfamily members provide support. Reliability tests have found Cronbach's as of.71 for family support and.70 for nonfamily support (Parkerson, Broadhead, & Tse, 1991). SCES. The 63-item SCES measures the influence of the LTC facility's environment on adaptation. It assesses three domains of social climate: relationship dimensions (Cohesion and Conflict subscales), personal growth dimensions (Independence and Self-Exploration subscales), and system maintenance and change dimensions (Organization, Resident Influence, and Physical Comfort subscales; Moos & Lemke, 1984). Internal consistencies (Cronbach's a) for six of the seven subscales were acceptable to high (as 5.59-.79), and the Resident Influence subscale indicated moderate internal consistency (a 5.44; Moos & Lemke, 1984). YI. The YI documents engagement in activities and social relationships. It uses a simple grid to record a person's report of activities during the previous day, including social partners, kinds of assistance needed, locations in which activities occurred, and whether activities were obligatory or discretionary. Obligatory activities are considered essential for survival and seen as a constraint; in contrast, discretionary activities are self-chosen and address needs for affection, knowledge, or pleasure (Moss & Lawton, 1982). For this study, we describe only the number of activities spent in obligatory and discretionary activities. A study by Horgas et al. (1998) reported good interrater reliability for activity codes and domains with ks >.80. QLI. The QLI determines QOL among nursing home residents. It rates satisfaction and importance measures for several constructs related to QOL by means of four subscales: (1) Health and Function, (2) Social and Economic, (3) Psychological/Spiritual, and (4) Family. For each subscale and overall score, satisfaction items are weighted by importance responses and summed; higher scores indicate high satisfaction or high importance, and lower scores indicate high dissatisfaction or low importance. The overall QLI scores can range from 0 to 30. Internal consistency for the total QLI scale has been described in 26 studies and is supported by Cronbach's as ranging from.84 to.98 (Ferrans & Powers, 1985). --- Data Collection Procedures and Management Before the group sessions began, enrollees were administered pregroup tools by a trained data collector with a geriatric nursing background who was blinded to the groups and sites. Postgroup tools were administered to determine changes in QOL, activity engagement, and social participation after the group activities. Participant names were coded for confidentiality. --- Data Analysis The YI was coded and analyzed by research team members to account for reliability of codes. Thirty raw codes were initially identified-for example, personal care, shopping, resting, and listening to music-and were collapsed into seven main categories: (1) self-care activities of daily living, (2) IADLs, (3) leisure activities, (4) social interaction, (5) spirituality, (6) rest, and (7) social participation. These categories were then identified as obligatory or discretionary activities. We examined the distributional properties of the data using means, standard deviations, frequencies, and percentages. Group differences in participant characteristics were examined with x 2 tests of associations. A series of analyses of variance (ANOVAs) and correlational analyses was used to address the research questions. More specifically, we conducted a one-factor between-groups ANOVA to assess group differences in QOL, family support, physical and mental health, activity engagement, social participation, and environmental factors (Research Question 1). We used correlational analyses to examine the relationships between baseline person and environment variables (Research Question 2). We used repeatedmeasures ANOVAs to address Research Question 3. Repeated-measures ANOVAs contained one between-groups factor (study group: intervention or control) and one within-group factor (time: baseline or postintervention). We conducted repeated-measures ANOVAs using a mixed-model format to allow for inclusion of participants with only baseline measures. --- Results --- Participant Characteristics Twenty-nine participants completed the group sessions with a range of 2-4 per group. They were recruited from seven LTC facilities and matched on the basis of ethnicity: predominantly African-American, predominantly White, and mixed African-American and White. There was differential representation of ethnic groups in intervention and control groups: African-Americans constituted 68.8% of the participants in the intervention group, and Whites constituted 61.5% of the participants in the control group. The median age range was between 71 and 75 yr for both groups, and the control group had a higher percentage of participants > age 80 (46.2% for the control group vs. 18.8% for the intervention group). Most participants (82.8%) were female. Additional information on participant characteristics is provided in Table 1. Although all participants had to pass the SPMSQ, participants with lower scores were disproportionately represented in the intervention group (56.3% vs. 30.8%). We detected no significant differences at baseline between the intervention and control groups, other than cognition, for which 69.2% of the control group fell into the normal to mild cognitive impairment range, in contrast to 43.8% of the intervention group. --- Findings From the Baseline Tools We conducted posterior power analyses to assess the detectable effect given the study sample size. Given an a level of.05 and 29 participants, the power to detect a large group main effect (Cohen's standardized d 5 1.09) and moderate associations (r 5.43) was 80%. Given the repeated-measures ANOVA and a correlation across time, the power to detect a moderate interaction effect was 80% (d 5 0.42; Faul, Erdfelder, Lang, & Buchner, 2007). Using baseline scores as dependent variables and study group as the factor, results from the ANOVAs showed no significant differences between groups on baseline mea-sures (Table 2). However, as measured by the SF-12, both groups had lower physical and mental scores than the norm (median 5 50), evidence of the frailty of this sample. The intervention group showed a trend (F [1, 27] 5 3.42, p 5.077) for a significantly lower physical health score than the control group. We calculated correlations of participant characteristics with QOL and found that QOL was significantly and positively correlated with the SF-12 physical health score (r 5.45, p 5.023), mental health score (r 5.69, p 5.0001), SCES personal growth dimension (r 5.53, p 5.003), and DUSOCS nonfamily support score (r 5.44, p 5.017); QOL was significantly and negatively correlated with DUSOCS family stress score (r 5 2.38, p 5.040) and social stress score (r 5 2.38, p 5.041). --- Findings From the Outcome Measures Results from the repeated-measures ANOVA showed that scores for the overall QOL (F [1, 24] 5 7.50, p 5.011), Health and Function (F [1, 24] 5 4.32, p 5.48), and Psychological/Spiritual (F [1, 24] 5 8.46, p 5.008) subscales improved over time for both groups. We observed no significant differences between groups for the Social and Economic and Family subscales. The control group showed an overall slightly higher increase on all QOL subscales compared with the intervention group (see Table 3). For the YI, examination of activity engagement and social participation revealed an average of 13-14 hr was spent awake, preintervention and postintervention, for all participants. A greater percentage of time was spent in discretionary time than in obligatory time both preintervention and postintervention, but the results of the repeated-measures ANOVA showed no significant difference between groups. --- Discussion Although literature on relocation into LTC facilities exists, little is known about interventions that facilitate the adaptation process (Lee, Woo, & Mackenzie, 2002). In addition, outcomes of adaptation vary depending on the discipline and research focus (Clark et al., 1996;Keister, 2006). In this study, we applied the OBCHI model by testing a cultural and social intervention and measuring the outcomes of QOL, activity engagement, and social participation as indicators of adaptation. We found no literature showing how an organized cultural heritage intervention might affect LTC adaptation; thus, this research was without precedent. The outcome measure of QOL, an indicator of adaptation, did improve for both intervention and control groups over time. Increased QOL may be attributed to several factors. One, in particular, is the client-centered approach whereby all participants received planned and meaningful group activities led by a certified occupational therapy assistant. Group sessions were structured for both groups and differed only by content. The structured activities provided the opportunity for activity engagement and social participation to occur in both groups. Engagement of residents in small-group interaction and meaningful oc-cupations fostered a sense of connection with other group members, as indicated by the positive comments made in the midsession and final satisfaction surveys completed by all participants (Robinson, 2009). On the basis of Hertz et al.'s (2007) research, one of the interventions suggested for postrelocation is to provide opportunities for participation in social gatherings and activities that are tailored to the interests and values of residents. Underlying such interventions is the assumption that meaningful activities are integral to the health promotion of the individual. Participants' activity patterns and social relationships not only served as measures for adaptation but also provided an understanding of life in LTC. Other occupational therapists have studied the everyday life of community-dwelling older adults (Larsson, Haglund, & Hagberg, 2009;McKenna, Broome, & Liddle, 2007). In this study, findings from the YI provided a description of how residents spend their time in an LTC facility. Onethird of time was spent in obligatory personal maintenance tasks. Yet many activities in which residents engaged were discretionary and included IADLs; leisure activities, both alone and with others; and social interaction with residents, staff, and family. An important element of the day was resting, which included sleeping, napping, and doing nothing. Rest and sleep are now considered in the Occupational Therapy Practice Framework (2nd ed.; AOTA, 2008) to be a performance area of occupation that "support[s] healthy active engagement in other areas of occupation" (p. 632). The question commonly asked of clients by therapists, "Tell me about a typical day," takes on greater importance when one sees the extent to which these performance areas play a part in a resident's life. --- Implications for Occupational Therapy Practice The findings from this study have implications for occupational therapy practice in long-term care expanding to include the following tasks: --- Limitations Limitations include recruitment challenges that decreased the number of available group participants. Frailty of an LTC population, which is characterized by cognitive deficits, hospitalizations, and death, limited our ability to reach the initial projected sample size. Originally, site matching, site randomization, and matching residents by ethnicity, gender, and age to the control and intervention groups were proposed; however, we did not completely accomplish this goal because of the limited availability of participants and the attempt to obtain a working group size. Adaptation may be influenced by length of stay in an LTC facility and reasons for admission. Although all study participants had been in the LTC facility £ 12 mo, the lengths of stay differed, and we did not obtain reasons for admission. Additional limitations were reduced power to detect changes, inability to examine potential moderating effects, and change in group facilitators, possibly affecting the continuity of the group sessions. --- Directions for Future Research Findings from this study demonstrate that a client-centered approach with specifically planned and meaningful activities in a social context can result in increased QOL for newly admitted residents. With that observation, additional research questions arise. Further consideration of an appropriate measure for adaptation and identification of alternative measures is needed to understand the relocation phenomenon. Investigating features of the intervention that made a difference in residents' lives, including dosage, duration, and effects on activity engagement and social participation, is crucial. Other research possibilities include examining the cognitive element and its relationship to benefits and having groups of like ethnicities rather than mixed ethnicities. The temporal factor appears to be a determinant in knowing just when to implement the intervention; that is, how soon after admission will give the best effect? Also, further investigation into the environmental features of LTC facilities influencing the adaptation of the resident is needed. As more older Americans from diverse ethnic backgrounds relocate to LTC facilities, the role of occupational therapy will expand to reach not only those requiring rehabilitation but also those entering to age in place. Occupational therapists' responsibility, then, will become one of facilitating the adaptation process so that residents' lives are satisfying and meaningful. s --- Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.

We investigated the effectiveness of an occupation-based cultural heritage intervention to facilitate adaptation to relocation into long-term care (LTC) facilities as measured by quality of life, activity engagement, and social participation. METHOD. We used a quasi-experimental nonequivalent control group design with pre-and posttests. Residents receiving the cultural intervention were compared with residents in a typical activity group. Eight sessions, two per week for 4 wk, were facilitated by certified occupational therapy assistants.Twenty-nine participants completed the group sessions. Quality-of-life scores improved significantly over time for both groups. Statistically, a greater percentage of time was spent in discretionary than obligatory time, pretest and posttest, with no significant difference between groups.The study demonstrated effectiveness of a structured, occupation-based social group intervention that improved quality of life, an indicator of adaptation. It also provided a description of activity patterns and social participation of LTC residents.

A. Introduction The measurement of tolerant views and practices towards the plurality of Indonesian society can be classified into two dimensions: socio-religious and socio-political. In the socio-religious dimension, trust and tolerance among youngsters from diverse backgrounds and interests are still a fundamental problem. For example, it can be seen during the Indonesian reform period, when religious activists and minority groups experienced violent behavior as a result of the state's failure to manage religious diversity and the plurality of society (Hasan, 2017, p. 107). Similar cases occurred in Africa between Muslims and animists and in India between Hindus and Muslims (Quinn, 2001, p. 57). In Norway, Christian and Muslim religious leaders have sought to gain followers and influence among their co-religionists by claiming to be better at checking social and political influence than their fellow religious leaders (Dowd, 2014, p. 7). The aforementioned instances indicate that underneath the surface of the prevalent attitude of religious tolerance, NAVIGATING THE NEXUS: GOVERNMENT POLICIES IN CULTIVATING RELIGIOUS..... underlying differences could lead to conflicts and give rise to extremist groups. Higher education, as an agent of social change, must be aware of problems related to intolerance and inclusivity. Strengthening religious moderation is important to ensure that educational institutions play a crucial role in sowing and strengthening diversity. Such institutions are expected to carry out this role so that the depiction of Islam in Indonesia looks friendly, hospitable, tolerant, moderate, and dignified in the eyes of the world. Indonesia's Muslim schools are also essential, as they can educate children to understand and practice religion while promoting a sense of nationalism (Zuhdi, 2018). Meanwhile, the State Islamic Higher Education (PTKIN) in Indonesia can also serve as a role model because the values of tasamuh (tolerance), tawasut (moderate), tawazun (balanced), and i'tidal (upright and straight) are developed and infused within it. These values are incorporated in an integrative manner into all courses while consistently developing an educational model that is in line with Pancasila as the basis and the philosophy of the state. This notion is proven by research showing that literary-based learning is useful in promoting and developing religious moderation (Manshur & Husni, 2020). Further, a study states that in most parts of the world, higher education institutions act as channels of social mobility as they support the establishment of national professions and industries (Fadjukoff, 2015). Higher education is expected to play a major role in building the state and the nation. The rise of discussions and movements on religious moderation in Indonesia shows evidence of university participation. Therefore, higher education and PTKIN, in particular, must oversee and ensure that the implementation of religious moderation in Indonesia can run effectively and productively. Religious moderation in Indonesia has been observed from various perspectives. Umar (2016, p. 399), in his writing of "Islam moderat dalam Politik Luar Negeri Indonesia Kontemporer" (Moderate Islam in Contemporary Indonesian Foreign Policy), stated that there are three discourses on Islam in Indonesian foreign policy using a genealogical approach. Meanwhile, Hilmy (2013, p. 24) analyzes moderate ideology in Nahdlatul Ulama (NU) and Muhammadiyah. Another study was conducted by Ni'am (2015, p. 111), which is about pesantren as a miniature of moderate Islam in Indonesia. In addition, Muhsin et al. (2019, p. 45) examine revolutionary movements by forming a moderate student organization called Lembaga Dakwah Kampus (the Campus Dakwah Institute, or LDK). Achilov and Sen (2017, p. 608) have also discussed moderate Islam and whether devout Muslims and moderate Muslims have political differences in attitudes and behavior. Furthermore, Menchik (2019) Practically, this research is expected to assist policymakers in making civil society governance more appropriate. In addition, this research is also expected to help stakeholders understand state policies to achieve inter-religious harmony under the Pancasila values. --- B. Literature Review --- Academic Policies The term 'policy' is generally used to describe the behaviour of a person, such as an official, a group, or a particular institution, to solve the problem at hand. In the United Nations, policies are guidelines for action (Wahab, 2017). The guidelines can be simple or complex, general or specific, broad or narrow, vague or clear, loose or detailed, qualitative or quantitative, and public or private. In this sense, policy is usually in the form of a declaration regarding guidelines for action, certain directions for action, or particular programs or plans. This opinion is reinforced by Knoepfel et al. (2007), who define policy as a series of decisions or actions as a result of structured and repeated interactions among various actors, both public (government) and private. These actors are involved in various activities, such as responding to, identifying, and solving a problem that is politically defined as public. The policy adopted thus implies two things: a group of problems with specific characteristics and policymaking as a process. When considering the perspective of educational advancement, the implications of national education policy refer to endeavors aimed at enhancing the overall standard and quality of a nation's existence by cultivating its national culture. Therefore, in making decisions, problems will always be found. In this context, policies are related to academic issues, namely education and teaching, research, and community service programs. According to Lian (2019, p. 102), these three areas are the basic pillars of a mindset that must be carried out in a balanced manner and adapted to the demands, developments, and needs of the times. Academic policies must refer to applicable laws and regulations and consider the principles of preparing a policy (Wibowo, 2011) All forms of academic policy development models will certainly have implications for educational and teaching models, curricula, learning materials, and instructional activities in the classroom. In general, a learning model is a form of learning that is illustrated from start to finish and is presented specially by educators and education staff. In other words, the learning model is a wrap or frame for the application of an approach, method, and learning technique (Komalasari, 2010, p. 57). --- Religious Moderation Moderate (al-wasat) is generally interpreted as a method of thinking, interacting, and behaving in a balanced manner in addressing two situations. This moderate attitude follows Islamic principles and community traditions, namely balance in faith, worship, and morals (Hanafi, 2013). According to Esposito, the terms "moderate" and "moderatism" are conceptual nomenclatures that are difficult to define (Hilmy, 2013, p. 25). The interpretation of this phrase varies depending on the religious groups or scientists involved, leading However, the use of the term religious moderation is not without problems. This term is usually juxtaposed with radical. Moderates are conventionally those who seek gradual change by working within the existing political system; radicals, by contrast, seek to overthrow that system in its entirety (Schwedler, 2011, p. 347). Furthermore, Schwedler (2011) examines the debate among scientists about this moderation when it is attributed to Muslims. According to him, scientists differ on whether the term moderate is more appropriate to use as an objective or a tactic. Scholars who understand the term moderate-radical as an objective state that the majority of Muslims use a fundamental approach in seeking changes to social, political, and economic relations and, therefore, tend to be 'radical.' On the one hand, scientists who use moderate-radical as a tactic argue that their entry-Islamic groups-into the existing legal constellation, such as participating in the general election, can be categorized as'moderate.' On the other hand, Islamic groups that use a violent approach to achieve their goals are categorized as 'radical.' Meanwhile, Islam and Khatun (2015) explain that Western scholars use the term as a 'process' rather than a 'category" when comparing the use of the term moderate by the West and Islam. They previously tended to use a harsh and radical approach when allowed to participate in democratic practices. In subsequent developments, this Islamic group began to accommodate democratic NAVIGATING THE NEXUS: GOVERNMENT POLICIES IN CULTIVATING RELIGIOUS..... practices and abandoned its old anti-western attitude to become pro-western. Islam and Khatun (2015) also highlight that the use of the term moderate by the West has significant political connotations. They emphasized that "the characteristic of the Western enterprise of moderation is merely a political one. For them, it has nothing to do with a belief or legal system." The moderate attitude in the Western perspective has nothing to do with the belief system held by Muslims; a viewpoint that is afterward refuted by Islam and Khatun (2015). In this case, religious moderation is not merely a position between the extreme left and the extreme right. Religious moderation is an intellectual, moral, legal, and behavioral approach that promotes non-extremism. What Schwedler (2011) and Islam and Khatun (2015) said above can make it easier to understand the concept of religious moderation in the Indonesian context. Religious moderation is the practice of religion that is not extreme or radical and always does not emphasize violence. With this character, it prioritizes tolerance, harmony, and cooperation with different religious groups. Developing an understanding of religious moderation in the Indonesian context is so important, considering that there are various religions and ethnicities within it. The notion of religious moderation encourages individuals to practice their religious beliefs in a contextual manner, acknowledging that variations and variety are inherent aspects of divine decree (sunnatullah), which cannot be disregarded. If this practice is implemented, it can be reasonably asserted that religion will serve as a catalyst for promoting peace and fostering humanitarian values. --- C. Methods The method used in this research is mixed methods with a sequential exploratory model, which combines qualitative and quantitative research sequentially. In the first stage, the research was carried out using qualitative methods to prove, deepen, and expand the data obtained; in the second stage, the research was conducted using quantitative methods to obtain descriptive and comparative data. Primary data sources include lecturers, students, and PTKIN leaders in Indonesia. The sampling technique used is simple random sampling, i.e., sampling is done randomly without regard to strata in the population because the population tends to be homogeneous. Here, the researcher collects data concurrently (at one time) and then compares the two data sets to determine whether there is convergence, difference, or some combination. In this strategy, mixing occurs when the research reaches the stage of interpretation and discussion. This methods-mixing is done by integrating or comparing the results of qualitative and quantitative data side by side in the discussion. --- D. Results PTKIN's seriousness in realizing religious moderation is realized through various policies that regulate the activities of the Tridarma of higher education. Almost all PTKIN leaders in Indonesia have policies that regulate efforts to develop religious moderation on campus. According to Mujiburahman in his interview, he said that life had entered an extreme period. Many students do not know their purpose. Thus, the initiated program required new students to live in the dormitory for two months to receive education, one of which was 'Islam and Nationality'. Its mission is to instill the values of religious moderation with a national perspective. In addition to this, our attention is also directed towards the psychological domains of students, with the aim of cultivating an understanding of 'Islam' as a comprehensive way of life rather than only a cognitive pursuit. The notion that warrants consideration is the concept of moderate Islam (Mujiburahman, interview, November 10, 2019). PTKIN must be able to become a center for the development of religious moderation; therefore, PTKIN seeks to make religious moderation one of the main issues in teaching, research, and community service activities. Related to this, the academic community-in this case, lecturers and students-responds positively to various efforts to develop religious moderation on campus. This can be seen from the results of the questionnaire calculations presented in Tables 1 and2 below. is rejected, and the alternative hypothesis (Ha) is accepted. To strengthen the results of the quantitative calculations above, this research also describes several policies in the academic field that are used to develop religious moderation. This policy is outlined in several academic programs covering the fields of education, research, and community service, as follows: --- Academic Policy in the Field of Education There One of the PTKIN leaders emphasized that: Implementation of the Pancasila course is not only an individual need as a citizen but also a state need. Progress in citizen education will automatically increase the greatness of the country. This issue is important so that PTKIN graduates can become Indonesian citizens who have a national character, desire to advance the country, and care for their nation. (Mahmudin, interview, September 30, 2019) This policy also received support from the On campus, lecturers do not discriminate against students, be it those from Muhammadiyah, NU, Al-Irsyad, or others. Another proof is that the campus also uses students as friends and discussion partners. We never make a problem out of differences in belief, whether it's about prayer or other acts of worship. Leaders and lecturers always provide space for tolerance, so there are rarely coachman discussions that cause tension. (Mahmudin, interview, September 26, 2019) The Hadith. Nearly 98% of students learn about the complexities of religious texts in responding to the dynamics of life. This aligns with the narrative of a student who admits that the lecturer's explanation of how to understand religion is very clear and detailed because it involves many perspectives. --- One of the courses that is always available on the PTKIN campus is --- Differences of opinion in implementing religious law often lead to divisions and hostility among Muslims. We emphasize to students that these differences are addressed carefully. For example, some khilafiah issues such as reciting qunut, the number of cycles of tarawih prayers, praying together out loud, congregational dhikr, tarekat, baiat (oath of allegiance), commemoration of the birth of the Prophet, Isra Mi'raj, and so on. In this nuance, students are educated to become broadminded undergraduate candidates. Apart from that, we also encourage them to study the legal basis of each opinion so that they have lots of references and arguments. So, in this way, students will be trained to be wise in their differences in religious understanding. (Mahmudin, interview, September 29, 2019) Differences in understanding religion will continue to exist in people's lives because everyone has different opinions and perspectives. Things like this must be instilled in students so that they do not understand religion only from one point of view or use one approach. With this, the students are not easy to blame when they find differences with themselves and can avoid radical ideas. e. Policy regarding the freedom of lecturers to explain religious teachings from various schools of thought (madzhab) To minimize extreme and radical religious views among students, PTKIN encourages lecturers to explain religious issues according to different schools of thought. This policy received a positive response, as the lecturers were really enthusiastic about providing religious insights from various references and points of view. Lecturers always provide opportunities for students to discuss differences in religious sects during lectures and outside lectures. The intensity of the discussion depends on the dynamics of issues that are currently developing, whether on a local, national, or global scale. The more sensitive an issue is, the higher the intensity of discussions involving lecturers and students. These discussions can occur in person or virtually. Specifically, one of the courses developed in the PTKIN curriculum is Masailul Fiqh. One lecturer stated: We use several steps in explaining khilafiyah (dissent). The first is mutual tolerance. We need to put forward an attitude of tolerance when a conclusion refers to Qhath'i sources of law. The second is not to force an opinion. No matter how much we believe in one opinion, which is ijtihadiyyah, this should not make us deny other opinions, let alone oblige everyone to follow our opinion. The third is prioritizing equality. Finding common ground is recommended in Islam. The fourth is to continue to explore the problem or tafaqquh. Tafaqquh means the earnest effort that we make to understand God's law. We continue to try to improve our tafaqquh so that we can understand the arguments that are used as the basis by the scholars in their concluding opinions. The fifth is mutual respect. Did the differences of opinion among the scholars make their relationship tenuous? Or humiliate each other? No, absolutely not. That's how we deal with differences of opinion. Students and community organizations should follow in the footsteps of their scholars, who have inherited the knowledge of the prophets consistently (istiqomah). (DUIL01, interview, September 24, 2019) The approach used by the lecturer is in line with the student's opinion that the PTKIN lecturer has provided insight into khilafiyah in a more There is a concern that if religious radicalism is increasingly mushrooming, it is predicted that it can distort and even oppose Pancasila as the nation's ideology. The facts show that the proliferation of radical and fundamental religious ideas cannot be separated from the influence of globalization. Many students do not fully understand the meaning of globalization and only take it in a negative light. If these symptoms are not immediately addressed, there will be many differences that lead to disunity. Therefore, my friends and I try to explain broadly the currents in Islam, which are one form of the different opinions of the ancient people. In Islam, there are actually many sects that spread and teach Islam in various versions. (DIP02, interview, September 29, 2019) Apart from the interview above, the quantitative data also shows students' acknowledgment that most lecturers at PTKIN (91.7%) try to explain to students the relationship between local culture and traditions and contextual religious values. Harmonization between these components is vital to create a harmonious life that protects and complements each other. --- Academic Policy in the Field of Research In addition to policies governing education and teaching, PTKIN campus leaders also regulate lecturer Campus leaders through LP2M socialize about research guidelines that will be approved by each campus (Satker). Planning, implementation, and reporting of research on campus must be carried out in a directed, measurable, and programmed manner by referring to the National Higher Education Standards and taking into account aspects of the integration of science and Islamic sciences that are rahmatan lil-alamin to build a religious, moderate, and tolerant society. (Mahmudin, interview, September 29, 2019) To strengthen the interview results above, the questionnaire calculation also showed that most lecturers (87.1%) stated the importance of research themes that used the Pancasila and Indonesian nationalism paradigms as national Their publications have complied with systematic scientific principles and methods in accordance with scientific autonomy, academic culture, and applicable standards. A lecturer explained that: The planning, implementation, and reporting of publication activities on campus are carried out in a directed, measurable, and programmed manner by referring to the National Higher Education Standards and taking into account the Islamic aspects that are rahmatan lil-alamin to create publication substance that promotes religious, moderate, and tolerant attitudes among students and the general public. (DIP04, interview, September 30, 2019) What was done by PTKIN lecturers received positive responses from students. Students acknowledged that the lecturers had explained the importance of studying program-based scientific publication themes from an Indonesian perspective. Apart from socializing the identity of the archipelago, this publication also reaches out to national and international journals in order to gain wider recognition. The results of the questionnaire filled out by students show that PTKIN lecturers are committed to campaigning for Indonesian insights and themes in scientific publications, both in periodical journals and popular media. In overall, 97.4% of lecturers apply policies regarding the publication of scientific papers from an Indonesian perspective. --- Academic Policy in the Field of Community Service The following academic policy is on the aspect of community service. PTKIN leaders also regulate One lecturer expressed his opinion as follows: Religious standards in community service activities are the minimum criteria regarding the depth and breadth of community service material in Islamic sciences that are rahmatan lil-alamin to build a religious, moderate, and tolerant Indonesian society. The depth and breadth of the community service material refer to religious standards for the results of community service. As a lecturer, I agree with this policy, considering that people must be properly educated to love their country and nation more. (Mahmudin, interview, September 29, 2019) What was done by the PTKIN lecturer above received appreciation from their students. The results of --- E. Discussion The existence of PTKIN has helped the government carry out tasks to improve the quality of society and the nation through access to higher education. (de Soto et al., 2018, p. 201). The majority of PTKIN campuses have provisions governing education and teaching that incorporate the values of Pancasila and Indonesian nationalism (Rohayana & Sofi, 2020, p. 213). All PTKIN leaders make Pancasila Education a compulsory subject. The existence of the Pancasila Education course has played a significant role in laying a strong foundation for Islamic higher education in Indonesia. Watson (2004, p. 268) states that there is a complementary relationship between religious education and citizenship education. This is also in line with research conducted by Mason (2018, p. 17) that suggests that these schools should be required to provide a civic education that is well-designed to help cultivate in children an appreciation of the importance of these virtues; they should be required to cultivate in children a capacity for critical reflection. In line with policies in the academic field, the entire lecture process must pay attention to Islamic values, in which learning outcomes are achieved through patience (istibar), perseverance (hirsun), honesty (sidiq), and trustworthiness. In addition, the process is also carried out by prioritizing good morals, meaning that learning outcomes are achieved through good character. Thus, lecturers must prepare a semester syllabus (RPS) by incorporating the campus vision and mission that lead to religious moderation. The hope is that the learning process takes place in the form of interaction between students and lecturers that is carried out humanely and andragogically. According to Gözükara (2015, p. 464) behaviors, academic success, and the future (Whitten et al., 2016, p. 58). Academic policies that lead to religious moderation also regulate the management of differences in the lecture process. Almost all lecturers educate about the importance of tolerance in dealing with differences in religious beliefs that are constantly developing in society. Tolerance has been proposed as a necessary response to global research on cultural and religious diversity (Verkuyten et al., 2019, p. 5). In addition, Hjerm et al. (2020, p. 898) also mention that tolerance is often invoked as something to which individuals and societies should aspire, especially given that diversity in all its forms is increasingly a feature of contemporary democracy. The majority of PTKIN also condition their lecturers to educate students and introduce them to the importance of practicing Islam in a polite manner and not using violence. Purwanto (2020, p. 3849) also agrees on this matter; deradicalization education or peace education must be realized in higher education since the complex challenges of life are increasing nowadays. This policy is very important, considering the widespread patterns of communication and dissemination of religion, which involve actions that lead to violence and are far from peaceful. Other studies also show that Islamic moderation is said to be one of the key factors contributing to the promotion of peace in Muslim societies (Zaduqisti et al., 2020). One way for lecturers to campaign for peaceful Islam and non-violence is through discussion forums regarding differences in religious sects in structured and nonstructured lectures. Generally, the policy of religious moderation in the academic field of the PTKIN campus also encourages its lecturers to explain religious issues according to different schools of Islamic thought. This policy received a positive response, as the lecturers were enthusiastic about providing religious insights with multiple references, especially on religious issues containing multiple interpretations. In line with this, Muhtada (2012, p. 79) said that pluralism and multiculturalism values are strongly promoted in Islamic teachings and can be a significant starting point for developing diversity management in the Islamic context. The students acknowledged that the role of the majority of lecturers in introducing Islam to various religious sects made the way of religious thinking much broader. This is in line with the findings of Van (2018, p. 44) that the role of academic advisors and lecturers has a positive effect on student development, including academic achievement, personality development, career development, and social development. In addition to opening students' insights and religious thoughts more broadly, campus policies in the field of education and teaching condition the lecturers to explain the relationship between local culture and traditions, and religious values contextually. These three variables are meeting points that cannot be denied in the process of Islamic da'wah. The lecturers illustrated the da'wah process as a process of grounding the Islamic religion by not abandoning the culture of the local community and local traditions that have characteristics. This is in line with the opinion of Schlehe and Nisa (2016, p. 16) that there is harmony between --- Nusantara in Indonesia. The term religious moderation itself is rooted in the Islamic tradition (Schmid, 2017). Through its long history and practice among the people, Islam is not only a belief that stands alone but has intersected with the culture and traditions that existed in the Arab world at that time. The majority of lecturers have a collective awareness to explain to students the relationship between local culture and traditions, and religious values contextually. Abdullah (2015, p. 175) argues that the paradigm of integration of Islamic sciences, science, and culture has a major influence on shaping religious perspectives, both social and cultural. Saihu et al. (2020, p. 3761) also believe that culture is a part of religion in the sense that the latter (religion) authentically aims to help bless people and perpetuate peace among them. The PTKIN campus academic policy also encourages lecturers to conduct research and community service with study program-based themes from an Indonesian perspective. This is in line with the results of research by Mayrl and Oeur (2009, p. 272), which found that new research into the demographic and institutional contexts of student religious engagements would greatly enhance our understanding of the role of religion in the academy. Amir (2013, p. 54) said that Pancasila ideology was included to realize the spirit of love for the motherland. These various policies, in the areas of education, research, and community service, positively impact the academic atmosphere by implementing religious moderation on campus. This is in line with the findings of Ekawati et al. (2019, p. 69), which state that they are fixing the curriculum system in education to be even more effective in preventing and deterring radicalism. These results are supported by the findings of quantitative data. Based on quantitative data analysis, the results of which can be seen in Table 2, the average score of the two questionnaires is above the middle value, or in other words, the hypothesis (Ha) that academic policy (both lecturers and students) at PTKIN supports the development system of religious moderation in Indonesia is acceptable. In addition, as the results of the calculations are presented in Table 3 above, it can be concluded that policies in the academic field, whether carried out by lecturers or students, provide significant support for the implementation of religious moderation in PTKIN. --- F. Conclusion Religious moderation is one of the top-down policies and is formulated explicitly in the national mid-term development plan document that has been stipulated by the President. This policy is strategic because it is oriented towards inter-religious harmony and relates to national stability. As part of the government system, PTKIN implements religious moderation through campus internal policy products. The qualitative finding is strengthened by statistical analysis using the t-test, and a significance value of less than 0.005 is obtained, which means that the null hypothesis (H0) is rejected. In other words, it can be concluded that PTKIN's academic policies support the development of a system of religious moderation in Indonesia. In summary, this study concludes that academic policies on religious moderation should be strengthened for the long-term preservation of national harmony.

This study aims to analyze the implementation of religious moderation at the State Islamic Higher Education (PTKIN) in Indonesia through academic policies in the fields of education, research, and community service programs. It is based on the empirical examination of the spread of radical, extreme, and exclusive religious sects among higher education civitas academica in Indonesia. The research combines qualitative and quantitative approaches (mixed methods) simultaneously. Data sources were randomly obtained from leaders, lecturers, and students at PTKIN through interviews, observations, questionnaires, documentation, and focus group discussions. Data analysis was carried out through data

Introduction Over the last two decades, hookup culture has expanded the boundaries of normative sexuality and introduced casual sexual interactions (i.e., "hookups") as a distinct pathway for relationship development (Allison, 2019). Dates and hookups can be understood as "two sides of the same coin" in the American courtship process, as 1 3 Scripting Sex in Courtship: Predicting Genital Contact in... they both carry the potential to lead to a relationship (Luff et al., 2016:76). Despite the flexible placement of sex in the courtship process, recited dating scripts remain traditionally gendered and sexually conservative. The traditional dating narrative states that men initiate, plan, and pay for dates. Sexual activity is involved, but not beyond kissing and potentially groping. Within this narrative, men initiate most of the sexual activity and women make sure the sexual activity stays within the parameters of respectability (Bartoli & Clark, 2006;Laner & Ventrone, 2000;Morr & Mongeau, 2004). This dating narrative reflects a culturally-determined script for appropriate behavior in the dating context. --- Sexual Scripts Sexual scripting theory conceptualizes "the sexual act as being a negotiated outcome," taking place on three interrelated levels: the cultural, the interpersonal, and the intrapsychic (Simon, 2005:294). Sexual scripts function as "blueprints" for appropriate behavior on the cultural level that influence how individuals "choos[e] a course of action and evaluat[e] behaviors already performed" on the interpersonal level (Rose & Frieze, 1989:258). On the intrapsychic level, scripting of one's innermost desires and motivations takes place, speaking to the fact that "individual desires are linked to social meanings" (Simon & Gagnon, 1984:53). In the context of dating, the cultural script dictates who asks, who pays, who initiates the sexual activity, as well as when, where, and how much sexual activity is appropriate. On the interpersonal level, negotiations are made between an individual's intrapsychic desires and society's expectations for proper behavior in a given cultural scenario (Gagnon & Simon, 2005). In this paper, we examine the sexual outcomes of dates as part of a scripted process, which allows us to assess how sexual processes in dates compare between the cultural script and reported practices, which reflect negotiations made on the interpersonal and intrapsychic levels. This is important because "[s]ites of 'disjuncture' between cultural and inter-or intrapersonal sexual scripts are a particularly promising location for the study of change in sexual scripts" (Masters et al., 2013:410). --- Historical Context of Traditional Dating Scripts The heterosexual dating script recited today originated in the early twentieth century when the dating system became the dominant courtship norm. At this time, gender roles were shifting as young, single men and women started socializing with each other in public spaces. Dates took place at dance halls, movie theaters, and other venues of commercial entertainment, all of which required money that men had and most women didn't. Dates, then, relied on men's money, which gave men control over date initiation and made them feel "entitled" to seek sexual compensation from women (Bailey, 1988:21). The early-twentieth century dating script, then, consisted of men asking women on a date, men paying for the night's activities, and then men initiating sexual activity. Women were tasked with receiving men's advances and limiting the amount of sexual activity that took place (Bailey, 1988;Spurlock, 2016). In the 1920s, sexual activity in the form of necking and petting-"caresses above the neck" and "caresses below"-were "customary" and "expected elements" of any date as part of what women "owed" to men for financing the night's activities (Bailey, 1988:80, 81). Importantly, however, many women took advantage of this customary practice to explore their own sexual desires in "respectable" ways (Littauer, 2015). Activities beyond necking and petting, such as those involving genital contact, were still conventionally reserved for marriage and would put a woman's reputation at risk if she were to go "too far" (Bailey, 1988;Spurlock, 2016;Syrett, 2009). In other words, necking and petting were part of the twentieth-century dating script, but genital contact was not, because women risked losing their respectability. Women walked a fine line, as they were responsible for limiting sexual activity, but they were also expected to compensate men for financing their dates. --- Contemporary Dating Scripts In many ways, the extant literature suggests that the contemporary dating script looks strikingly similar to the script from over a century ago, despite increasing egalitarian views expressed by young adults. This script dictates that men initiate and pay for dates, and women limit whatever sexual activity is initiated by men. This sequence of behaviors has been reported consistently by scholarship over the last 30 years (Bartoli & Clark, 2006;Cameron and Curry, 2020;Laner & Ventrone, 1998, 2000;Morr Serewicz & Gale, 2008;Rose & Frieze, 1989, 1993;Seabrook et al., 2017). Although much of the research on dating scripts has focused on first dates, scholarship on dating practices in general has found that the early stages of the courtship process are characterized by the traditionally gendered script, wherein men take an active role and women remain passive (Bartoli & Clark, 2006;Lamont, 2020;Sassler & Miller, 2011, 2017). Bartoli and Clark (2006) focus specifically on the scripting of "typical dates," finding traditional gender behaviors are not limited to first-date contexts. Furthermore, despite variation in how relationships progress, Sassler and Miller (2011:490) find "more consistency than contestation with traditional gendered scripts." Rose and Frieze (1993:500) argue that gender roles "are more operative early in courtship than at later stages," in part, because "relationship continuation [to exclusivity] often depends on the adequate fulfillment of these roles." Ultimately, dates that take place before an exclusive relationship is established seem to follow the traditional dating script. An exclusive relationship is often the point at which the labels "boyfriend" and "girlfriend" are introduced and a couple becomes "officially" monogamous. Importantly, exclusivity requires an explicit conversation, as exclusive relationships are "formed through verbal discussion of relationship status, or 'the talk'" (Allison, 2019:371). Dates, on the other hand, are not always accompanied by a conversation to define the interaction. As such, individuals rely on cultural scripts and gender roles to navigate the ambiguity in the early stages of the courtship process (Cameron & Curry, 2020;Rose & Frieze, 1993). --- 3 Scripting Sex in Courtship: Predicting Genital Contact in... For example, scholars have found that women rely on men's initiation and payment to confirm that an interaction is, in fact, a date and that mutual romantic interest is present (Allison, 2019;England et al., 2012;Lamont, 2020). --- Alternative Scripts While it is conventional for men to initiate dates, it is not unheard of for women to do the same (Mongeau & Carey, 1996;Mongeau & Johnson, 1995;Morr Serewicz & Gale, 2008). In 1993, Mongeau et al. found that most college students reported experiencing at least one heterosexual female-initiated date. Data from the Online College Social Life Survey, collected between 2005 and 2011, shows that 12 percent of dates reported by surveyed college students were female-initiated. Additionally, England et al., (2012:567) reported that over 90 percent of students, including both men and women, "approve heartily of women asking men on dates." Female-initiated date processes in the twenty-first century have been largely neglected by scholarship, but Morr Serewicz and Gale (2008) examined whether variations in the traditional script, including gender of date-initiator, would lead to differences in how a first date script was recited. They conclude that "traditional gender roles appear to be alive and well in the scripting of first dates," while also noting that "female-initiated first dates result in greater complexity in expectations for sexual behavior" (Morr Serewicz & Gale, 2008:161). Their analyses suggest that a female-initiated date signals a different sexual script, but this script has been largely uninterrogated in research on dating scripts over the last 20 years. Because we cannot assume that dates with nontraditional scripts follow the same sexual processes as dates with traditional ones, this study approaches male-initiated and female-initiated dates as separate processes. --- Standards for Sexual Behavior In the 1920s, women were responsible for limiting sexual activity on dates to necking and petting due to the pressures of what can be considered a sexual double standard, wherein women would lose their respectability if they went "too far" (i.e., engaged in genital contact), but men's reputations would be unaffected. Today, the dominant cultural script dictates that genital contact is not appropriate on a date, but it is unclear if this is also true in practice given the changing circumstances of respectability in contemporary America with the rise of a hookup culture around the turn of the twenty-first century. Hookup culture encompasses a set of values, ideals, norms, and expectations that are part of the system that accepts casual sexual interactions (i.e., hookups) as a feature of, not replacement for, courtship (Heldman & Wade, 2010;Kuperberg & Padgett, 2016;Monto & Carey, 2014;Wade, 2017). Within the hookup culture context, women can engage in sexual activity beyond "petting" without risking their reputations. This has led to an increasing lack of consensus among scholars regarding whether a sexual double standard still exists and if so, to what extent. In fact, Crawford and Popp (2003:14) describe the "heterosexual double standard" as a "'now you see it, now you don't' phenomenon," given the inconsistency in empirical evidence supporting its existence. If the influence of the sexual double standard has decreased in the twenty-first century, as some scholarship suggests (Jackson & Cram, 2003;Marks & Fraley, 2005;Milhausen & Herold, 2002;Weaver et al., 2013), then women may not feel compelled to limit sexual activity given their reputations would not be at risk. This may be especially true if men both ask and pay for a date, leaving women to feel like they "owe" something. With that being said, many scholars argue for the continued relevance of the sexual double standard to some extent, either suggesting different ways of conceptualizing it or proposing new methodological approaches to measure it (Armstrong et al., 2012;Farvid et al., 2017;Kettrey, 2016;Reid et al., 2011;Thompson et al., 2020). Lack of empirical evidence aside, it seems that "gender remains central to evaluations of sexual behaviors in at least some contemporary social settings" (Allison & Risman, 2013:1193). The inconsistencies in reports of the sexual double standard in the twenty-first century may be attributed to the fact that the scripts for appropriate sexual behavior are context dependent. In other words, the operation of the sexual double standard is affected by whether sex takes place within the context of a hookup or a date, which are two distinct cultural scenarios. Reid et al. (2015:189) report a general consensus among college students that sex on a date is "a situational impropriety," even if the pair has previously engaged in casual sex. In another study, Reid et al. (2011:559) found students described sex as acceptable for women in a hookup context because it signals sexual agency, but within the context of a date, women are expected to "moderate [their] sexuality" to show that they are "dating material." Other scholars have found that both men and women express losing interest in dating someone who is perceived to be promiscuous, suggesting a conservative single standard for sexual activity in dating contexts (Allison & Risman, 2013;England & Bearak, 2014). The traditional dating script may not have changed much in the last 20 years, but sexual norms and the parameters for appropriate sexual behavior certainly have. Regarding standards for sexual behavior in contemporary America, there is a distinction to be made between being respectable and being relationship material. Historically, the sexual double standard's regulation of women's respectability also regulated whether a woman was considered marriage material. In other words, a loss of respectability corresponded to a loss of relationship prospects. This equation between respectable and dateable no longer holds true in all contexts. We propose that there is a relational standard for sexual behavior, which speaks to the belief that going "too far," or engaging in genital contact, on a date disqualifies someone from being considered "relationship material." Although women are held to higher standards and lower benchmarks of how much sexual activity is "too much," the relational standard also applies to men to the extent that heterosexual women report being less interested in dating men who are perceived to be promiscuous (England & Bearak, 2014;Klein et al., 2019). In sum, the sexual double standard speaks to who can have sex and still be respectable. The relational standard speaks to where sex can happen and still lead to a relationship. There seems to be a general consensus that the cultural script for dating dictates that dates are not appropriate contexts for sexual activity that involves genital contact 1 3 Scripting Sex in Courtship: Predicting Genital Contact in... (Allison, 2019;Klein et al., 2019;Reid et al., 2011Reid et al.,, 2015)). Research addressing sexual activity in dating contexts, however, tends to stop with the cultural script and does not entertain the possibility that practices might not align with recited expectations. With that being said, Kuperberg and Padgett (2015:525) found that while sex was more likely to happen in hookup contexts, "one-third of dates [in their sample] included sex." Certain sexual behaviors, such as oral sex and intercourse, may be considered inappropriate on a date, but in practice, it is not uncommon for dates to involve genital contact. In other words, college students may recite a cultural script with sexually conservative date outcomes, but this does not align with reported practices, which reflect negotiations taking place on the level of interpersonal scripting. Given this inconsistency, this study investigates how sex is being re-scripted on the interpersonal level in dating contexts by examining how genital contact is associated with traditional and nontraditional components of dating scripts and standards of sexual behavior. --- Research Questions and Hypotheses Because recited dating scripts are still enacted to the extent that men ask and men pay on most dates, there are assumptions that sexual activity has also remained traditionally conservative. Over the last two decades, there have been dramatic shifts in sexual norms, as evidenced by the incorporation of casual sex alongside dates in the courtship process. Scholarship focuses almost exclusively on the changing sexual norms in the context of casual sexual interactions, not dates. While at the same time, research on dating practices continues to focus on the traditionally gendered behaviors, often overlooking the possibility of changes in the sexual script regarding the extent of sexual activity on dates. In this study, we examine sexual outcomes of dates as part of a scripted process, with consideration for the possible "disjuncture" between a date's cultural script and its interpersonal one (Masters et al., 2013:410). In doing so, we assess how sexual processes in dates compare between cultural expectations and reported practices. Our first two research questions examine how sexual practices are associated with script components from a dominant cultural scenario. First, we explore whether traditional components of the male-initiated dating script (men paying; men initiating sexual activity) lead to traditional sexual outcomes. Specifically, which components of the traditional (i.e., male-initiated) dating script explain the likelihood of genital contact on a date? (RQ 1). Because traditional dates are not supposed to involve genital contact, we hypothesize that the likelihood of genital contact will decrease when dates are traditionally scripted-that is when men pay on male-initiated dates. Because women are the "gatekeepers" and men are the pursuers of sex in the traditional dating narrative, hypothesis 1 states that the likelihood of genital contact will decrease on male-initiated dates when men initiate more of the sexual activity compared to when women initiate or when respondents indicate being unsure of who initiated more sexual activity. Second, we examine the sexual processes of female-initiated dates. Specifically, which components of the alternative (i.e., female-initiated) dating script explain the likelihood of genital contact on a date? (RQ 2). Given female-initiated dates signal a different type of cultural script that has yet to be thoroughly explored, we are interested in identifying the sexual outcomes of these dates in addition to which components of the script are associated with nontraditional sexual outcomes. Hypothesis 2 states that the likelihood of genital contact on female-initiated dates will decrease when women pay for part or all of the date, but it will increase when women initiate more of the sexual activity. Due to the lack of research on female-initiated dates, our hypotheses are exploratory. In one of the only extensive studies of female-initiated dates, Mongeau et al., (1993:66) find that "males tend not to equate a direct date initiation as a direct sexual invitation" despite previous research that suggested otherwise. More recently, Emmers-Sommer et al., (2010:350) speculate that men may be less likely to expect sex when women initiate the date or women split the bill: "when men's currency of asking and solely paying is absent they perceive that they've lost their 'card to play,' if you will, in terms of sexual expectations on dates." Our third research question attends to the interpersonal level of sexual scripting, where individuals make negotiations between their intrapsychic desires and the cultural expectations for appropriate behavior. The sexual double standard, relational standard, and interest in another date are context-specific and subject-specific factors that play a role in the interpersonal scripting process. We examine how attitudes about sex and gender, as well as one's personal desires, are reflected in the sexual outcomes of a date. Specifically, which attitudes about sexual behavior are associated with the likelihood of genital contact on a date for male-initiated and femaleinitiated dates? (RQ 3). Hypothesis 3a states that the likelihood of genital contact on male-initiated dates will decrease when respondents hold a sexual double standard, when respondents hold a relational standard, and when respondents indicate being interested in going on another date. Historically, genital contact did not take place on dates because of the sexual double standard and women's need to maintain respectability. Although the sexual double standard's influence is contested, it may still inform one's behavior on a date; therefore, if the respondent expresses holding a sexual double standard, then the likelihood of genital contact will decrease. In addition, the relational standard may limit the extent of sexual activity on a date because dates carry the potential for romantic interest and future relationshipbuilding. So, if respondents believe that engaging in genital contact may disqualify them as a potential boyfriend or girlfriend, then they would be less likely to engage in genital contact on a date. As such, we hypothesize that genital contact on maleinitiated dates will decrease when respondents express holding a relational standard. Similarly, individuals interested in going on another date will be more likely to conform to the cultural expectation that genital contact does not take place: "[f] ew individuals wander far from the formulas of their most predictable successes" (Simon & Gagnon, 1984:58). Given a female-initiated date itself represents a deviation from a traditional script, we suspect that sexual activity will not follow the same expectations for sexual behavior. As such, we hypothesize that the likelihood of genital contact on a female-initiated date will increase when a respondents' beliefs do not reflect a sexual double standard or a relational standard, thereby reflecting more egalitarian ideals. Similarly, hypothesis 3b states that the likelihood of genital contact on a female-initiated date will increase when respondents indicate being 1 3 Scripting Sex in Courtship: Predicting Genital Contact in... interested in going on another date, because there are no established guidelines that preclude sexual activity when there is romantic intent. Again, these hypotheses are exploratory given the lack of extensive research on female-initiated date processes. --- Method --- Data We used data from the Online College Social Life Survey (OCSLS), which was developed by Paula England and collected between 2005 and 2011 from a convenience sample of 24,131 students across 21 institutions of higher education in the United States. The survey was optional to students 18 and older, administered in entry-level college courses, and took students about 20 min to complete. Most students who completed the survey were offered extra credit, and students who opted out of the survey were offered an alternative option for extra credit. Students were asked to respond to questions about their experiences and attitudes regarding sexual activity, hookups, dates, and relationships. The OCSLS is the only dataset of this scale to provide this level of detailed information about college students' dating practices, types of sexual activity, and standards for sexual behavior, all of which are needed to answer our research questions. Although our findings are not generalizable beyond those who took the survey, given the large sample size recruited from 21 institutions and the near-100 percent response rate, we believe, like other scholars, that they reflect the practices of a significant cross-section of the US student population (Allison & Risman, 2013;Kettrey, 2018;Kuperberg & Padgett, 2017). Our analysis draws from student reports of their most recent "date," after respondents were prompted, "Now some questions about the last date that you went on with someone you were not already in an exclusive relationship with." Although we do not know if the respondent has been on previous dates with this person, the fact that they are not in an exclusive relationship suggests that they are still in the early stages of the courtship process. Due to our interest in gendered sexual power dynamics in courtship rituals, we limited our sample to self-identifying heterosexual, cis-gender respondents who are not married and who do not have any children. Because we are interested in the types of sexual behaviors that take place on a date, we limited our sample to those who indicated any level of sexual activity took place on their most recent date when asked, "Did anything sexual happen (kissing, petting, oral sex, intercourse all count as sexual here) happen on your date?" (N = 8,034). It is worth noting that over 60 percent of all dates involved sexual activity. After dropping cases with missing data on one or more explanatory or control variables, our total sample is comprised of 7,377 respondents. --- Measures Our dependent variable was dichotomous, measuring the extent of sexual activity on the respondent's most recent date with someone with whom they were not in an exclusive relationship. After being asked if "anything sexual" took place on their most recent date, respondents were asked, "Which behaviors did you engage in?" and instructed to "Check all that occurred," from a list of descriptions of various sexual behaviors (Table 1). When respondents selected at least one of the behaviors that included "genitals" in its provided definition or described "anal" or "oral" sexual activity, genital contact, which we operationalize as indicative of a nontraditional sexual outcome, was considered to have occurred on the respondent's most recent date (1 = genital contact). The reference group, then, is traditional sexual outcomes, or no genital contact, which could be categorized as "petting." Our decision to dichotomize this variable aligns with prior approaches that operationalize questions about sexual activity to examine specific sexual behaviors (Bearak, 2014;England & Bearak, 2014;Kettrey, 2016). --- Explanatory Variables The key explanatory variables indicated who paid for the date and who initiated more of the sexual activity. We constructed a categorical variable from responses to the question, "Who paid for the date?" We converted the responses (I paid; They paid; We both paid; There was no money spent) into gender-specific categories: man Scripting Sex in Courtship: Predicting Genital Contact in... paid, woman paid or both paid, and no money was spent. We collapsed "women paid" and "both paid" into one category because women paid on less than two percent of dates. Respondents were asked, "Overall, who initiated more of the sexual activity?" We converted the responses (I did; Other person did; I don't know) into the following categories: "Man initiated more," "Woman initiated more," and "I don't know." We measured the relational standard based on the survey item, "If someone has hooked up a lot, I'm less interested in this person as a potential girl/boyfriend." The 4 response options ranged from "Strongly Disagree" and "Disagree" to "Agree" and "Strongly Agree." Following the conventions established by England and Bearak (2014), the creators of the survey, we dichotomized these items into "Disagree" (0) and "Agree" (1). Those who agreed with this statement were classified as holding a relational standard. We measured the sexual double standard based on two survey questions where respondents were asked their opinion on the following statements: "If women hook up or have sex with lots of people, I respect them less" and "If men hook up or have sex with lots of people, I respect them less." The statements were separated by 15 other survey items to account for bias stemming from the respondents' conscious understanding that should not judge men and women's sexual behaviors differently. Both of these statements were measured by 4 items: "Strongly Disagree," "Disagree," "Agree," "Strongly Agree." Because we have no reason to believe the distance between each item is equal, we dichotomized the responses into "Disagree" (0) and "Agree" (1). Respondents who agreed with the first statement (respect women less if they hook up a lot) and disagreed with the second statement (respect men less if they hook up a lot) were classified as holding gender values that align with the sexual double standard. Our construction of the relational standard and sexual double standard variables followed conventions established by other scholars who have operationalized these survey items in similar ways (Allison & Risman, 2013;England & Bearak, 2014;Kettrey, 2016). We operationalized respondent's interest in going on another date as an indicator of potential romantic interest based on the date. Respondents were asked, "At the end of the date, were you interested in going out on another date with this person?" and selected between the following 4 items: "No, I wasn't at all interested"; "Possibly; I didn't really know yet"; "Maybe; it had some appeal"; "Yes, I was definitely interested." Because being "possibly" interested and "maybe" interested are particularly ambiguous and we have no reason to believe that the distance between each item is equal, we dichotomized these responses into "not 'definitely interested'" (0) and "definitely interested" (1). This variable construction lends itself to a more conservative estimate. --- Control Variables Gender, race, and age were operationalized as demographic controls. Respondent gender was indicated by a dummy variable (male = 0; female = 1) derived from the question, "What is your gender?" Controlling for gender addresses potential sources of biases reported by previous research, which finds women underreport and men over report sexual behavior (England & Bearak, 2014). Measures for racial and ethnic identity were derived from the question, "If you had to pick one racial or ethnic group to describe yourself, which would it be?" where respondents selected from 14 racial categories. We recoded responses into 5 racial groups: White, Black, Hispanic, Asian, and Other. Age is determined from the question, "How old are you?" Respondent age ranged from 18 to 25. The average age of the sample was 20, with the majority of cases concentrated between 18 and 21 years. We controlled for alcohol consumption and drug use before or during the date, given previous research identified the influence of alcohol on sexual activity (Kuperberg & Padgett, 2017; Morr & Mongeau, 2004;Reid et al., 2015). For alcohol consumption, respondents were asked to indicate how many beers, glasses of wine, mixed drinks or shots, and malt beverages they consumed before or during their most recent date. If respondents indicated having 1 or more of any of these beverages, alcohol was considered to be involved (1 = alcohol consumed). Respondents were asked to indicate what, if any, illegal drugs they used before or during the date by selecting all that applied from a list including marijuana, amphetamines, cocaine, ecstasy, heroin, and mushrooms. An "other" option was also provided. If respondents selected 1 or more of these options, drugs were considered to be involved (1 = drugs involved). Because sexual history has been found to influence sexual activity (Bartoli & Clark, 2006;Olmstead et al., 2013), we controlled for respondent's disposition toward sex using three variables: number of sexual partners, a sexual history including maintaining multiple casual sexual relationships at the same time, and a preference for having sex when in love. Respondents were asked, "How many people have you had intercourse with?" We defined 3 categories from the responses: 0 to 1 past partners; 2 to 5 past partners, and 6 or more past sexual partners. About 25 percent of respondents indicated having had intercourse with 0 to 1 people, about 50 percent of respondents indicated having had sex with 2 to 5 people, and about 25 percent of respondents indicated having had sex with 6 or more people. Respondents were asked, "Have you ever had two ongoing sexual partnerships involving intercourse at the same time?" (1 = Yes). We controlled for respondent's association between sex and love as indicated by responses to the following statement: "I would not have sex with someone unless I was in love with them." This statement was measured by 4 items ranging from "Strongly Disagree" to "Strongly Agree." We dichotomized the responses into "Disagree" (0) and "Agree" (1), because we have no reason to believe that the distance between each option is the same. Other versions of the model included controls for immigrant status (not born in the USA), location of high school (rural, urban, suburban), religiosity, political views, parents' relationship status, where respondent met their date, respondent's desire to be in a relationship, and respondent's overall enjoyment of the date. In order to ensure statistical power, we excluded these from the final model because they carried little-to-no significance, and their presence did not notably change the coefficients of interest. It is important to address the issue of coercion and feeling pressured to engage in certain sexual behaviors, especially given the gendered power dynamic when men initiate and pay. We could not include a variable indicating whether the respondent 1 3 Scripting Sex in Courtship: Predicting Genital Contact in... was pressured into sexual activity, because the variable would only apply to the subset of the sample that did engage in genital contact, rather than applying to anyone who engaged in sexual activity. With that being said, it is important to note that less than 7 percent of respondents in our sample reported feeling pressured to engage in genital contact, with 6 percent of respondents reporting performing oral sex or hand stimulation because they felt they owed their partner an orgasm but did not want to have intercourse and less than 2 percent of respondents reporting engaging in sexual intercourse because they felt verbally pressured. --- Analytic Strategy We obtained univariate descriptive statistics for the sample to assist in the operationalization of the previously described measures and examine sample distributions. To determine potential differences between male-and female-initiated dates, we use t-tests and chi-square test for independence to examine the relationship between key variables of interest and demographic controls by gender-specific date initiation. This information guided the decision to run separate models for male-and femaleinitiated dates to allow us to identify unique relationships between key variables and genital contact by traditionally scripted male-initiated dates and alternatively scripted female-initiated dates. We used logistic regression to assess how much date-specific and individuallevel attitudes predict genital contact occurring on a date, with separate models for male-initiated and female-initiated dates. We conducted all analyses using Stata 16 (StataCorp, 2019). First, we conducted simple logistic regressions that provided unadjusted model coefficients for each variable in the model separately. We followed these analyses with a multivariate logistic regression. The unadjusted and adjusted model coefficients from our bivariate and multivariate analyses were exponentiated, allowing us to report and compare odds ratios. This approach allows us to report and compare changes in odds ratios between the unadjusted, bivariate comparisons and the fully adjusted, multivariate logistic regression. We examined regression diagnostics and assessed for goodness of fit prior to selection of the final models (Long & Freese, 2014). In our assessment of missing data, we determined that our data was missing at random, given there were no significant relationships between missing values and other variables. No variables had levels of missingness above 2 percent. Based on our analyses of missingness in the data, we proceeded with a complete case analysis. With complete case analysis, a total of 657 observations (<unk> 8.2 percent) were dropped. The final analytic sample was 7,377. The sample size of dates initiated by women (N = 805) is significantly smaller than that of dates initiated by men (N = 6,562), but we conclude that the sample still holds enough power for complete case analysis (Long & Freese, 2014). --- Results --- Univariate & Bivariate Analyses Table 2 displays descriptive information about the distribution for the total sample and subsamples of male-initiated and female-initiated dates. Male initiation of dates, which aligns with the initial stage of traditional dating scripts, represents 89.1 percent of the total analytic sample while female initiation of dates, which aligns with alternative dating scripts, represents only 10.9

Despite increasing egalitarian values expressed among college students, dating is still characterized by traditional gender roles. Because traditional dating scripts are predominantly recited and enacted to the extent that men initiate and pay, there are assumptions that the sexual processes have not changed. This study investigates the sexual processes of male-initiated and female-initiated dates among college students in the US. Using data from the Online College Social Life Survey, we ask whether traditional components of the dating script explain traditional sexual outcomes (nongenital contact), as well as whether alternative dating scripts explain nontraditional sexual outcomes (genital contact). Using multivariate logistic regression models, we found that violations of the traditional script are associated with higher odds of genital contact for male-and female-initiated dates; however, the predictors of genital contact for female-initiated dates are not the same as those for male-initiated dates. This study highlights the variability of sexual scripts in dating practices, suggesting that the sexual scripts associated with dates are not as homogenous as we have previously believed.

e, 2014). In our assessment of missing data, we determined that our data was missing at random, given there were no significant relationships between missing values and other variables. No variables had levels of missingness above 2 percent. Based on our analyses of missingness in the data, we proceeded with a complete case analysis. With complete case analysis, a total of 657 observations (<unk> 8.2 percent) were dropped. The final analytic sample was 7,377. The sample size of dates initiated by women (N = 805) is significantly smaller than that of dates initiated by men (N = 6,562), but we conclude that the sample still holds enough power for complete case analysis (Long & Freese, 2014). --- Results --- Univariate & Bivariate Analyses Table 2 displays descriptive information about the distribution for the total sample and subsamples of male-initiated and female-initiated dates. Male initiation of dates, which aligns with the initial stage of traditional dating scripts, represents 89.1 percent of the total analytic sample while female initiation of dates, which aligns with alternative dating scripts, represents only 10.9 percent of the total analytic sample. Bivariate inferential tests demonstrated significant differences between male-initiated and female-initiated dates by genital contact. Genital contact took place on over 56 percent of dates with sexual activity, occurring on over 63 percent of female-initiated dates and on approximately 56 percent of male-initiated dates. Based on this descriptive information alone, we can see that there is a discrepancy between the widely-recited cultural expectations for sexual behavior and what is actually being reported as practiced on dates. Although men paid for the majority of male-initiated dates (68 percent), women contributed at least part of the payment on 17 percent of dates, and no money was spent on 15 percent of dates. Among those dates following a male-initiated script, men paid and initiated most of the sexual activity on approximately 36 percent of dates. In other words, more than 60 percent of dates violate the traditional scriptdefined as men asking, paying, and initiating sexual activity-in some way. On female-initiated dates, which violate the script from the outset, men still paid 41 percent of the time. Women paid or both paid on 33 percent of female-initiated dates, and no money was spent on 26 percent of female-initiated dates. In addition, we observed differences by gender initiation with demographic controls, such as age (t(7375) = -4.7, p <unk> 0.001) and gender ( <unk> 2 (1) = 81.7, p <unk> 0.001), and key explanatory variables, such as the presence of the sexual double standard ( <unk> 2 (1) = 9.4, p <unk> 0.002). For age (which is not presented in Table 2), we observed an average age of 20.2 years (SD = 1.7) with an average of 20.5 years (SD = 1.8) for respondents reporting female-initiated dates and 20.2 years (SD = 1.7) for respondents reporting male-initiated dates. We did not observe differences in relational standard, interest in another date, or racial/ethnic identification between male-and female-initiated dates. Given the significant variation by this initial stage of courtship, we choose to model predictors of genital contact separately for male-initiated and female-initiated dates, which likely correspond with two different courtship scripts in contemporary America. Table 3 displays the results of a series of simple logistic regressions that provide unadjusted odds ratios of genital contact regressed on each explanatory variable separately. This approach allowed us to compare our bivariate results directly with the odds ratios of our multivariate analyses. The unadjusted models demonstrated that variables associated with scripts and attitudes were significant within the male-initiated date sample. The bivariate analyses of the female-initiated date sample, however, demonstrated no significant association with scripts and attitudes except for when women initiated the sexual activity (compared to when men initiated sexual activity). In addition, bivariate analyses indicated significant explanatory factors were similar across both male-and female-initiated date models. --- Multivariate Analyses Table 4 shows the results of the multivariate logistic regression models that regress genital contact occurrence on dating scripts, attitudes/beliefs, and identified control variables. Among male-initiated dates, the odds of genital contact increased by about 31 percent when no money was spent (p <unk> 0.001) and approximately 39 percent when women paid for part or all of the date compared to when men paid (p <unk> 0.001). Holding all else equal, when women initiated more of the sexual activ- ity on male-initiated dates, the odds of genital contact increased by approximately 39 percent compared to when men initiated more of the sexual activity (p <unk> 0.001). There was no significant difference in the odds of genital contact when the respondent indicated that they did not know who initiated more of the sexual activity compared to when men initiated. These results support Hypothesis 1, which predicted that the odds of genital contact would decrease on male-initiated dates when men paid for the date or when men initiated more of the sexual activity. Among female-initiated dates, the odds of genital contact increased most when no money was spent, with about a 71 percent increase in odds compared to when men paid (p <unk> 0.01). The odds of genital contact when women paid or both paid on a female-initiated date increased by approximately 45 percent compared to when men paid (p <unk> 0.05). Among female-initiated dates, the effect of who initiated more of the sexual activity on the odds of genital contact was not significant. We hypothesized that the likelihood of genital contact would decrease when women paid for all or part of a female-initiated date, and that it would increase when women initiated 1 3 Scripting Sex in Courtship: Predicting Genital Contact in... more of the sexual activity. Hypothesis 2, then, was not supported, because women paying actually increased the odds of genital contact, and the effect of women initiating more of the sexual activity was not significant. When respondents expressed a sexual double standard, the odds of genital contact occurring on a male-initiated date increased by about 35 percent (p <unk> 0.001). When respondents indicated holding a relational standard -that is, they are less interested in someone who hooks up a lot as a future boyfriend or girlfriend-the odds of genital contact on male-initiated dates decreased by about 16 percent (p <unk> 0.01). When respondents expressed interest in going on another date, the odds of genital contact occurring on a male-initiated date increased by approximately 30 percent (p <unk> 0.001). Hypothesis 3a was partially supported by these estimates. As expected, holding a relational standard was a significant predictor associated with decreased odds of genital contact on a male-initiated date. Unexpectedly, however, holding a sexual double standard and being interested in another date were both significant predictors associated with increased odds of genital contact. Among female-initiated dates, the sexual double standard and relational standard were not significant predictors of genital contact. The odds of genital contact on a female-initiated date increased by approximately 43 percent when respondents expressed interest in another date (p <unk> 0.05). We predicted that the odds of genital contact would increase on female-initiated dates when respondents indicate being interested in another date and when respondents do not reflect traditional values, as indicated by holding a sexual double standard or a relational standard. Due to the lack of substantial significance, hypothesis 3b was inconclusive. It is also important to note that we observed consistency in the significance of control variables such as gender, alcohol consumption, and sexual history across both male-and female-initiated dates. The effect of gender on genital contact was significant in both multivariate models, with the odds of reported genital contact decreasing when the respondent identified as a woman. For both male-and femaleinitiated dates, alcohol increased the odds of genital contact. Additionally, the effect of the number of previous sexual partners, as well as the effect of having experience maintaining multiple casual sexual arrangements at one time, increased the odds of genital contact for both male-and female-initiated dates. --- Discussion In contemporary America, hookups and dates are both acceptable pathways to relationship formation, but they are governed by different sexual scripts. The sexual behavior in hookups is ambiguously defined, and anything from kissing to intercourse is acceptable. Dates, on the other hand, are associated with more conservative sexual approaches. Scholarship has established that casual sexual interactions (i.e. hookups) can lead to dates, but we have not explored the extent of changes of sexual practices within dating contexts. Most scholarship that examines emerging adult sexual practices focuses on hookup contexts, not dates. Because traditional dating scripts are still recited and largely enacted to the extent that men initiate and pay, there are assumptions that the sexual processes that follow have not changed. This study investigated the sexual processes of dates among college students in the US. First, we asked whether components of the traditional dating script led to traditional sexual outcomes ("petting"). Then, we asked whether components of an alternative dating script led to nontraditional sexual outcomes (genital contact). Lastly, we asked how attitudes about sexual behavior and romantic interest affected the sexual outcomes of both traditional dates (i.e., male-initiated) and nontraditional dates (i.e., female-initiated). --- 3 Scripting Sex in Courtship: Predicting Genital Contact in... --- The Traditional Script: Male-Initiated Dates Consistent with previous scholarship on dating scripts, sexual activity is more restricted on dates when men pay on male-initiated dates (Reid et al., 2011(Reid et al.,, 2015)). This is also true when men initiate more of the sexual activity. The increase in odds associated with women initiating sexual activity is expected given the logic of the traditional cultural narrative. In the traditional script, sexual activity is limited because women are expected to limit it. It follows, then, that more sexual activity would occur if women were not only allowing sexual activity, but were also the ones initiating it. Genital contact may be more likely to accompany nontraditional components of the script, but it is not absent in traditional ones. In other words, individuals may be following traditional components of the dating script, such as men paying, while still engaging in nontraditional sexual outcomes. This suggests a discrepancy between the cultural scenario and actual practices, which may be evidence of changing sexual scripts. --- The Alternative Script: Female-Initiated Dates Although the majority of dates in our study were male-initiated, over 88 percent of students in our sample agreed with the statement that "It is okay for women to ask men on dates." Given this wide social acceptability, in addition to increasing egalitarian views and inclinations, the low number of female-initiated dates that we observe today reflects a lag in practice. It is likely, then, that we will see an increase of female-initiated dates in the future, and it is important for us to become attuned to their processes as distinctly different from dates that are male-initiated. In many ways, conservative sexual practices are associated with traditionally gendered dating scripts, but there is no such association when scripts veer off the dominant cultural scenario. Female-initiated dates, which deviate from the traditional dating narrative before they even start, do not follow a recognizable sexual script, as evidenced by the general lack of significance in the model. This lack of substantial significance among female-initiated dates prompts more questions than it provides answers, but it does tell us that the processes for sexual conduct are different when traditional scripts are not followed. Ultimately, we find that predictors of genital contact on female-initiated dates are not the same as the predictors for genital contact on male-initiated dates. Future scholarship should attend to female-initiated dates and their sexual processes as part of a distinct cultural scenario. Qualitative research may be needed to assist scholars in identifying and characterizing new sexual scripts that come from female-initiated date scenarios. The effect of who paid on the date is of particular interest, specifically the effect of no money being spent, as it is the explanatory variable with the most substantial statistical significance among female-initiated dates. When no money is spent and genital contact happens, the interaction seems to fit the description of a hookup, but the respondent specifically identified the interaction as a date. This brings up questions about what defines a date. Notably, almost 20 percent of all dates were classified as having no money spent. While it is possible that college students intentionally seek out free date activities due to their low income, they also continue to identify men paying as a defining feature of a date. This speaks to an underlying question of how a date is confirmed in this scenario, given the act of men paying on a date plays such a strong role in defining the interaction (Allison, 2019;Lamont, 2020). When women initiate the date and no money is spent, the classification of a date is determined by different criteria. In this way, no money being spent could signal a more egalitarian date formula, given neither person in the date scenario holds financial power over the interaction. At the same time, the fact that no money being spent is the most significant predictor of genital contact on a female-initiated date suggests that some dating practices may be informed by the sexual scripts guiding hookups in ways that have yet to be uncovered. --- Sexual Respectability: Double Standards and Future Dates The sexual double standard, relational standard, and interest in going on another date speak to beliefs about what is appropriate and respectable sexual behavior. Examining the effect of standards for sexual behavior on the sexual outcomes of dates sheds light on the interpersonal scripting process that influences decisions to engage (or not engage) in sexual activity: "interpersonal scripts provide the bridge between what the parties want and what they believe is deemed to be socially appropriate and normative for a first date" (Emmers-Sommer et al., 2010:341). On male-initiated dates, the effects of script components aligned with our expectations, but the attitudes about sexual behavior and romantic interest did not. The sexual double standard may signal a general lack of respect, which may lead to the increased odds of genital contact, assuming limiting sex is considered the "proper," respectable thing to do. Being interested in another date increased the odds of genital contact on a male-initiated date, which is counterintuitive to the relational standard, which would dictate that sexual activity is withheld if there is interest in pursuing a relationship. While it is possible that respondents retrospectively identified being interested in another date to justify whatever sexual activity took place, we cannot be sure. The positive association between interest in another date and genital contact on a male-initiated date may also reflect how sexual boundaries and practices are being negotiated within dating contexts on the interpersonal level in ways we are not yet aware. Sex may serve as an added signal of mutual romantic interest after an interaction has been confirmed as a date and relational intent has been established, whether through verbal cues or as indicated by a man initiating and paying. It would seem, then, that despite the continued practice of certain components of the traditional dating script, with men initiating and men paying on the majority of dates, there is a discrepancy between the recitation of conservative sexual scripts and the sexual practices taking place. Notably, neither the sexual double standard nor the relational standard had a significant effect on whether genital contact took place on a female-initiated date, suggesting that standards for appropriate sexual behavior carry less weight on 1 3 Scripting Sex in Courtship: Predicting Genital Contact in... female-initiated dates. This is further demonstrated by the positive relationship between genital contact on female-initiated dates and being interested in going on another date. Sexual activity may assume different meanings in the context of a female-initiated date. For instance, having sex on a female-initiated date may not be considered a violation of the relational standard because of some agreed-upon mutual interest that takes place outside of the context male-initiated, male-funded date. --- Contextual Negotiations Although women no longer depend on men to invite them out and pay for them, men still initiate the majority of dates. Scholars have suggested that the contemporary adherence to gender roles in dating scripts may be attributed to ambiguity regarding the legitimacy of a date and uncertainty regarding the other person's intentions (Allison, 2019;Cameron & Curry, 2020). Dating most certainly has been influenced by the sexual ambiguity of hookup culture, even if conservative sexual practices are recited alongside traditional dating scripts. Current research often equates "sex" with "hookups" when looking at how sexual activity has been reordered in the courtship process. Sex may still be restricted in the scripted narrative recited by college students, but in actual practice, there seems to be more room for negotiation, especially when the date veers off script. These negotiations start on the interpersonal level of scripting, where expectations for appropriate behavior (the cultural) confront individual desires (the intrapsychic). We can see evidence of these negotiations in our observations of how the relational standard and being interested in another date are differentially associated with nontraditional sexual outcomes. The relational standard for sexual behavior reflects the traditional expectation that sexual activity it limited in contexts where one might seek a boyfriend or girlfriend. Given the date is a context for romantic development, it makes sense that holding a relational standard would be associated with a decrease in the likelihood of genital contact. Being interested in another date reflects a desire to pursue a possible romantic relationship with someone, but unlike the relational standard, interest in another date was associated with an increase in the likelihood of genital contact. We can understand this as evidence of changing sexual norms. Men still initiate and pay for most dates, but when the script is altered in any way, we see significant changes in the sexual processes. So, although the traditional script is still relevant, it is time to examine alternative scripts and their sexual processes. Regarding sexual practices, dates are not as homogenous as recited scripts have led us to believe, and only a minority of dates follow the traditional script completely. The dominant norm isn't the only norm, and this study suggests that what seems to be dominant on the surface, is more diverse than we realized. The further we get from the dating script, the more ambiguous the nature of the interaction and the more nuanced the sexual scripts become. In the case of the female-initiated dates, there is a normlessness when it comes to sexual outcomes. We see that the likelihood of genital contact increases whenever the traditional script is violated. Does veering off the script also reflect more egalitarian practices related to sex? Perhaps we are slowly moving away from these traditional dating scripts in the form of sexual negotiations. In this way, if we attend to the sexual processes of dates, we may find that the traditional dating script is not as enduring as we have come to believe. --- Conclusion This article examines whether genital contact is associated with traditional or alternative components of dating scripts. We examined variations of a dating script and their ability to predict genital contact. This study highlights the variability of sexual scripts in dating practices, suggesting that the sexual scripts associated with dates are not as homogenous or conservative as they have appeared. We cannot assume that traditional date components lead to traditional sexual activities. Scholars have grappled with the enduring relevance of traditional dating scripts despite evidence of increasingly egalitarian views (Lamont, 2014(Lamont,, 2020)). Although we do see gendered patterns in scripted behavior when it comes to the initial logistics of the date (who asked; who paid), it seems like the sexual rules are more contextual, and there may be more room for negotiation than scholarship has previously assumed. Our findings suggest a discrepancy between what college students are saying and what they are doing. The absence of sexual activity on dates relative to hookups has monopolized the focus of discussions about dating and the sexual processes in hookup culture. With the way hookup culture has incorporated casual sex alongside dates in the courtship process, it is important that we attend to how these changes in sexual norms may inform the sexual processes of dates. As research on traditional gender roles in courtship and the stalled gender revolution looks to dating scripts to shed light on gender inequalities, it is crucial to examine the function of sex in dating and to understand what scripts are actually being practiced and what factors may be informing them. --- Limitations and Future Research This study has some limitations that should be addressed and considered when interpreting the results. For one, as previously mentioned, the OCSLS survey data comes from a convenience sample, which means it is a nonrandom sample and therefore not generalizable. With that being said, given the large sample size with a near-perfect response rate, we believe that the data set reflects the attitudes and practices of a significant cross-section of the college student population (Allison & Risman, 2013;Kettrey, 2018;Kuperberg & Padgett, 2017). Extra credit was offered to students who took the survey, which decreases selection bias (Allison & Ralston, 2018). Students took the survey privately online, which "decrease[s] desirability bias and improve [s] the validity of responses" (Allison & Risman, 2017:480). --- 3 Scripting Sex in Courtship: Predicting Genital Contact in... The respondent's subjective assessment may also present a limitation to this study, given we do not know if the other person on the date would have defined the interaction in the same way. This is especially true of dates that veer off the traditional script. We were also limited to the respondent's most recent date, which is not necessarily representative of their typical dating experiences. Another limitation of this study is that we do not know if the couple has gone on a date (or hooked up) prior to the date in question. Research on dating scripts pays closest attention to first date scripts, though scholars who have examined dating scripts more generally have found similar gendered patterns (Bartoli & Clark, 2006;Lamont, 2020). Future research should consider how the number of previous dates shapes sexual outcomes. For instance, it is possible that first dates follow the cultural expectation for no genital contact, with future dates involving more sexual activity, even if the other components of the date (initiating and paying) remain traditionally gendered before exclusivity. We also do not know how a "date" is being defined. It is generally accepted that dating "implies some level of romantic or sexual interest" (Morr & Mongeau, 2004:7). Beyond that, however, the definition of a date is taken for granted, as dates are often defined in terms of their script components. For example, women report relying on the act of men paying to signal that an interaction is a date (Allison, 2019). The variety in scripts classified as a date by respondents, however, suggests the need for a better understanding of what constitutes a date beyond the traditionally gendered signifiers. Although we do not know the respondent's criteria for what qualifies as a date, we do know that the interaction was classified as a date with someone they were not in an exclusive relationship with. In this study, we limited our analysis to dates where sexual activity occurred. Future research could estimate multinomial logit models to examine the effects of dating script components and attitudes on three sexual outcomes: no sexual activity, petting, and genital contact. This type of analysis may provide a more nuanced understanding of the sexual scripting process. Future research might also consider the different operations of the sexual double standard and the relational standard. Data from the Online College Social Life Survey reported that only 16 percent of surveyed college students held a sexual double standard, in that they indicate they respect women less if they hook up with a lot of people, but not men. Over 70 percent of students held what we call a relational standard, in that they report being less interested in someone as a potential girl/boyfriend if they hook up a lot. The sexual double standard may be less articulated as college students are becoming more likely to recite egalitarian ideals. The relational standard, however, remains pervasive in its influence. In contemporary America, it seems that being chaste matters more for relationship building than reputation building. This distinction between who is considered "respectable" and who is considered "relationship material" is important for understanding the persistence of traditional gender roles in courtship despite increasing egalitarian ideals. Our study sheds light on nuances of the dating script and sexual processes that require additional attention. These questions may become even more important as the dating landscape is shifting within the context of the COVID-19 pandemic. With stay-at-home orders, mask mandates, and heightened safety precautions, dating logistics have been changing and sexual scripts are being reformulated. In the future, we may expect to see an increase in female-initiated dates, as indicated by Kendrick's (2021) preliminary research on pandemic courtship culture, which suggests that women have been more intentional about taking an active role in dating during the pandemic. In highlighting how the sexual processes of female-initiated dates differ from male-initiated dates, our study creates an important point of departure for future research on female-initiated dates. Funding No funding was received to assist with the preparation of this manuscript. --- Availability of Data and Material The original Online College Social Life Survey (OCSLS) was designed by Paula England and the codebook was provided by Jonathan Bearak. The data and survey instrument can be accessed at https:// pages. nyu. edu/ ocsls/ 2010/. Code Availability StataCorp., 2019. "Stata Statistical Software: Release 16." Declarations --- Conflict of Interest The authors have no conflicts of interest to declare that are relevant to the content of this article. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Despite increasing egalitarian values expressed among college students, dating is still characterized by traditional gender roles. Because traditional dating scripts are predominantly recited and enacted to the extent that men initiate and pay, there are assumptions that the sexual processes have not changed. This study investigates the sexual processes of male-initiated and female-initiated dates among college students in the US. Using data from the Online College Social Life Survey, we ask whether traditional components of the dating script explain traditional sexual outcomes (nongenital contact), as well as whether alternative dating scripts explain nontraditional sexual outcomes (genital contact). Using multivariate logistic regression models, we found that violations of the traditional script are associated with higher odds of genital contact for male-and female-initiated dates; however, the predictors of genital contact for female-initiated dates are not the same as those for male-initiated dates. This study highlights the variability of sexual scripts in dating practices, suggesting that the sexual scripts associated with dates are not as homogenous as we have previously believed.

situations such as bullying, or a negative self-concept. Positive and problematic behaviors can coexist, and manifest in diverse ways across youth experiences and in the varied domains that young people inhabit -in schools, in families, with peers, online, and in after-school programs. --- A Positive Youth Development Perspective on Afterschool and Social Media A positive youth development (PYD) perspective suggests that when the strengths of youth are aligned with the assets in their contexts, thriving occurs. PYD has been extensively documented through research about youth development and after-school programs (Geldhof et al., 2014;Smith et al., 2017). In the Five Cs model, positive development is operationalized as competence, confidence, connection, caring, and character (Lerner, 2004). When young people exhibit the Five Cs, they contribute positively to themselves, to others, and to civil society (Lerner, 2004). Ross and Tolan (2021) suggest that digital contexts such as social media also have the potential to be PYD contexts. They indicate that because PYD is focused on this alignment between youth strengths and the context, the digital setting is a context "brimming with opportunity for positive interactions to occur" (Ross & Tolan, 2021, p. 532), and that "digital media shares many of the same characteristics of traditional PYD settings that make them ideal for positive development to occur (e.g., permanence, engaging, interactive, collaborative, and mutually beneficial)" (p. 535). In particular, Ross and Tolan highlight that young people can build their social emotional skills and relationships online. Although measures do not currently exist to capture PYD in digital spaces, it is possible that the Cs can be operationalized in digital settings (Ross & Tolan 2021). For example, youth can demonstrate caring by engaging empathetically with others online (Ross & Tolan, 2021). In the present research we employed the PYD perspective and in particular the relational aspects of caring and connection conceptualized within the Five Cs model to understand the links between youth's inperson and online interactions. --- After-School Activities Shape Social and Emotional Outcomes After-school activities can help adolescents develop the skills associated with positive peer relationships and a healthy sense of self. Research has shown many positive outcomes associated with high-quality activity participation for youth. For example, in a meta-analysis of 68 studies of after-school programs (37% serving middle school youth) that seek to promote personal and social skills in youth, researchers found an association between youth attending after-school programs and increased positive feelings about themselves and their schools, and increased positive social behaviors (Durlak et al., 2010). Russel et al. (2006) reported that middle school programs provided opportunities for identity formation and leadership development which can be helpful to address the transition from elementary to middle school. Russell et al. concluded that after-school programs play an important role in developing youths' social skills and provide a space less demanding than the school day where youth have opportunities to form and sustain relationships. This overview of research associated with activity participation suggests that after-school contexts have the potential to promote social development (e.g., developing relationships, social bonding) and emotional development (e.g., positive feelings about oneself, identity development). Next, we review youth social media use and how social media engagement might also shape social and emotional development for youth. --- Social Media Experiences Like after-school activities, social media use can be related to prosocial behavior within online communities. Despite the perception of mostly negative online experiences, only a quarter of teens (24%) describe social media as a primarily negative experience (Anderson & Jiang, 2018a). In fact, in nationally representative studies of teens aged 13-17 using social media (Anderson & Jiang, 2018b), 81% felt more connected to their friends and 68% of online friends supported them through tough times through social media. There are ways that teens interact online which may shape their social behaviors, and the majority of teens used the Internet as a healthy venue for social interaction (Lenhart et al., 2010). For example, frequent online communication was associated with higher quality friendships (Valkenburg & Peter, 2007), and frequent phone use, email, and messaging is related to increased social competence (Ohannesian, 2014). Adolescents who are doing well socially may also benefit from online activity because it supports the formation of friendships (Kraut et al., 2002;Peter et al., 2005). For example, the stimulation hypothesis suggests that the time that youth spend online involves intimate disclosures which enhances closer friendships (Alison Bryant et al., 2006;Valkenburg & Peter, 2007). Furthermore, interactions through texting and social media have been found to promote a sense of belonging (Davis, 2012). This online communication has also been found to facilitate better self-concept clarity across social situations (Davis, 2013). Finally, social media can improve adolescent social connectivity and sense of belonging as well as provide a forum for self-disclosure and identity exploration (James et al., 2017). This research suggests that rates of problematic experiences online are relatively low, and that the majority of youth are more likely to have positive emotional (e.g., self-concept) and social (e.g., quality friendships) developmental experiences. It is important to acknowledge that like any context in the lives of youth, there is the potential for less desirable youth behaviors and interactions amidst the potential for positive development (Ross & Tolan, 2021). According to Common Sense Media (Rideout & Robb, 2019), 8-to 12year-old youth spent an average of 4 hours and 44 minutes per day on screen media which increases with age, such that 13-to 18-year-old youth spend an average of 7 hours and 22 minutes online per day. Given the average amount of time spent on social media per day, youth often spend more time using digital media than participating in after-school or other supervised programming. Young people's use of social media can span the spectrum of positive to problematic behavior. In a recent meta-analysis of cyberbullying victimization, studies varied quite widely in prevalence estimates (3% to 72%) due to inconsistent definitions and time periods assessed (Selkie et al., 2017). Pew Research (Anderson, 2018) has demonstrated that the more frequently teens are online, the more likely they are to be cyberbullied. Cyberbullying and online victimization has also been related to student experiences in school such as number of detentions, suspensions, and truancy (Ybarra et al., 2005). When measuring recency and frequency, the rate of cyberbullying was rather low (especially compared to in-person forms of bullying). In a population-based sample of 120,000, only one in 20 girls and one in 50 boys experienced cyberbullying (Przybylski & Bowes, 2017). Despite these inconsistent and relatively low rates of cyberbullying, it remains important to document if and how the potential for this risk may exist in the lives of middle school youth. --- Connecting Afterschool With Social Media The research described above suggested that high quality after-school programs can contribute to positive social and emotional outcomes such as better self-esteem, school bonding, and prosocial behaviors (Durlak et al., 2010). Notably, high participation in these programs has been found to influence prosocial behavior (Fredricks & Eccles, 2008). Social media also has the potential to contribute to young peoples' social connectivity and identity development (James et al., 2017). The structures, philosophies, and strategies of after-school activities (e.g., the expectations for positive peer relations) may reinforce standards for positive and supportive interactions on social media, and "in-person" and virtual friends might connect across these two domains. Pragmatically, it is also possible that being engaged in an after-school activity limits the amount of time that a young person has available to check and participate in social media. An alternative is that engagement in after-school activities may facilitate online connections with friends beyond in-person experiences and lead to increased interest in engaging online. Despite the potential for positive engagement in both domains, and in particular the potential for social media to deepen relationships which started in person, research has not yet linked these two domains. In the present research, we were interested in two indicators of afterschool participation and their associations with youth online engagement. First, given that high participation is related to "in-person" prosocial behavior (e.g., Fredricks & Eccles, 2008) we incorporated the amount of time that youth spend in after-school programs to assess whether this type of "dosage" either limits online engagement or enhances youth social and emotional skills. Second, we examined whether youth are connected to their "in-person" peers from afterschool as "friends" online. Given the potential for both positive and problem behavior in the online space, our hypothesis about this indicator was open-ended. Overall, we hypothesized that being a part of after-school activities may be related to more supportive online behaviors due to possible scaffolding that may occur in these programs which typically offer mentoring and structured peer interactions (Eccles & Gootman, 2002). In particular, we focused on outcomes related to seeking support (connecting) and providing support (caring) via social media. Acknowledging the potential for risks online we examined the links between these afterschool indicators and experiencing negativity online. Given the application of a PYD theoretical framework, and existing research documenting the positive and prosocial ways that youth engage online, we expected a positive association between after-school indicators (i.e., social media friends from afterschool, and time in afterschool) with the PYD-focused outcomes, and a negative association with the risky outcome (i.e., experiencing negativity). --- Method Procedure As part of an ongoing longitudinal study of the social contexts and behavioral consequences of adolescent social technology use (Charmaraman et al., 2022;Charmaraman et al., 2020;Charmaraman et al., 2021), middle schools in the Northeastern United States were recruited in 2019 based on varying school enrollment size, Internet accessibility, and diverse racial/ethnic composition. Sites were also selected that had robust after-school and/or sports activity offerings. Upon obtaining approval from the Wellesley College Institutional Review Board, and institution and school district-level permissions, we worked with liaisons in one school and in one district-wide after-school program spanning three schools to distribute informed consent/opt-out forms (in English, Spanish, and Portuguese) to parents through paper flyers, parent email listservs, school e-newsletters, and direct emails. For the Fall 2019 data collection, members of the research team proctored the online Qualtrics survey in person during a prescheduled advisory period or after-school program break lasting up to 60 minutes. Youth primarily used school or after-school program-provided Chromebooks and the survey took about 25-40 minutes to complete. Because survey links were emailed to youth through their Google Classroom or after-school program listserv, those who were absent during the survey administration were able to participate from home. An honorarium was provided to schools for participating as well as gift card incentives to teachers and program coordinators to help with survey recruitment. Youth who participated in the survey were given an embossed pen, snacks (in after-school programming), and were entered into a drawing prize for a chance to win a $25 gift card. --- Participants Participants (N = 1033) in the larger study were in fifth through ninth grades, 49% female, 49% male, and 2% other. Self-reported race was 7% Asian, 10% Black, 19% Latinx, and 48% White. Twenty-three percent of youth received free or reduced-price lunch and 77% did not receive or did not know if they received free or reduced-price lunch. The sample for the present analyses included youth in middle school (Grades 6 through 8) who also responded to the time in activities indicators described below. This selection resulted in 687 participants: 33% sixth, 34% seventh, 34% eighth grade. Ninety-three percent of youth participated in an "after-school" or "sport" based activity. Youth described their gender as 50% female, 48% male, and 2% other. Youth reported their race as 8% Asian, 14% Black, 32% Latinx, 5% Native, 52% White. Twenty-four percent of youth received free or reduced-price lunch, 44% of youth did not receive free or reduced-price lunch, and 33% did not know. --- Measures --- Checking Social Media To indicate how often youth check social media, we asked: "On a typical school week, how often do you check social media (like Instagram)?" Responses were 1 (never/does not apply to me), 2 (every few days), 3 (once a day), 4 (every few hours), 5 (every hour), 6 (more than every hour). The average score for checking social media was 3.50 (SD = 1.92). --- Experiencing Negativity Online (Risks) Experiencing negativity was measured with an average of three items adapted from a scale of Internet harassment developed by Ybarra and colleagues (2007). Youth responded to three items requesting how often a certain online experience happened to them: "You were hurt by someone making you feel left out online," "Someone made a rude or mean comment to you online or by text," and "You were hurt by someone making you feel left out online (including social media, games)" on a scale of 1 (Never) to 5 (Always). The average score for was 1.40 (SD =.54) and <unk> =.77. --- Giving Support (Caring) Youth were asked how often they: "post something to make others feel good," "respond positively when friends share good news," and "try to make friends feel better when they share bad news." These indicators were developed by the project team. Responses ranged from 1 (Never) to 5 (Always). The average score for giving support was 3.27 (SD = 1.14) and <unk> =.82. Online Support Seeking Behaviors (Connection) Support seeking behaviors on social media were measured with an average score of five items, adapted from the Facebook Measure of Social Support (McCloskey, 2015), using subscales Perceived Support and Negative Social Support. Youth responded to five items: "When I am stressed out, I turn to my friends for help on this site," "The support I get on this site makes me feel better," "When I have a need that friends ignore on this site, I'm hurt," "This site makes me feel close to people," and "It's important that my friends like or comment on my posts." Responses were on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). The average score for seeking support was 2.27 (SD =.93) and <unk> =.85. --- Social Media Friends From Afterschool Youth were asked "Who are your friends (or who do you follow) on social media (Instagram, etc.)?" If they selected "Friends from after-school activity or team" they were coded as (1) and compared with youth who did not select this category (0). Fifty-three percent of youth in the present sample were social media friends with peers from their after-school activities. --- Social Media Friends From School Youth were asked "Who are your friends (or who do you follow) on social media (Instagram, etc.)?" If they selected "Classmates in upper grade" they were coded as (1) and compared with youth who did not select this category (0). Similarly, if they selected "Classmates in your grade or younger" they were coded as (1) and compared with youth who did not select this category (0). Forty-five percent of youth reported friends who were older classmates and 59% of youth reported same or younger age classmates. Social Media Friends From Afterschool and PYD 36 as described by researchers and practitioners, however we use this language here because of relevance to ease of understanding for youth. --- Demographics Three demographic indicators were included as covariates in the present analyses. Two gender categories were assessed, female (1) youth were compared to male (0) youth. If youth responses to their gender did not correspond to one of these two options, they were included in the analyses, but their specific gender effects were not sufficiently powered to detect effects in the present analyses. Four race categories were assessed: Black and Latinx and Asian youth were compared to White youth (0). Free or reduced-price lunch participation was used as a proxy for income. Youth who received free or reduced-price lunch (1) were compared to a combined group of youth who were unsure or who did not receive free and reduced-price lunch (0). Finally, youth grade in middle school was assessed continuously: sixth grade (6), seventh grade (7), and eighth grade (8). Demographics and descriptive statistics for all indicators are included in Tables 1234. --- Analysis Plan The purpose of this analysis was to test the hypothesis that there is an association between after-school experiences in terms of time spent in afterschool and having social media friends (SM friends) from afterschool, with youth PYD-related experiences online. Using linear regressions conducted in SPSS (v26), we tested the relationship between after-school experiences (i.e., time in afterschool, having a SM friend from afterschool), and four outcomes. PYD-related outcomes included providing support and seeking support. The risky outcome included experiencing negativity. Checking social media was included as an outcome which could span the categorization of positive or problematic. Covariates were included in this model to account for potential differences in background: race, gender, income, and grade level. Social media friends from school were also included as covariates in order to understand the potential for after-school SM friendships to have a unique role in the way that youth typically interact online. --- Results --- Checking Social Media As shown in Table 1, linear regression suggested that having each type of friend on social media was related to increased checking of social media compared to the group of youth who did not indicate having that type of friend on social media: same/younger age classmates (B =.91, SE =.18, <unk> =.24, p <unk>.001), older classmates (B = 1.00, SE =.18, <unk> =.26 p <unk>.001), and after-school (B =.93, SE =.16, <unk> =.24 p <unk>.001). The amount of time in afterschool was not related to checking SM. In this model, youth enrolled in the free/reduced-price lunch program were also more likely to check social media than those who did not report participation in this program. --- Seeking Support Online Having SM friends from afterschool (B =.27, SE =.10, <unk> =.14, p =.006), and having SM friends who were older classmates were both positively associated with seeking support (B =.35, SE =.11, <unk> =.19, p =.001) when compared with youth who did not report having social media friends from these groups (see Table 2). The amount of time in afterschool was not related to seeking support online. Youth who reported being female and were enrolled in the free/reduced-price lunch program also were more likely to seek support online than male youth and youth who did not report enrollment in free and reduced-price lunch, respectively. --- Providing Support Online Having SM friends from afterschool (B =.38, SE =.11, <unk> =.17, p =.001), and SM friends in the same/younger grade (B =.45, SE =.13, <unk> =.19, p =.001) were associated with providing more support online when compared with youth who did not report these types of social media friends (see Table 3). The amount of time in afterschool was not associated with providing support online. Note. N = 474. SM = social media. a 0 = white, 1= Black, Latinx, or Asian. b 0 = male, 1 = female. c 0 = not reporting free/reduced lunch, 1 = reporting free/reduced lunch. d 0 = not reporting this type of friend on social media, 1 = reporting this type of friend on social media. e time reported in days attended. ***p <unk>.001 --- Experiencing Negativity Online The only indicator associated with experiencing negativity online was having older classmates as SM friends (B =.19, SE=.08, <unk> =.15, p =.020) compared with those who did not report this type of SM friend (See Table 4). Neither after-school indicator (SM Friends nor time in afterschool) was related to experiencing negativity. Note. N = 425. SM = social media. a 0 = white, 1= Black, Latinx, or Asian. b 0 = male, 1 = female. c 0 = not reporting free/reduced lunch, 1 = reporting free/reduced lunch. d 0 = not reporting this type of friend on social media, 1 = reporting this type of friend on social media. e time reported in days attended. **p =.006 --- Discussion The purpose of this exploratory research was to assess the relationship between after-school participation and PYD experiences online. Research has not yet assessed the relationship between these two realms of influence in the lives of youth. The present study showed preliminary evidence that there is a link between youth after-school connections and online experiences, in terms of the peers (i.e., SM friends) that span both contexts. Despite this connection, few after-school programs offer guidance on prosocial behaviors in the digital worlds of youth, recognizing the need for positive reinforcement of social technology use (James, 2013). Prior research has found that frequent checking of social media and online communication is related to both positive and negative online influences (Charmaraman et al., 2018), so this outcome was assessed to better understand the context of social media use. Youth in afterschool programs were checking social media more frequently, which can be either an indicator of feeling connected to one's supportive online networks or the need to browse passively without connecting. The frequency of youth in afterschool checking social media could be due to the fact that increased network size and diversity of contacts would result in more activity to check. Other research has also found that after-school programs use social media to communicate directly with youth (e.g., Ram Lee & Horsley, 2017). In these cases, youth may be checking social media more frequently to keep up with information and interactions from their after-school programs, which informally extends the offline interactions into the online worlds. We found partial support for the hypothesis that after-school experiences would be associated with PYD exhibited by youth online-time in afterschool was not related to PYD online, but friends from afterschool did relate to indicators of PYD online. The finding that the amount of time in afterschool did not relate to any of the tested positive or problematic indicators was contrary to our expectations. This finding suggests that to understand the experiences of youth on social media in terms of afterschool, future research should look beyond solely participation in programming. Anecdotally, afterschool may be considered a way to limit the time youth spend online. However, this idea does not bear out in the current data, with more evidence pointing to the relationships and connections from afterschool being extended in the online environment. Furthermore, it is possible that social media use might be concurrent to attendance in afterschool, and the "boundaries of experiencing being on media and being 'in person' are disintegrating" (Ross & Tolan, 2021, p. 533). The peer relationship-based component of afterschool was related to each of the PYD-related outcomes in the present study. There was a positive relationship between having a SM friend from afterschool with seeking support online (connection), and with providing support online (caring). The association between having SM friends from afterschool and school with both seeking and providing support is consistent with research which suggests that youth who are doing well socially might also be doing well online (Peter et al., 2005), and that social media might be a way for youth to extend and deepen their friendships (Alison Bryant et al., 2006;Valkenburg & Peter, 2007). It is also notable that the present research did not find evidence for experiencing negativity online in relation to having SM friends from afterschool. Rather, the evidence suggests that older classmates outside the after-school environment may contribute to negatively perceived online experiences, which suggests that having older classmates may be a risk factor to consider when counseling youth about their online networks. This finding may, in part, alleviate some protectionist concerns that when youth leave the supervision of an afterschool space, problem behaviors will occur. Our suggestions for future research about afterschool would include a focus on how variation in program practices such as a facilitated supportive environment, and the establishment of peer and community norms within and beyond programming might also shape PYD-related outcomes online. Addition of these types of after-school experiences may also illuminate the non-significant finding related to the amount of time in afterschool. Namely, it might not be only the amount of time in that program, but the quality of time spent in an after-school program, including the ways that quality programs facilitate development of relationships in after-school programs (e.g., Durlak et al., 2010). --- Limitations and Future Directions These findings should be interpreted in light of a few limitations. This research capitalized on an existing dataset to explore how two after-school experiences-amount of time in program and friends from afterschool-might relate to social media experiences for middle school youth. After-school programming also varies widely in focus, content, and structure, and similarly might result in different social media experiences. Future research should explore specific types of programming and their relationship with youth experiences on social media. In addition, although this sample is diverse in terms of demographic indicators, they engaged in problem behaviors at similarly low rates as those in their age group and participated in programs at high rates. Future research should assess the relationship between activity participation and social media in samples that may have less access to after-school activities. Finally, the present research utilized self-report data which may not provide the full picture of youth experiences on social media or in after-school programming. The present research also was conducted before social distancing and remote learning were introduced to schools and after-school programs as a result of the COVID-19 pandemic. During this time, school and after-school programming could have been provided entirely or partially in the digital context. This experience may have changed youth's perception, understanding, and engagement in digital spaces, and is also necessary to document in future research. Furthermore, questions remain about how to assess the rapidly changing digital context. Diverse methods including self-report, observed, and networked methods could be employed. More detailed information about the links between activity participation and social media engagement should be elucidated particularly in the unique cases when after-school activities make intentional efforts to support youth's positive and informed engagement on social media. We hope that this research, though preliminary, provides inspiration for future research. --- Conclusion Taken together, these findings indicated preliminary evidence of a link between after-school activity participation, in terms of friends from SM, and PYD-related social media use. Furthermore, these findings may provide after-school practitioners with ideas on how to develop programming that may provide social role modeling for how their youth connect to peers online. Peer relationship building is a natural part of after-school program environments. Knowing that youth in after-school programs may continue to connect with each other digitally outside of the program time and space may prompt program staff to be more intentional in talking about how (a) friendships carry over to different settings, (b) friends can support each other through different aspects of their lives, and (c) programs can infuse frequent opportunities for peer relationship building. We encourage after-school program practitioners to also take a PYD perspective on digital spaces, given the findings in the present research. They may continue to support these types of caring and connected behaviors online by sharing messaging about engaging with their friends from afterschool in supportive ways in and outside of the program. Future research may take up the unanswered questions that arise from these preliminary findings including what features of activity participation (e.g., adult supervision, hands-on learning, group activities) can shape online peer communities, and how activities and online behaviors can be explicitly linked to foster positive youth development. --- Author Note Research supported by: 1R15HD094281-01 (PI: Charmaraman) Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We have no known conflict of interest to disclose. We extend our gratitude to the youth who participated in this survey, and the youth workers/ educators who helped facilitate recruitment and access. We also acknowledge and appreciate Alyssa Gramajo for project coordination, Amanda M. Richer for data management, and the WCW Writing Seminar for their feedback on this manuscript.

Positive youth development has been extensively documented in contexts such as the family, school, and afterschool. Emerging theory and research indicate that digital contexts such as social media may also be venues through which young people develop skills and attributes associated with the 5 Cs model of positive youth development and thriving. This research attempted to understand if and how middle school youth's in-person and online networks connect, and if they do connect, do these connections relate to engaging in beliefs and behaviors associated with PYD. Results suggest that in this sample, middle school youth include peers from afterschool in their online networks, and those who have friends from afterschool and school engaged in PYD-related social media behaviors at higher rates than those who were not connected to in-person networks. No association was found between the amount of time spent in after-school contexts and any of the positive or problematic social media outcomes in this study. Implications for youth development professionals considering the influence of social media on youth, and next steps for research on after-school activities and social media use of middle school youth are discussed.

Introduction Global migration has led many countries to become multicultural societies (International Organisation for Migration, 2010). Language barriers have been identified as a major obstacle to migrants receiving appropriate healthcare. In Sweden, there is a law (Fo <unk>rvaltningslagen, 1986: 223) stating that people who do not understand or speak Swedish have the right to an interpreter in all contacts with public authorities. In a foreign country, the family can be an important support as many migrants have a limited social network (Giger and Davidhizar, 2008). Health-care professionals often rely on family members as interpreters, although they feel insecure in encounters with families from other cultures than their own (Free et al., 2003;Hultsjo änd Hjelm, 2005;Gill et al., 2011). Individualized and holistic care should focus on the interaction between health-care staff, patients and families. It is important to investigate the families' perspective because family members represent a basic social unit in healthcare. Their involvement is perceived as a source of mutual support, security and fulfilment for the patient. The family member who is a relative of an individual who needs an interpreter in her/his health-care contacts also faces problems in communication when using an interpreter because of the trinity of the individual, family members and health-care providers (Giger and Davidhizar, 2008). No previous study has been found focusing on adults' experiences and describes their family members' use of interpreters in health-care encounters. --- Literature review From the patients' (Hadziabdic et al., 2009) and health-care staff's (Hadziabdic et al., 2010) perspective, the benefits of using professional interpreters were their ability to interpret literally, objectively and without having any relation to the patient. A previous study (Barron et al., 2010) found that patients were unaware that health-care staff could access interpreting services for their health-care consultations. Reliance on family members as interpreters is common in healthcare (Free et al., 2003;Gerrish et al., 2004;Gill et al., 2011). Earlier studies have found that the positive aspects of using family members as interpreters are that they can protect confidentiality within their own communities, offer support in consultations and enable shared understanding of advice and instructions once the consultation is over (Rhodes and Nocon, 2003;Edwards et al., 2005). However, professional interpreters have been found in previous systematic literature reviews (Flores, 2005;Karliner et al., 2007) to be more effective than other types of interpreters in bridging communication barriers. Research on interpreter use in healthcare has previously focused on experiences of using interpreters from the perspectives of health-care staff (etic, outsider knowledge; Rosenberg et al., 2007;Fatahi et al., 2008;Hadziabdic et al., 2010) and patients (emic, insider knowledge; Edwards et al., 2005;Hadziabdic et al., 2009;MacFarlane et al., 2009). However, there are studies focusing on bilingual young people's experiences of interpreting (Free et al., 2003;Green et al., 2005;Yang and Gray, 2008). The youngsters felt that they were being used because of limitations in interpreter services. Family members saw this as part of their responsibilities as family members, concerned about the well-being of the person for whom they were interpreting (Rosenberg et al., 2008). However, no previous studies have been found investigating how adults experience and describe their family members' use of interpreters in health-care encounters when their family member(s) face language barriers in these encounters. The families' perspective is important because health-care professionals provide healthcare to the individual and the family, and healthcare staff face the need to use interpreters in their contacts when they meet language barriers. Examining the family members' perspective gives the opportunity for etic (outsider) knowledge of the use of interpreters in health-care encounters. Therefore, it is best to examine the variations and similarities of experiences that exist in family members' experiences of the use of interpreters in order to supply the missing piece to ensure a holistic view of all parties involved in the health-care encounter. The family's expertise and involvement must be recognized, acknowledged and used throughout the health-care process. Furthermore, this study contributes to the increased knowledge and understanding of interpreter use in healthcare and the implications this has for healthcare, such as improved health-care outcomes and lower costs for healthcare through the tool of improved communication (Giger and Davidhizar, 2008;Leininger and McFarland, 2006). --- Aim The aim was to explore adults' experiences of their family members' use of interpreters in health-care encounters. --- Method --- Design An exploratory qualitative approach was adopted. Focus groups were used for data collection as the group process enables members to express views that might not have been disclosed in an individual interview (Krueger and Casey, 2009). --- Participants and procedure Purposive sampling was used to ensure a range of participants differing in age and educational level and representing different perspectives (Krueger and Casey, 2009). The study included adult individuals who had Serbo-Croat (Bosnian/Croatian/Serbian) as their native language, and who had accompanied a family member and thus experienced the use of an interpreter in health-care encounters from a family member. The reason for choosing this migrant group was that individuals from former Yugoslavia constitute the second largest group of migrants living in Sweden (Sveriges Officiella Statistisk (SCB) 2009). Representatives of migrants' associations for former Yugoslavians in south Sweden, localized in an immigrant-dense region, were contacted to invite people to participate. A time was set for an information meeting. All participants also received written information, about the aim of the study focusing on the use of an interpreter in health-care encounters from their perspective as a family member, on the implementation of the study, and stating that participation was voluntary. Written information was given in Swedish and Serbo-Croat and the first author's contact details, together with a prepaid envelope. Those interested in participating sent their address to the first author who contacted them to set a time and place for the interview. Two men and eight women, aged 29-61 years (median 45 years), length of residence in Sweden 12-18 years (median 17 years) with different educational levels, seven with high school level and three with university educational level had participated in the study. All were refugees, born in former Yugoslavia and with valid residence permits. Three focus-group interviews with 10 individuals were conducted. Two groups comprised female participants and the third group had two men and one woman. --- Data collection Data were collected between May and September 2009. A semi-structured interview guide was used as a prompt to encourage discussion (Krueger and Casey, 2009), on the basis of a literature review and experiences from previous studies (Hadziabdic et al., 2009;Hadziabdic et al., 2010). The interview guide was translated into Serbo-Croat to improve the quality of the information received and to increase reporting within the group (Hennink, 2007). As preferred by informants, all interviews were conducted in Serbo-Croat by the same investigator (first author) who was a native speaker, thereby reducing communication barriers (Hennink, 2007;Krueger and Casey, 2009). Examples of questions in the interview guide were: How did you perceive the use of interpreters for your near ones? What functioned well? What functioned less well and why? Written informed consent, including information about the voluntary nature of participation and assurance of confidentiality, was obtained before the interviews. Thus, the participants were informed again that the focus was on their family members' use of interpreters in health-care encounters and about the implementation of the study. The first focus group was held to test the interview guide and the role of the moderator (Hennink, 2007;Krueger and Casey, 2009). The focus group turned out well and the data were found to be of good quality, requiring no corrections, and were therefore included in the analysis. The focus groups took place in a setting chosen by participants in a secluded room at an immigrants' association for former Yugoslavians, in an office at the first author's workplace and at one informant's workplace. The moderator conducted the focus-group discussion with participants and made field notes immediately after the sessions to recall the group discussions (Hennink, 2007). Mini focus groups (mainly three participants) were used in order to make it possible for the moderator to take notes and observe the group interaction (Krueger and Casey, 2009). These notes described topics discussed, impressions of the topics discussed, interaction patterns and group dynamic and level of participation. Non-verbal communication was also registered. Each session lasted about 1 h and included three to four individuals. The interaction in each group was lively, with knowledge transfer and supportive communication. Body language was noted, demonstrating active engagement. The interaction in the focus-group interviews was particularly intensive while discussing literal interpretation and interpreters' nationality. Interviews were audio taped, transcribed verbatim and then translated into Swedish by the first author. The translation was checked by a professional translator (Hennink, 2007: Squires, 2008) and showed high agreement. --- Ethical considerations Swedish law (SFS, 2003: 460) was followed. Written informed consent was obtained from the participants (World Medical Association Declaration of Helsinki, 2008). To preserve the confidentiality of the data, the tapes and transcripts were anonymized and coded by number. The analysis and presentation of the data were carried out in a way that concealed the participants' identity. Participants could withdraw from the focus groups at any time without explanation. All data were stored in a locked space to which only the first author had access. To preserve the confidentiality of the participants, they agreed that discussions held within the group should be confidential and not be shared outside it. The first author pointed out that she could not guarantee that others in the group would maintain confidentiality. --- Data analysis Data analysis was performed as described by Krueger and Casey (2009), as this method considers the influence of interaction in the group, to identify patterns and discover relationships between ideas. The data sources included field notes, summary expressions and verbatim discussion. Analysis of data proceeded simultaneously with data collection until no new information emerged. Analysis started with notes directly after the group interviews about what the informants said and the interaction in the group (see Table 1; Krueger and Casey, 2009;Morgan, 2010). Thereafter, the text from field notes and interviews was read several times to give a comprehensive picture of the data. The text was coded and opinions with similar meanings were grouped in subcategories according to their differences and similarities. The process of grouping codes assisted in developing an understanding of the patterns in the data. Comparisons were made during the whole analysis between subcategories and the text as a whole. When no new information appeared, subcategories with similar meanings were combined into categories (Krueger and Casey, 2009). --- Rigour Investigator triangulation was used to validate the findings (Patton, 2002). The first author performed the analysis and established subcategories. Categories were checked and discussed with the co-authors to ensure that they agreed with the interview material. Quotations were used to illuminate the results and to verify the categorization to ensure conformability (Patton, 2002). To increase the credibility, analysis proceeded to the point where no new information was obtained. This was reached after three focus-group interviews, as Krueger and --- Findings Three categories -(1) Experiences of the use of professional interpreters; (2) Experiences of being used as an interpreter; and (3) Experiences of what needs to be improved when using interpreters -were identified from family members' experiences of the interpretation situation with the respective subcategories (Table 2). The second category, the experiences of being used as an interpreter, was an incidental finding stated by the majority of the respondents. --- Experiences of the use of professional interpreters --- Communication aid Some participants found the use of professional interpreters beneficial for their relatives. They felt that a professional interpreter ensured a literal transfer of information and privacy during an intimate/sensitive examination. Furthermore, they valued the existence of a law to ensure them the same right to correct information as native Swedes in contacts with healthcare. This inspired trust among family members in supporting their relatives in matters relating to healthcare. I appreciate that he /professional interpreter/ interpreted word-for-word from Swedish to Bosnian (I:2:1). Whatever your condition y in Sweden you have the right to phone and ask for an interpreter (I:3:1). Some family members disliked their loved ones using professional interpreters, because the interpreters could give information they did not want the patient to hear, especially bad news. They related this to generational and cultural issues in their home country. there's still the old idea that you shouldn't say it directly to y patients y you tell the family (I:3:4). Trust in professional interpreters depending on their education, gender, language competence and national background The participants perceived that professional interpreters' education, skills in both languages and medical terminology increased their trust in the interpreters. Other essential factors were same gender as the patient, wearing non-provocative or neutral clothes and being of the same age. The interpreters' professional attitude was important, shown by their behaviour towards the patient and the ability to keep the code of confidentiality. Continuous use of a particular professional interpreter and face-to-face interpretation were felt to give security for their near ones. it /the professional interpreter's sex/ is significant for elderly women in gynaecological examinations. y For elderly men if a young girl comes to interpret for them, they might feel uncomfortable (I:2:2). y/The professional interpreter/ should be properly dressed. You can't come dressed just any way, for example with dirty, wrinkled and torn clothes (I:1:3). y /The professional interpreter/ comes and introduces himself and behaves professionally towards you, observes confidentiality and also informs you about professional secrecy (I:2:1). There were informants who found it important that the patient and professional interpreter had the same origin and the same native dialect. It was the language that conveyed about the national background. They suspected the professional interpreter's objectivity if he/she had a strong national agenda and doubted whether the patient answered honestly in those interpretation situations. y it depends on the interpreter's nationality y it can feel a bit uncomfortable y Whether he interprets everything or not and the patient doesn't understand Swedish, and it can happen that he interprets subjectively (I:1:2). Some of the informants did not trust the professional interpreter to maintain confidentiality. They felt that there was no guarantee that the interpreter would not take advantage of the information given during the consultation. --- Modes of interpretation depending on the situation The informants stated that modes of interpretation were dependent on the care situations, the patient's age and gender. Using telephone interpretation, family members or bilingual health-care professionals as interpreters could be advantageous in sensitive matters, as they felt the patients trusted these modes more. In relation to mental health, some accepted an unknown professional interpreter, which gave the opportunity to remain anonymous on subjects that were difficult to talk about. Using telephone interpretation was considered a good alternative for young people. It /the mode of interpretation/ depends on the disease. y when it comes to sensitive Health-care staff's adaptation of language to patients' preferences needs to be improved when Better collaboration between patient, professional interpreter and healthcare using the interpreters Developing the professional interpreter's professional attitude things that the people find it hard to talk to strangers about, it's better to have bilingual health care staff if they're available. y then you know that the information won't go any further and that a psychiatrist can't pass the details to others (I:1:1). The informants perceived that the family members predominantly preferred a face-to-face professional interpreter as it enabled observing body language. The interpreter's professional attitude and good language skills were also factors that helped ensure adequate treatment for their relatives, especially regarding bad news. a /professional/ interpreter on the spot is better because if you're with the doctor and say ''It hurts here'' /pointing at the body/ y feel more trust when y you can see through his reactions y it's better to have a professional interpreter who can express himself better so that the patient will understand better (I:2:3). The potential influence of negative personal feelings between patient and professional interpreter could be a risk when using face-to-face interpreters. Family members as interpreters were perceived as a disadvantage because of their limited language knowledge, and also as it could have negative effect on the family member's work and private life, when she/he was obliged to follow the patient to different encounters. There were also negative experiences of the use of bilingual health professionals because they were perceived as not interpreting objectively and because interpreting was not part of their work assignment and therefore was regarded as stressful for the staff. Informants felt that on unexpected visits their relatives seldom had access to a face-to-face professional interpreter. In those cases, the health-care staff expected accompanying family members to interpret or use telephone interpreters. However, face-to-face professional interpreters were mostly used when visits were planned. --- Importance of professionalism According to the participants, the ideal qualities of a professional interpreter were skill in languages and medical terminology, and ability to adapt to different dialects. Most of the informants emphasized that the professional interpreters need to have a professional attitude by being polite, introducing themselves and showing empathy. Some considered that a professional interpreter wearing neutral clothes and of middle age could improve an interpretation situation. ythe /professional/ interpreter should introduce himself, /be/ normally dressed, talk both languages fluently (I:2:1). y master the terminology used in examinationsy (I:1:1). --- Professional interpreters' different roles Informants felt that the professional interpreter had an important role as a communication aid. There were informants who found it important that professional interpreters transfer the information literally and objectively, even regarding bad news, for example a cancer diagnosis. Others considered that professional interpreters should adjust the interpretation to the patient's age, hearing and educational level. y the /professional/ interpreter should not translate word-for-word but should adapt the information to a level that old people understand. There are some who don't hear well, don't see well, don't understand well, someone not well enough educated who thinks that certain words are too complicated and someone who thinks that some words are shameful and shouldn't be used (I:3:4). Most informants felt that the professional interpreter could also have an important role in helping patients with practical matters such as meeting the patients at the entrance and getting to know them. Others approved the current policy forbidding professional interpreters to have any contact with the patient outside the interpreter situation, so that their role as family member was to help with practical matters and not interpret. --- Problems with the use of professional interpreters Participants found it problematic that healthcare staff did not book professional interpreters or ask for patients' wishes about the use of aprofessional interpreter, and that they expected the accompanying family member and/or bilingual health-care staff to act as an interpreter. The health-care staff's unwillingness to book professional interpreters was related to economic issues, in their opinion. Other factors that were perceived as problematic were professional interpreters who broke off the consultation prematurely. ythat they /care staff/ just don't want to book /professional/ interpreters. y that it's because of the cost, how they can best save money. Nobody has even asked if my mother needs an interpreter ysomeone from the family has come and can act as interpreter (I:2:1). it has happened that he /professional interpreter/ apologized for having to end a conversation because he had to go to the other side of town to interpret for others (I:1:3). --- Lack of information about the availability of a professional interpreter Sometimes informants found that written information sent to the patients' home did not state whether a professional interpreter was booked. The family members then had to ensure that a professional interpreter would be present during the consultation. when he /patient/ is called y I phone to check if an interpreter has been ordered. It sometimes says in the letter that an interpreter is ordered but not always (I:1:3). --- Experiences of being used as an interpreter An incidental finding, but one stated by the majority of the respondents, was the experiences of being used as an interpreter. --- Practical and emotional support Informants discussed a number of benefits deriving from interpreting experiences. There were emotional benefits in enjoying helping the family and having their interpretation skills trusted more than an unknown interpreter. They valued the opportunity as interpreters to obtain more information as they were able to ask additional questions, share understanding of advice and give practical and emotional support during/ after the consultation. ywhen I interpret for my mother I find out much more than when it's a professional interpreter y because I'm the one who asks questions, not my mother (I:2:1). There were also disadvantages of interpreting: it was a great responsibility, it takes time from their work and family life and it was difficult to ensure complete information transfer because of limited language skills (Swedish/medical terminology). Moreover, there were negative emotional consequences. Some participants felt that they could not be objective and transfer complete information. Others reported that some consultations involved sensitive information, difficult to interpret because they could be blamed for holding the ideas expressed by health-care staff. y feels great responsibility y must learn certain words in Swedish that you don't use every day (I:1:1). I can't be there to interpret every time it's needed. Although I try, leave work early, organize it somehow so the children don't have to be there. But there have been situations when I was forced to have my children with me (I:2:1). For example my father-in-law had diabetes and y I interpreted for him about what he could eat or not. I get the feeling that he didn't like me telling him, as if it was me forbidding him to eat things (I:3:2). --- Family members' conflicting roles Family members discussed their role of interpreting negative news. Some felt that it was important to ensure literal transfer of information to their relatives because it was the law, and the health-care staff expected them to do it. Those situations were perceived as emotionally difficult and they wished not to be used as interpreters. Others felt it was their duty not to transfer all information but to adapt it to patients in a gentler way. They explained that it was related to a generational and cultural issue from the home country where the older people were not comfortable with such statements. Further, they stated that it was emotionally difficult to pass negative news on to relatives as it might upset them. The informants who adapted the information in the interpretation situation preferred being interpreters for their near ones. ycould never interpret a cancer diagnosis for someone close to me y would put it in a milder wayy older people are not used to the direct way of expressing a message like that (I:3:4). But according to the law y you have to interpret word-for-word (I:3:1). Participants considered that they could be more objective in their interpretation when they interpreted for persons with whom they had no close emotional ties. --- Experiences of what needs to be improved when using interpreters Health-care staff's adaptation of language to suit patients' preferences It was suggested that, to facilitate professional interpreter use, health-care staff must ensure that both the interpreter and patient have correctly understood the information. This could be done by health-care staff using easy Swedish and simple medical terminology and by talking slowly. A doctor can y try to explain to a /professional/ interpreter in simpler Swedish (I:1:2). There were also desires that health-care staff should not expect family members to act as interpreters in all care situations and that they should ask about the patients' preferences. --- Better collaboration between patient, professional interpreter and healthcare The participants wished that professional interpreters should be employed permanently to ease availability and access. They also suggested that it would be better to clarify the policy for when and how bilingual health-care staff should be used as interpreters. Other suggestions included written information in both languages in the letter that patients received at home, better cooperation with other care institutions, better accessibility to professional interpreters and continuity in the use of professional interpreters. Furthermore, better documentation of the patient's communication status, including the appropriate language and practical help such as booking a taxi was important. Someone suggested developing an agency for non-Swedish-speaking patients where they could turn for help in booking interpreters. y that there is better contact with home help, y that /professional/ interpreters are available (I:2:1). important that GPs write that the patient also needs help to get from home to the hospital (I:1:2). There should be a single number that they [patients] can call to get an answer in their own language so that they themselves can talk. y Mostly you have to be able to speak Swedish yourself to be able to book a /professional/ interpreter (I:3:4). --- Developing the interpreter's professional attitude It was emphasized that, to facilitate communication with patients, professional interpreters should be trained in the native language and how to encounter different people. Further, the professional interpreter should ensure that information is correctly understood by patients, and meet the patients before consultations to get to know each other. The professional interpreter should be available at the appointed time and throughout the consultation. yafter every conversation you should ask the patients if they have understood everything, to be able to talk more with the doctor about it. y that they /professional/ interpreters/ should do that, it ought to be their duty (I:1:3). ythere should be enough time set aside for the patient. y both patient and /professional/ interpreter should come at least fifteen minutes earlier, if they are meeting for the first time y to make contact and get to know each other (I:1:1). --- Discussion This study is the first investigation focusing on experiences of a near one's use of interpreters from adult family members' perspective. The main findings were that there was great variation in family members' experiences of using interpreters for their near ones. Family members had different views about whether the professional interpreter should interpret literally or not, the type and mode of interpretation and the interpreter's professional role. In situations where they were used as interpreters, family members felt their role was to act as practical and emotional support, which could lead to both positive and negative emotions. The experiences of interpreting were related to the nature of the consultation. For some participants, literal transfer of information was essential in all consultations. Others did not want their relatives to have bad news translated, which was related to generational and cultural issues. It was an interesting finding when people from same culture perceived this differently. This study was based on individuals from former Yugoslavia of differing age and educational status but with similar migrational and socio-economic status. The degree of individuals' acculturation and educational levels may influence their health-care needs (Berry, 1997) and experiences of the use of professional interpreters. However, more studies are needed to investigate whether this may be because of acculturation and whether the findings also apply to other migrant groups. Thus, some informants' desires were contrary to the Swedish Health and Medical Services Act (SFS, 1982: 763), which states that patients need to be fully and directly informed about serious health conditions, and contrary to professional guidelines in Sweden (Kammarkollegiet, 2010), which state that professional interpreters should translate literally. Culture has an impact on how people respond to illness. In all countries, the model of healthcare, social policy and health education is strongly influenced by cultural and religious factors (Giger and Davidhizar, 2008). It is common in many countries not to convey negative news directly to the patient and inform the family instead (Blackhall et al., 1999). This is important to consider in interpretation situations where there is a difference between what is stated in health-care laws, which aim for patient autonomy and cultural groups, where patient autonomy may be seen as harmful. The professional interpreter's use of the right dialect, associated with his/her origin, was important for having trust in the process. This finding was in contrast to earlier studies of patients' (Hadziabdic et al., 2009) and health-care staff's perspectives (Hadziabdic et al., 2010), where professional interpreters' dialect was not related to the ethnic origin of interpreters except insofar as it ensured better understanding. The professional interpreter's use of dialect was important for some informants and might be because of history. Besides the alphabet, Serbo-Croat languages differ in vocabulary, grammar and intonation (Resic, 2006). The dissimilarities between family members' and patients' perspective may be because of the different roles they have during the consultation; this was not directly compared in this study and needs to be further studied. Trust between parties in interpreter consultations is essential as a prerequisite for effective communication and to provide quality care (Greenhalgh et al, 2006;Robb and Greenhalgh, 2006;Rosenberg et al., 2007). Furthermore, other personal qualities of professional interpreters discussed by participants were similar to the patients' (Edwards et al., 2005;Hadziabdic et al., 2009) and health-care staff's (Hadziabdic et al., 2010) preferences. In Sweden, there is a legal right (Fo <unk>rvaltningslagen, 1986: 223) to access an interpreter in all encounters with public authorities. The recommendation is to use licensed health-care interpreters particularly trained for this (Kammarkollegiet, 2010). However, the incidental finding suggests that there will always be some situations in which family members contribute as interpreters in healthcare. The duties of the family members in interpretation situations were perceived differently by informants. There was disagreement regarding the role of the family as interpreters, especially in the delivery of bad news. This was in contrast to patients' wishes for literal interpretation (Hadziabdic et al., 2009). In previous studies (Rosenberg et al., 2007;Fatahi et al., 2008;Hadziabdic et al., 2010), health-care professionals were suspicious of the ability of family members as interpreters in conveying essential information to migrant patients and family members, as the interpreters focused on the well-being of their near ones (Rosenberg et al., 2008). This study's finding is in agreement with previous findings (Ho, 2008) that judgements of family members as interpreters should be made on a case-by-case basis, as they may have varying abilities to interpret for their near ones. It is important that health-care staff allow patients and their families to decide an acceptable level of involvement on the basis of the trust patients have in family members as interpreters. However, in the first instance, the health-care staff should explore patients' wishes through the use of an independent professional interpreter. Participants in this study experienced an emotional disadvantage with the interpreter role for their family members. It had a negative impact on their social life and they wanted their relatives to receive social support in the form of practical support and information from different healthcare institutions, which has not been previously described. Health-care staff need to examine family functions in relation to families' social properties to meet their wishes (Giger and Davidhizar, 2008). Social support from healthcare services could be very important in maintaining and promoting the health of participants and their relatives (Debs-Ivall, 2007). Additional support, in the form of increased collaboration between different health-care institutions, is also warranted to facilitate appropriate healthcare for foreign-born people (Debs-Ivall, 2007). The limitations and potential dangers of family members as interpreters include lack of familiarity with medical terminology, misrepresentation, translation errors, a tendency to summarize or omit data, subjectivity and ethical conflicts, as also found in young people's experiences of interpreting (Free et al., 2003;Green et al., 2005;Yang and Gray, 2008). Finally, an interesting finding was that the informants felt that health-care staff did not ask about either the patient's wish for a professional interpreter or the family members' wish to interpret. This is contrary to the Swedish Health and Medical Services Act (SFS, 1982: 763) and World Health Organization (WHO) (1994) recommendations in which the main goal is individualized care and autonomy. Health-care staff are required to involve the patient in the decision process and avoid placing a family member in the emotional position of conveying devastating news to a family member (SFS, 1982: 763). It is essential that both the patient's and the family's voices be heard to achieve communication and good patient care and autonomy. --- Limitations and strength of the study Our study is limited because of the number of participants; only 10 people took part and of these only two were men. The collection and analysis of data in the study proceeded until no new information was added (Krueger and Casey, 2009). The study attempted to recruit an equal balance of men and women, withoutsuccess. However, in Europe, it is mostly women who are involved in the care of their family members (Socialstyrelsen, 2006), as represented by the participants in this study. The difficulties of running a mixed-gender focus group, for example the peacock effect (Krueger and Casey, 2009), could also be viewed as a limitation in this study. Men have a tendency to speak more frequently and with more authority when in groups with women, which might lead to limited possibilities for women to express their views (Krueger and Casey, 2009). However, there were no signs of dominance as the interaction in the group was lively, all expressed themselves in an equal way and after the analysis of the three groups, no new information was added to the data. One limitation of this study could be that there was no assistant moderator during the focus-group interviews, for practical and financial reasons. Therefore, a mini focus-group design (three to four individuals) was chosen to make it possible for the moderator to facilitate the group process and also to take notes about the interactions during and after the interview (Carey, 1994;Krueger and Casey, 2009). Mini focus groups also eliminated the risk of frustration resulting from participants not having enough time or opportunity to express themselves in larger groups. An effort was made to minimize the effect of the absence of an assistant moderator. Furthermore, allowing participants in focus groups to respond in their native language increased their comfort level with the moderator, who had a similar cultural and linguistic background, which also helped to maximize the quality of data (Squires, 2008;Krueger and Casey, 2009). Otherwise, the disadvantages could be that it limits the total range of experiences because the group was smaller. A group with fewer participants will have fewer total experiences than a larger one; conversely, larger groups work well when the participants do not have a lot of knowledge about the topic (Krueger and Casey, 2009). However, the outcome depends more on the involvement of the participants in each group and their interaction than on the actual number of participants (Krueger and Casey, 2009). When having an exploratory aim one should run groups of smaller size, as the prime objective is to obtain the maximum

The aim was to explore adults' experiences of their family members' use of interpreters in health-care encounters. Background: Language barriers are a major hindrance for migrants to receive appropriate healthcare. In a foreign country, family members often need support in care of migrant patients. No previous studies focusing on adult family members' experiences of the use of interpreters in healthcare have been found. Method: A purposive sample of 10 adult family members with experiences of the use of interpreters in health-care encounters. Data were collected between May and September 2009 by focus-group interviews and analysed with qualitative analysis according to a method described for focus groups. Findings: Three categories emerged from the analysis: (1) Experiences of the use of professional interpreters, (2) Experiences of being used as an interpreter and (3) Experiences of what needs to be improved when using interpreters. The main findings showed no agreement in family members' experiences; interpretation should be individually and situationally adapted. However, when family members acted as interpreters, their role was to give both practical and emotional support, and this led to both positive and negative emotions. Use of simple language, better collaboration in the health-care organization and developing the interpreters' professional attitude could improve the use of professional interpreters. The type of interpreter, mode of interpretation and patient's preferences should be considered in the interpretation situation. In order to achieve high-quality healthcare, health-care professionals need to organize a good interpretation situation case-by-case, choose the appropriate interpreters with the patient in focus and cooperate with members of the patient's social network.

ey, 1994;Krueger and Casey, 2009). Mini focus groups also eliminated the risk of frustration resulting from participants not having enough time or opportunity to express themselves in larger groups. An effort was made to minimize the effect of the absence of an assistant moderator. Furthermore, allowing participants in focus groups to respond in their native language increased their comfort level with the moderator, who had a similar cultural and linguistic background, which also helped to maximize the quality of data (Squires, 2008;Krueger and Casey, 2009). Otherwise, the disadvantages could be that it limits the total range of experiences because the group was smaller. A group with fewer participants will have fewer total experiences than a larger one; conversely, larger groups work well when the participants do not have a lot of knowledge about the topic (Krueger and Casey, 2009). However, the outcome depends more on the involvement of the participants in each group and their interaction than on the actual number of participants (Krueger and Casey, 2009). When having an exploratory aim one should run groups of smaller size, as the prime objective is to obtain the maximum amount of information (Tang and Davis, 1995). There was lively interaction in the focus groups, and after three groups had been analysed, no new information was added to the data. The study provides a deeper understanding of the studied topic, and as the results were carefully collected and analysed they may be transferred to other settings or groups with similar characteristics (Krueger and Casey, 2009). Participants were from former Yugoslavia, of differing age and educational status but with similar migrational and socio-economic status. The slight differences between the informants' backgrounds may have the result that some family members felt less confident and were afraid to express their views. However, there were no indications of this during the focus-group interviews. The ability to communicate in the group was supported by the openness of informants while discussing sensitive topics such as the interpreter's nationality. Cross-language research has the potential for altered meaning (Squires, 2008); the use of interpreted data must be noted as a limitation in this study. However, the translation of data was checked by a professional translator for accuracy in the transcriptions (Hennink, 2007;Squires, 2008). Another limitation might be that the interviews were held at different venues, after participants' desires. In our study, the venue for the focus groups needed to be both neutral and socially acceptable to participants. However, the venues were accessible and easy to find, neutral and quiet so that participants were not likely to have needed to explain their reason for their presence (Krueger and Casey, 2009). The strength of the investigation was that focus groups worked well with the current population through the good interaction and group climate during the interviews. --- Conclusion The findings emphasized that there was no agreement in family members' experiences of their near ones' use of interpreters; instead it depended on the situation and the individual. Perceptions differed as to whether the interpreter should interpret literally or not, the type and mode of interpretation, the interpreter's professional role and the families' roles when used as interpreters. Family members desired to adapt interpretation to the patients' preferences, the nature of interpretation and their own satisfaction with interpreting for near ones. --- Implications for nursing practice Health-care professionals need to be aware of different family members' views about interpreting literally and objectively. It is vital in individual care planning to provide information about the patients' right to an interpreter and to ascertain individual preferences. Nurses need to organize a good interpretation situation with the patient's active involvement and choose the appropriate interpreter according to the nature of the interpretation, the patient's preference and family members' satisfaction with interpretation for their near ones. Health-care professionals also need to be able to cooperate with members of the patient's social network to ensure communication and retain autonomy in patient-centred and highquality healthcare.

The aim was to explore adults' experiences of their family members' use of interpreters in health-care encounters. Background: Language barriers are a major hindrance for migrants to receive appropriate healthcare. In a foreign country, family members often need support in care of migrant patients. No previous studies focusing on adult family members' experiences of the use of interpreters in healthcare have been found. Method: A purposive sample of 10 adult family members with experiences of the use of interpreters in health-care encounters. Data were collected between May and September 2009 by focus-group interviews and analysed with qualitative analysis according to a method described for focus groups. Findings: Three categories emerged from the analysis: (1) Experiences of the use of professional interpreters, (2) Experiences of being used as an interpreter and (3) Experiences of what needs to be improved when using interpreters. The main findings showed no agreement in family members' experiences; interpretation should be individually and situationally adapted. However, when family members acted as interpreters, their role was to give both practical and emotional support, and this led to both positive and negative emotions. Use of simple language, better collaboration in the health-care organization and developing the interpreters' professional attitude could improve the use of professional interpreters. The type of interpreter, mode of interpretation and patient's preferences should be considered in the interpretation situation. In order to achieve high-quality healthcare, health-care professionals need to organize a good interpretation situation case-by-case, choose the appropriate interpreters with the patient in focus and cooperate with members of the patient's social network.

Introduction Globally, breast cancer is now the leading cause of cancer accounting for 11.7% of 2.3 million new cancer cases [1]. In 2020, it accounts 7% (0.6 million) of 9.9 million all cancer deaths annually and the second leading cause of all oncological deaths [1]. In the recent decades, while there has been a decline in stomach, cervical and penile cancer, the incidence of breast, colorectal and prostate cancer has been rising [2]. By 2040, there would be three million new breast cancer cases diagnosed annually [3]. The prevalence, incidence and mortality from breast cancer varies enormously within and between the countries [1]. These variations may be attributed to a set of reproductive (early age at menarche, late menopause, childlessness, late childbearing, less breastfeeding), metabolic (weight, height, Body Mass I), lifestyle (diet, lack of physical activity, substance abuse etc.) and environmental and occupational factors (exposure to radiation, shift work involving disruption of circadian cycle etc.) [4][5][6][7][8][9][10]. Besides, advancement of medical technology, availability and accessibility to cancer screening and treatment have increased the diagnosis of this disease and its burden in low-and middle income countries (LMICs) [11]. Deaths due to breast cancer has long term consequences on growth and development of children and social well-being of families as mother, spouse, or daughter [12]. Breast cancer and its treatment deteriorate the physical, mental and functional health of the patient [13,14]. The five-year survival of patients with breast cancer varies from 87% in United States, 84% in China, 83% in Sweden, 62% in Iran, 49% in Malaysia and 44% in Uganda [15][16][17][18][19][20][21]. Co-morbidity, depression among patients with breast cancer is very common including mild depression [22]. Overall, cancer patients have a lower quality of life (QoL). Literature document strong socio-economic gradient of breast cancer screening, prevalence, survival and treatment discontinuation. The breast cancer screening and prevalence are lower among women belonging to low socio-economic status (SES) in LMICs [23,24]. However, the risk of mortality from breast cancer is high among women belonging to low SES [17,25]. The five-year survival rate of women belonging to poor SES was 78.6% compared to 83.8% for high SES [17]. Racial differences in survival of breast cancer are also large [26]. Treatment discontinuation is one of the major factors that affect the span of treatment and disease progression. It is often associated with symptoms exacerbation, relapse, comorbidity, death and higher economic burden at later stage [27]. Financial crisis due to high out-of-pocket expenditure for treatment of breast cancer is the major reason for treatment discontinuation [28]. Women in India are at a disadvantage, not only due to the high morbidity but also due to familial neglect of health care [29]. The disease burden due to breast cancer in India is higher than the world average. In 2020, India with 178,361 new cases (7.9% of global cases) and 90,408 deaths accounting for 13% of global mortality due to breast cancer only [1,30]. Among women in India, breast cancer accounts 13.5% new cancer cases and 10.6% of cancer related mortality [30]. Many of the breast cancer mortality are premature and could have been saved with timely screening and medications [31,32]. The age-standardized incidence rate of cancer among Indian females in 2018 was 90 per 100,000 females per year similar to males (89.8 per 100,000 males per year) [31]. Studies suggest that rising burden of breast cancer in the younger ages needs special focus in terms of reduction in treatment cost, quality management along with improved referral pathway and financial security against the disease. The discontinuation of breast cancer is important as cancer patients often come from outside of the state to get treatment, it primarily affect women in working and reproductive age group, the mortality level is high and there has been rise in risk factors of breast cancer. The economic and social loss due to the disease is numerous to women, mother, children and family and also to the nation. To our knowledge no scientific study on treatment discontinuation of patients with breast cancer examined in Indian context. In this context, this paper examines the socio-economic variation in treatment discontinuation of the patients with breast cancer in a tertiary health care centre in India. --- Data & methods --- Study design The study was a prospective non-interventional study. --- Study site The study was conducted jointly by the Tata Memorial Centre (TMC), Mumbai, India and the International Institute for Population Sciences (IIPS), Mumbai, India. TMC is one of the country's largest and the oldest public sector tertiary cancer hospital and registers more than 50,000 patients annually and IIPS is the leading demographic research and training center in the country. The study was designed by TMC and IIPS and the data collection was carried out at TMC. --- Sample design TMC is one of the leading public sector tertiary care health center in India, located in Mumbai and dedicated to cancer treatment and research. Patients with cancer comes from all over the country and are often referred from other health centres on the country. The total number of patients registered for breast cancer treatment at TMC was 4,518 in 2019, 2,505 in 2020 and 3,588 in 2021. We have selected a total of 500 patients that account for about 8% of the breast cancer patients registered for treatment at TMC between June 2019 and March 2022. Our selection of 500 cases is guided by the fact that it provides enough power for disaggregated analyses of the economic condition of breast cancer patients and captures those treated under private and general category. According to WHO protocol, 200 samples is the minimum requirement for any health study [33]. Assuming 79% of catastrophic health spending by cancer households in India [34] and 95% confidence interval with 5% margin of error, a 255 sample size would require to estimate treatment-related cost. A similar procedure has been adopted in a Lancet study on catastrophic expenditure and treatment attrition among colorectal cancer patients in India [35]. Our sample size is about twice higher than the required sample. On average, 12 to 15 newly invasive breast cancer patients were registered every day in the hospital and 4 to 5 patients were selected randomly. The data was collected on working days only (excluding public holidays and weekends). There was disruption in data collection during March 2020-March 2021 due to COVID-19 restriction. --- Sample collection Two separate questionnaires were developed and canvassed: a household questionnaire and an individual questionnaire. The household questionnaire covered demographic and socio-economic characteristics of a participant's household at the time of registration at TMC. The individual questionnaire collected information on treatment history about current breast cancer diagnosis, treatment history at TMC, detailed record of the direct and in-direct health expenditure for each hospital visits during the entire course of treatment, comorbidities and self-rated health status of patients. Data collection was carried out by three medical social workers appointed in the project on daily basis. The data were collected and stored at TMC server and validated by principal investigators and researchers on weekly basis. The data collection began from June 2019 and followup was continued till March 2022. Although during the planning of the study, it was decided to collect the baseline sample within one year period, but due to COVID-19 pandemic less patients were visited in the facility and hence the data collection timing shoots up to two years. Data were collected for base line and selected questions during each visit of the treatment, at the end of treatment and six months after completion of treatment (termed as 1 st follow up). Often the data collection was contingent on the visit of patients for the services. --- Inclusion and exclusion criteria The following inclusion criteria was set for data collection: • Pathologically confirmed new invasive female breast cancer cases • Intending to receive entire treatment at TMC • Age > 18 years • Patients willing to provide the information. --- The exclusion criteria was as follows: • Inability to follow up • Recurrent or progressive breast cancer cases. --- Follow up Each participant has been followed from their date of registration to their date of treatment conclusion or treatment discontinuation. The date of registration is termed as baseline whereas date of conclusion is termed as endline. An active follow up mechanism was set up to collect information from each of the participant or their accompanying person whenever they visit the facility. --- Censoring We censored the data for 71 patients who had died or discontinued treatment for various reasons and not concluded in study time period. The discontinued patients were categorized in three major groups: discontinued due to death, discontinued due to financial crisis and other reasons (patients defaulted treatment or unable to contact patients). --- Survival time Survival time is calculated at the time between the date of registration of the patients at TMC and conclusion date or date of last treatment just before the discontinuation. --- Other variables A set of socio-demographic, economic and households' variables were used in this study. These are age of the patient, level of education, marital status, financial dependent, health insurance coverage, patient's category, family type, religion, major source of income, household income, household size, place of residence, state of residence, distance from native place. Age at diagnosis of cancer is the difference between date of cancer diagnosis and date of birth of the patient. --- Statistical analysis Descriptive statistics, Kaplan-Meier survival estimation and cox proportional hazard model were used to examine the socio-economic profile and correlates of treatment discontinuation among the patients. Kaplan-Meier (KM) survival estimated the probability of discontinuation of breast cancer treatment. Each survival estimate used number of days under treatment at TMC as measure of time and whether patients discontinued (yes = 1 or no = 0) as the final event (failure). The KM estimate of survival time S(t) is given by: where n i is the number of patients observed at time t i, and d i is the number of patients discontinued at time t i. Cox-proportional hazard model was used to examine the socio-economic correlates of patient's treatment discontinuation at TMC. The model estimates the risk of a patient to discontinue the treatment at time t, given that, the patient continued treatment up to time. The final event of interest for each of the patient was status of their treatment (discontinued = 1 or continued = 0) within the given span of time. The Cox proportional hazard model is specified by: where h i (t i ; x i ) is the hazard function of discontinued patients at time t i to the patients who continued the treatment given the specified set of independent variables denoted as x i. and <unk> i is the parameters to be estimated. --- Ethical consideration The study obtained approval from the institutional ethics committee of the TMC and was registered on the Clinical Trial Registry of India with CTRI No CTRI/2019/07/020142 on 10/07/2019. --- Results Table 1 shows the sample characteristics of 500 patients with breast cancer undergoing treatment at TMC. About 5.6% were under 30 years, 57.4% were between 31-50 years, and 37% were 50 years and older. The youngest age at diagnosis was as early as 21 years. The mean years of schooling were 7 years and over four-fifths of the patients were married and financially dependent. Only 9% of the patients were covered by any health insurance scheme. Majority (85%) of the patients were registered under the general category to get treatment at TMC. The majority of the patients belonged to the Hindu religion (78%), and 52% were from the unreserved social class. More than half of the patients were from outside of the state of Maharashtra. On average, a patient travelled 1,044 kms to get breast cancer treatment at TMC. Half of the patients were inhabitants of rural areas (53%) and 16% resided in urban slums. Of the 500 patients registered for treatment, 429 patients had concluded their treatment at TMC. The socioeconomic variation of the concluded patients almost remains the same as of the baseline. Figure 1 presents the flow chart of the patients discontinued and the reason of discontinuation. About 71 patients discontinued their treatment. Among them 24 patients discontinued due to financial reason, 26 due to deaths and 21 for other reason. A total 429 patients had completed the treatment. S(t) = k i = 1 (ni -di) ni hi(ti; xi) h0(ti) = exp(<unk> i x i ) Table 2 presents the socio-economic variation of the patients who discontinued treatment at TMC. Overall, 14.2% of the patients were discontinued the treatment and deaths (37%) being the major cause of treatment discontinuation followed by financial crisis (34%). A higher percentage of the patients discontinued treatment were over 46 years (15.9%), never attended schooling (25.6%), not currently married (19.2%), treated under general or non-chargeable category (14.9%), diagnosed at stage IV of cancer (46.4%), had atleast one comorbidity (19.7%) and labour as major source of household income (20.2%). Among those who discontinued treatment, death accounts the largest share (37%) followed by financial reason (34%). The highest discontinuation due to financial reason were reported by the households with self-employment (54%), followed by service and pension (32%). The higher discontinution due to death were reported by households with agricultural income (50%) followed by self-employed (39%). Discontinution due to financial reason was higher in urban areas (36%) while, a At TMC, the patients are classified as a) general b) private and c) nonchargeable. During the registration, a patient registers either as a general or as a private patient depending on their ability to pay for treatment. The cost of treatment for private patient category is much higher while the waiting time for availing treatment is much lower than their other counterpart discontinued treatment due to death was higher in rural areas (54%). Figure 2 shows the Kaplan-Meier survival curve for the discontinued patients at TMC with overall survival rate is 85.8%. Patients who sought treatment under general or non-chargeable category had higher probability of discontinuing treatment than the private patients. Table 3 presents the hazard rates of discontinued patients by socio-economic variables. The estimated hazard shows that compared to the patients aged 45 years and below, patients aged 46 years and above were more likely (HR: 1.14, 95% CI: 0.66-1.97) to discontinue treatment. Similarly, patients who are not currently married, had advanced stage of cancer, had at least one comorbidity, belonged to household size 7 and more and from Maharashtra were more likely to discontinue treatment at TMC. On the other hand, patients with education level up to secondary (HR: 0.48; 95% CI: 0.27-0.84) and higher secondary or above (HR: 0.42; 95% CI: 0.19-0.92) were significantly less likely to discontinue the treatment. --- Discussion The rising prevalence of breast cancer is a major public health challenge in India. There is dearth of comprehensive studies on socio-economic and health condition of the patients with breast cancer seeking active oncological treatment and reasons for discontinuation. We document the socio-demographic and economic profile of treatment discontinuation of breast cancer patients undergoing active cancer treatment. The followings are the salient findings of the study. About three-fifths of the patients with breast cancer were under 50 years and the median age was 47 years. This is suggestive that majority of the patients are in child bearing age and a significant proportion are in prime child bearing ages (30% under 40 years). Cancer to young mothers has adverse implications on child breast feeding, rearing and caring of children. Besides, over 90% are under 60 years of age suggesting that it may adversely reduce the work potential. These findings are consistent with literature suggesting that the average age is low compared to developed countries; more than 50 years in USA and Europe [36,37]. We found about 14% discontinued treatment and the discontinuation was significantly higher among poorer women, less educated and older women. The discontinuation is primarily due to three reasons; death, financial crisis and defaulted. During two-year period, 5% discontinued due to financial crisis and 5% died. The survival rate was little higher as it was for two-year reference. Studies suggest five-year survival rate ranging from 20 to 80% in India [21]. The discontinuation of services due to death was higher among poor, less educated and those in higher stage III/IV of breast cancer. Studies suggest that half of the incidence and mortality of breast cancer is under 50 years in countries with a lower Human Development Index (HDI) [38][39][40]. Discontinuation of services due to financial reason were also higher among poor and less educated. Our findings suggests that the economic condition of majority of the patients with breast cancer was poor. Over 86% patients were treated as general or non-chargeable cases. Moreover, during the COVID-19 pandemic the financial situation of most of the patients worsened significantly [41]. Our study also showed that more than half of the patients travelled from outside of the state. Distance is an important factor for cancer patients to continue treatment as they have to make frequent visits to the hospital during the course of treatment [42]. Studies also suggest that distance is negatively associated with the stage of diagnosis, appropriate treatment and outcomes, and quality of life [41,[43][44][45]. Distance majorly contributes to the increased cost of travel and arranging accommodation close to the hospital. The effect is more prominent for patients coming from rural areas. Cancer treatment facilities in India are limited in number and mostly metro-city centric. The socially and economically disadvantaged population from rural areas faces numerous challenges in access to cancer treatment. Patients from remote and rural areas travel long distances for treatment, which has a significant effect on their economic and health status. Health insurance plays a significant role in reducing financial burden. We found lower coverage of insurance among the patients compared to entire population [46]. In 2018, the Government of India launched a comprehensive cashless health insurance scheme, Ayushman Bharat, for the bottom 40% of the population, providing <unk>500,000 per family per year for health care expenditure. This scheme has the potential to deliver quality health care for cancer by linking reimbursement directly to the evidence-based management guidelines recommended by India's National Cancer Grid, which is important for a disease where affordability of treatment is a big issue [47,48]. According to a recent study, there are 1575 hospitals in India where cancer treatment costs can be reimbursed through this scheme; however, only 438 hospitals, including TMC, have multimodality treatment facilities [47]. We have some limitations of this study. First, this study is limited to patients treated at a single tertiary care hospital and may not be generalised. Though TMC cater services to all economic group, we believe that majority patients treated at TMC are poor. Second, we have not followed up patients for longer duration. The breast cancer associated mortality would have been higher in five-year period. Third, some of the patients who left discontinued treatment could not be contacted. Fourth, the study period also coincides with the COVID-19 pandemic which might affect the economic condition of the households of the study participants. --- Conclusions Our study called for free screening of breast cancer for socially and economically disadvantageous women in public health centres and strengthening referral mechanism for early treatment of the patients with breast cancer. The health infrastructure for female cancer screening and treatment is inadequate and even non-existent in many states of India. Public investment on cancer treatment in terms of providing financial safety net will benefit women and reduce the burden of the disease. Health insurance should not only reduce the out-of-pocket burden for the treatment but should encourage the patients to continue their planned treatment in respective facilities. --- Availability of data and materials The datasets used and/or analysed during the current study is not publicly available and cannot be shared. However, one may contact Dr. Tabassum Wadasadawala, ACTREC Navi Mumbai, email: twadasadawala@actrec.gov.in for the study data and upon reasonable request the data may be shared. It may be noted that Dr. Wadasadawala has every right to make decision on data sharing. --- Abbreviations --- Funding This research was funded by an extramural grant from the Women's Cancer Initiative and Nag Foundation and intramural grant from IIPS. The content of the article is solely the responsibility of the authors and does not necessarily represent the views of the funders. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. --- Declarations Ethics approval and consent to participate The study obtained approval from the institutional ethics committee of the TMC and was registered on the Clinical Trial Registry of India with CTRI No CTRI/2019/07/020142 on 10/07/2019. Written consent from each of the participant had been taken prior to the interviews. All methods were carried out in accordance with relevant guidelines and regulations. --- Consent for publication Not applicable. --- Competing interests The authors declare no competing interests. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research? Choose BMC and benefit from:? Choose BMC and benefit from: --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The study examined the socio-economic variation of breast cancer treatment and treatment discontinuation due to deaths and financial crisis.We used primary data of 500 patients with breast cancer sought treatment at India's one of the largest cancer hospital in Mumbai, between June 2019 and March 2022. This study is registered on the Clinical Trial Registry of India (CTRI/2019/07/020142). Kaplan-Meier method and Cox-hazard regression model were used to calculate the probability of treatment discontinuation.Of the 500 patients, three-fifths were under 50 years, with the median age being 46 years. More than half of the patients were from outside of the state and had travelled an average distance of 1,044 kms to get treatment. The majority of the patients were poor with an average household income of INR15,551. A total of 71 (14%) patients out of 500 had discontinued their treatment. About 5.2% of the patients died and 4.8% of them discontinued treatment due to financial crisis. Over one-fourth of all deaths were reported among stage IV patients (25%). Patients who did not have any health insurance, never attended school, cancer stage IV had a higher percentage of treatment discontinuation due to financial crisis. Hazard of discontinuation was lower for patients with secondary (HR:0.48; 95% CI: 0.27-0.84) and higher secondary education (HR: 0.42; 95% CI: 0.19-0.92), patients from rural area (HR: 0.79; 95% CI: 0.42-1.50), treated under general or non-chargeable category (HR: 0.60; 95% CI:0.22-1.60) while it was higher for the stage IV patients (HR: 3.61; 95% CI: 1.58-8.29).Integrating breast cancer screening in maternal and child health programme can reduce delay in diagnosis and premature mortality. Provisioning of free treatment for poor patients may reduce discontinuation of treatment.

Introduction In recent years, the deep involvement of parents in their children's education has become a social phenomenon that has attracted much attention, and parents' educational involvement behaviour has become a major issue that needs to be studied in depth by academics (Heckman & Letkiewicz, 2021;Wati & Sahid, 2022). Family education is the foundation of all education and has a significant impact on educational justice and the quality of future citizens (Molla & Pham, 2019;Ocampo-González, 2019). Early-childhood high-quality parental investment is consistently linked to lifelong good mental and physical health (Bachmann et al., 2022). Similarly, the education of their children deserves sustained attention because it is an important component of the nation's human capital, and the family's investment in their children's education will directly determine their children's educational status and govern their children's access to resources in the education process, which in turn will have a critical impact on their ultimate educational level and attainment. Their children's future development and life trajectory are influenced (Bachmann et al., 2022;Zhang, 2022). The main body of investment in education consists of two parts, the family and the government. Public investment by the government has an integral impact on educational Vol 12, Issue 3, (2023) E- ISSN: 2226-6348 To Link this Article: http://dx.doi.org/10.6007/IJARPED/v12-i3/18566 DOI:10.6007/IJARPED/v12-i3/18566 Published Online: 17 September 2023 equity in society. (Jackson & Schneider, 2022). The governments of Australia, Japan, and Brazil have been promoting education in their countries by increasing their fiscal spending on education (Lewin, 2023;Vasconcelos et al., 2021). The Chinese government promotes educational equity by regulating taxes, expanding access to college, establishing an equitable human capital transmission mechanism and investment system, and increasing third-party education funding for government school societies to provide a favourable investment environment for family parents to invest in education (Liu & Ma, 2022). At present, China's economy is facing a stage of development and social transformation, and Chinese residents' concept of education is quite different from before. Chinese parents are fully aware of the functional role of education in individual development and social development, and their demand for education has gradually emerged. Educational issues have become the most concerned, most direct, and most realistic prayer for the interests of rural Chinese parents (ZHOU & WANG, 2019). The government's investment in education has increased significantly in recent years, but family education expenditure is still the main pillar of education expenditure. In the past ten years, the average annual growth rate of household education expenditure in China has been around 10.7%. In 2021, the national general public budget for education (including education expenses, infrastructure expenses, and education surcharges) was $537.7 billion, an increase of 5.17% over the previous year in the same calibre. Among them, the central government spent $ 80.55 billion on education, an increase of 3.66% over the previous year. One of the crucial aspects of individual financial planning is the planning of investments, which entails creating several investment strategies (Abubakar et al., 2022). The cost of financing, an investor's estimation of future profit potential, and historical profit experiences all have an impact on the choice to invest (Purnamasari et al., 2021). There is a close relationship between educational investment decisions and educational investment, and the quality and correctness of decisions can determine the effectiveness of educational investment and the direction of educational development. Studying the factors that influence educational decision-making can help parents provide targeted, rational, l and effective educational investment decisions that can contribute to the continuous improvement and development of education. --- Literature Review It is clear from the literature that parents' investment in their children's education can be influenced by a variety of factors (Chen & Zhang, 2023). According to Sharma (2020), there is a significant relationship between investment decisions and the demographic profile of the respondent, including gender, age, educational attainment, and socioeconomic class. In their study, Celhay & Gallegos (2022) found that in low-income families, the investment in education that children receive is influenced by parents' beliefs and material investments. Demographic factors of investors, such as gender, age, and education, have much significance in the investment decision process (Lotto, 2023;Mittal & Vyas, 2009;Su et al., 2022). --- Investment decisions Based on gender Male participants were found to be more aware of the increased availability of negative emotions following suboptimal financial decisions than female participants. Based on Yuliana & Kholilah (2019), PLS analysis of LQ45 companies listed on the Indonesian Stock Exchange for the years 2014-2017. The findings indicated that the presence of a female chief executive officer can mediate the relationship between investment decisions and the value of the company. Gender diversity influences differences in levels of optimism, self-assurance, and risk preferences. The feminine nature of women affects the quality of investment decisionmaking, and this has an effect on the enhancement of a company's value. Females have been found to be more conservative in financial markets than males, which led Chen (2005) to conclude that females were more risk-averse than males due to individual characteristics and systematic factors. Other studies also contradicted the experimental findings, exposing that there were no significant differences between men and women (Schubert et al., 1999). Susanto et al (2023), who explained that women were exposed to fewer risks than males and that their approaches were distinct, supported the research. According to Xu (2022), using survey data on migrant workers' households from the China Labor Force Dynamics Survey (CLDS 2012(CLDS -2018)), the number of children and their personality traits influence fathers' investment in their children's education. The number of children was significantly and negatively correlated with children's education level, with each additional child in the household reducing the number of years of education in the sample by 16.3%. The increase in the number of siblings was more detrimental to the educational attainment of children than the increase in the number of sisters. In terms of birth generation, the increase in the number of children is less conducive to the increase in the educational attainment of the younger generation of children (Wang, 2020). Lotto (2023) supports that employed families are more likely to make prudent financial decisions because the majority of them are believed to have access to official financial literacy education due to their higher levels of education. Furnham & Cheng (2019) demonstrates that intelligent people from more affluent social backgrounds are more likely to have higher levels of education and Occupation, as well as higher incomes and thus make more active investment decisions. Elizabeth et al (2020) are of the opinion that demographic factors, such as profession, have an effect on the behavioural biases that investors have, namely disposition bias. (Vyas et al., 2022) made the observation that investors with jobs unrelated to finance tend to have less self-assurance than those with jobs in the financial industry. Comparing investors with nonfinance employment to investors with finance jobs. In addition, research shows that investors in business class are more susceptible to the effect of behavioural biases than salaried investors are. The researchers discovered that a person's line of work has a more significant association with overconfidence, optimism, and temperament bias than the herding bias (Sapkota & Chalise, 2023). Households with different incomes have different considerations regarding investment decisions (Bonneau & Grobon, 2022). Yusnita et al (2022) during the period of March to May 2021, primary data were collected through the distribution of questionnaires using the snowball sampling technique, and as many as 247 samples were collected. Using crosstabs analysis and multiple regression analyses, the data were analyzed. The findings of the multiple regression test indicated that both individual income and financial literacy had a positive and statistically significant impact on the investment decisions of Tasikmalayans. There is a significant influence of variable income on financial behaviour, as well as a significant effect of variable lifestyle. And the factor of financial knowledge, income, and lifestyle all have significant effects on financial behaviour, thus influencing investment decisions (Siregar & Simatupang, 2022). Bonneau & Grobon (2022) present new stylized data regarding the inequality of access to higher education in France based on parental income. On average, a 10-percentile increase in parental income is associated with a 5.6-percentage-point increase in the proportion of children with access to postsecondary education. Parental education had a significant positive effect on children's educational attainment, and the positive effect was higher for mothers than for fathers (Wang, 2020). Wagner & Walstad (2023)supports that employed families are more likely to make prudent financial decisions because the majority of them are believed to have access to official financial literacy instruction due to their higher levels of education. A person's level of knowledge influences their ability to make investment decisions. It can be said that the more education a person has, the more cautious they will be when deciding to invest, particularly in the context of managing and spending money based on the benefits (Awais et al., 2016). Expecting an average return on average financial risk was negatively influenced by marital and income status (Bayar et al., 2020). This was studied by distinguishing married men from married women. Single males were found to have the highest risk tolerance and highest willingness to invest, followed by married males, followed by unmarried females, and finally married females (Yao & Hanna, 2005). Examine the functions of marital status and gender in investment decisions by analyzing data on asset allocation in individual retirement accounts. It is discovered that there is a significant difference between married and single households in their allocation decisions for hazardous assets (Mandal & Brady, 2020). The influence of subjective norm variables on the investment decisions of investors may be moderated by social demography moderating variables which include age and investing experience; however, social demography factors such as gender, profession, and education are not moderating investors' objective norm variables (Nurbarani & Soepriyanto, 2022). Senda et al (2020) found that among the demographic factors, age, income, and investment experience influence investment decisions through the Chi-Square test. --- Methodology This study is a quantitative survey-based investigation. According to Creswell (2017), the survey is a research method used in the social sciences to characterize the attitudes, ideas, beliefs, perceptions, behaviours, or attributes of a sample. Utilizing the powerful, precise, and widely accepted instruments of statistics for measurement, categorization, and analysis, quantitative methods related to literature express aspects or qualities of literature as mathematically as possible. The researchers determined the sample by simple random sampling of 437 parents of different age groups from Shandong, China. The demographic information of the participants is shown in Table 1. --- Results Parental investment decisions in children were studied based on variables such as parental gender, number of children, Occupation, income, education, and age. Techniques including the arithmetic mean, standard deviation, independent test (independent sample test), and one-way analysis of variance (ANOVA) were used for the data to analyze it. The t-test and analysis of variance (F) were used to determine if there were statistically significant variances between two sets of data and between more than two groups (Guetterman & Fetters, 2018) A t-test was used to determine whether there were statistically significant differences in parents' investment decisions about their children's education based on their gender (Table 2). Although Cohen's (d) calculation is the one that is most often used to determine effect sizes, there are other calculation techniques like Hedge's d and Glass's that may also be found in the literature. Cohen suggests that the impact size be classified as weak if the d value is less than 0.2, medium if the d value is between 0.5 and 0.8, and large if the d value is more than 0.8 (Rice & Harris, 2005). As can be seen in Table 5, there is a statistically significant difference (p<unk>0.05) in parents' education investment decisions about their children in terms of their gender. The Cohen (d) effect value showing the size of the difference was 0.21 in the motor characteristics factor, which also indicates that there is a statistically significant difference in the investment decisions of parents regarding their children by gender. Therefore, it can be concluded that mothers' investment decisions for their children are higher than fathers' investment decisions for their children. One-way analysis of variance (ANOVA) was used to find out whether there were statistically significant differences in parents' investment decisions regarding their children depending on the number of children (Table 3), occupation (Table 4), income (Table 5), education level (Table 6), marital status (Table 7), and age (Table 8). --- Table 3 ANOVA Results by Number of Children Table 3 shows that there is a statistically non-significant difference (p>0.05) in parents' investment decisions for their children's education depending on the number of children. Table 4 shows that there is a statistically significant difference (p>0.05) in parental education investment decisions for their children depending on the job. Therefore, the difference in parents' jobs has a significant effect on parents' investment decisions about their children's education. Parents whose Occupation is farmer place more importance on investment decisions for their children, and those whose Occupation is government official place the least importance on investment decisions for their children. 5, there is a statistically significant difference in parents' investing choices for their kids based on their income (p>0.05). Therefore, the parents' investment choices for their children's education are significantly influenced by the disparity in their income. In contrast, parents with earnings below 3000 pay the least attention to their children's investing choices, while parents with incomes between 3000 and 4000 pay the most. There is a statistically significant difference (p>0.05) between parents' investment decisions for their offspring based on the level of education, as shown in Table 6. Consequently, the difference in educational attainment between parents has a substantial effect on parental investment decisions regarding their children's education. Parents with secondary education are more influential in their children's investment decisions, whereas parents with no formal education are the least influential. Table 7 shows that there is a statistically significant difference (p>0.05) in parents' investment decisions for their children depending on their marital status. Thus, parent's marital status has a significant effect on parents' investment decisions regarding their children's education. Parents who are alone with their children place more emphasis on investment decisions for their children. --- Table 8 ANOVA Results by Age Table 8 shows that there is a statistically significant difference (p>0.05) in parents' investment decisions for their children depending on their age. Thus, parental age has a significant effect on parents' investment decisions regarding their children's education. In particular, younger parents are more important in their children's investment decisions, and older parents invest less in their children's education in comparison. --- Discussion It has been detected that Parental investment decisions in children are related to the variables of parental gender, parental Occupation, parental income, parental education, parental marital status, and parental age. There is research that supports that mothers and fathers make different decisions about their children's investments due to their respective genders. In terms of meeting their children's investment needs, (Dizon-Ross & Jayachandran, n.d.) showed that of the 1084 parents living in this area of Iganga district in eastern Uganda, fathers' willingness to pay for goods is lower for daughters but not for sons. The coefficient for Daughters is negative and significant, indicating that fathers are 0.10 standard deviations less willing to pay for their daughters than their sons. The coefficient for mothers with daughters is positive, significant, and similar in magnitude to the coefficient for Daughters, implying that the net effect of daughters on mothers is 0. Also, the article reports whether mothers spend the same on daughters and sons, with the same p-value. Similarly, in Serbian Roma mothers also have a positive impact on children's investment, and for low-income families, the choice of the mother's investment level seems to be crucial for children's educational investment is crucial (<unk>vorovi<unk>, 2022). It is seen that the influence of parents' occupations on their children's educational investment decisions is very important. A study of national data for Brazil, linking multiple administrative data sets and taking an integrated approach to examine the impact on education and other key aspects of children's lives, found that parental Occupation affects parents' willingness to invest in their children's education and that unemployed parents directly increase dropout rates by 1.5 percentage points (Britto et al., 2022). Anand (2021) discover that money and time investments in education are negatively correlated with the intensity of a parent's occupational identity ( influences his or her self-image and identity). In the same vein, the correlation between social class and Occupation and saving and investment. It is clear that Occupation is one way of determining social class and income/financial status, which is related to how much a person must save and invest (Furnham & Cheng, 2019). Beltran (2021) discovered that families with varying occupations have varying effects on their children's investment decisions, with the mother's Occupation having the most significant impact. Different incomes also have a different impact on parents' decisions to invest in education. Adil et al (2021) found from a study of Korean households that individuals with low incomes are unable to make quality investment decisions when faced with investing. Conducted three sets of mediated analyses through a study using data from the 2014 Consumer Empowerment Index Survey of the Korea Consumer Agency to verify that households in different income brackets in Korea make different decisions about investments (Son & Park, 2019). Using the 2003-2017 Consumer Expenditure Surveys, Orestes P. Hastings evaluates two candidate pathways the fact that may account for connections between familial relationships and financial investment in children in the United States. These pathways are differences in economic resources and differences in long-term commitment. Hastings compares the differences between married, cohabiting, and single parents. Parents who are not married or who cohabit make less investment in their children than married parents. Income explains the full difference for single people but just a small portion of the difference for couples who cohabit, which suggests that commitment and preference may play a role in the difference. The yearly household income of the households who took part in this research fell somewhere between 300,000 and 500,000 (£2,974 and £4,958) in British pounds. It was discovered that different income classes in the United Kingdom have different school choices and differing attitudes toward investing in their children's education, with the mother's attitude often dictating the family's approach (Gupta, 2023). Through her research, Lippi, n.d. (2022) discovered that parental education affects their propensity to invest in their offspring. In the study, the results indicate that mothers with higher education appear to negatively influence their daughters' financial behaviour, while fathers with higher education degrees appear to positively influence their sons' financial behaviour. In the context of a 10-fold expansion of China's higher education sector since 1999, investigates the role of parental input in university admission. Using Logit regression, they determine that an increase in a parent's level of education considerably increases their child's likelihood of enrolling in college, and there is a difference in the level of educational attention and the level of investment received (Gu et al., 2022). A study by Liu & Yang (2022) found that less-educated parents had higher educational expectations than more-educated parents. The findings of the study indicate that investors require training programs, workshops, and seminars that improve their financial literacy and financial knowledge, allowing them to surmount behavioural biases when making investment decisions. Those with a higher level of education are more inclined to invest actively (Adil et al., 2021). Using the 2003-2017 Consumer Expenditure Surveys, Hastings & Schneider (2019) study disparities in parental financial investments in child care, education, and enrichment activities depending on the family structure of the household. We analyze two alternative paths that may explain correlations between family composition and financial investment in kids: variations in disposable income as well as variations in long-term commitment. They evaluate the differences that exist between married, cohabiting, and single parents. Parents who are not married or who cohabit make less investment in their children than married parents. Several empirical studies (Altintas & Sullivan, 2016;Kalil et al., 2012;Pepin et al., 2018) investigate disparities in time spent with children by family structure. (Nurbarani & Soepriyanto, 2022) employed social demography moderating variables on 400 respondents in the Greater Jakarta region. The test results indicate that subjective norms variables have no significant positive effect on Willingness to invest but can be moderated by sociodemographic variables like age and investment experience. Based on the CGSS2006 data, Gu et al (2022) found that families with complete families have a more complete investment structure for their children, and parents are more willing to invest in their children, while single-parent families rely more on grandparents to care for and invest in their children. Alani & Hawas (2021)found that the rural family environment and the marital status of parents can influence the learning environment of children, directly affecting their performance. --- Conclusion In this study, researchers examined whether gender, Occupation, income, education, age, and marital status had significant effects on demographic factors and their impact on Chinese parents' decisions to invest in their children's education. These differences reveal the subjective motivations that influence Chinese families' decisions regarding education investment. The findings of this study serve as a reference for future research on Chinese parents' investment behaviour toward their children's education. The goal of this study was to examine the level of variance among various demographic parameters and their impact on Chinese parents' decisions regarding educational investment. The statistical results indicated that parents' gender, Occupation, income, education, age, and marital status significantly influenced Chinese families' investment decisions in their children's education. However, the number of children did not influence Chinese parents' decisions regarding educational investment. This study aims to examine these demographic factors to help researchers and policymakers gain insight into the educational priorities and values of Chinese parents. This allows us to demonstrate how various demographic factors influence the understanding of the importance of education and the allocation of educational resources among Chinese parents. Understanding how demographics influence parental decisions can reveal the barriers and challenges faced by different types of Chinese parents when making decisions about investing in their children's education.

Investment in their children's education is one of the most tangible ways through which Chinese parents demonstrate their interest in their children's academic lives. This investment behaviour is almost inevitable for Chinese parents. This study aims to investigate the demographic characteristics that influence the educational investment choices made by Chinese parents. A sample of 437 rural Chinese families was randomly selected for the study. Data were collected both offline and online and analyzed using t-tests and ANOVA with IBM SPSS version 26 software. The results revealed that factors such as parental gender, Occupation, income, education, marital status, and age significantly impacted the educational investment choices of Chinese parents within the sample. However, the number of children did not have an influence on the educational investment decisions made by Chinese parents. The researchers specifically focused on parents living in rural regions. These findings provide a crucial foundation for ongoing research on the educational investment behaviour of rural Chinese parents and have implications for studying the variable nature of educational resources in Chinese society.

INTRODUCTION The first victims of covid-19 were older people, which raised distinction in the way of treating them and highlighted the ageism present in societies. Ageism 1 manifests itself when one age group addresses another, based on stereotypes created to discriminate against people based on their chronological age 2, whether due to ideological aspects -based on characteristics attributed to an age group -or practical/behavioral aspectsthrough judgments, beliefs and attitudes. In the context of the pandemic, this phenomenon became evident in the treatment given to older people, over 60 years old, in the association with stereotypes/negative images and deterioration of physical and cognitive/behavioral capacities 3. Prevention procedures were used to justify attitudes of depreciation and discrimination/stigmatization of older people 4,5, it is important to emphasize that stigma is a mark/impression that is carried throughout life, established by society to categorize people and the attributes considered as common and natural for members of each of these categories 6. The stigma that permeates old age/aging was boosted during the pandemic, when prejudiced attitudes made some people think that the pandemic was an "older people's problem" and only the older people should be in social isolation 7, since old age is associated with economic spending, social burden and symbol of unproductivity 8. This stigma also arises as a consequence of the non-enforcement of laws that protect and guarantee the rights of Brazilian older people 9. This problem disregarded a history of epidemic outbreaks that occurred over the centuries and showed that the best preventive measures for the advancement of highly contagious pathogens were vaccination, quarantine and lockdown 10 of the entire population, not just risk groups. During social distancing, it was necessary to seek means that would serve as a bridge between people and the new knowledge that emerged about the disease, as well as to achieve forms of socialization during distancing. For this, it was possible to use the internet, which despite having negative aspects in its use, such as the consumption of untrue content and excessive time in front of the screen, which cause concerns, repercussions on well-being, exhaustion and sleep disturbance, is of great importance for streamlining communication and disseminating information. Social networks are the methods of choice for posting common activities, especially the YoutubeTM platform, due to the ease of sharing videos capable of expressing opinions, transmitting knowledge, spreading news and being used as a source of information on health-related matters 11. In view of this, videos on the YoutubeTM platform gained national repercussion and visibility, raising relevant debates and reinforcing the importance of this study, especially by demonstrating ageism, based on narrated situations, and its repercussions for the older population. In addition, it is important to demonstrate how these narratives relate to the Theory of Stigma 6, with a view to strengthening the fight against the problem. In this context, the objective of this article was to analyze the repercussions of ageism directed at older people during covid-19, through the content available on the YoutubeTM platform. --- METHOD Exploratory study with a netnographic qualitative approach developed based on the methodological rigor criteria of the COREQ checklist, which has been frequently used for ethnographic approaches applied to the study of cultures and online communities within consumer and marketing research. Netnography is distinguished from other types of qualitative research on the Internet by presenting, in a single term, a set of guidelines for carrying out computer-mediated ethnography and its integration with other forms of cultural research 12. The "YouTubeTM" video sharing site has the virtual address: www.youtube.com. This investigation was not submitted to the Research Ethics Committee for consideration because it was the use of publicly accessible data, as established by the ethical standards of the platform itself, as well as by Resolution 510/2016 of the Brazilian Health Council 13 and by the Federal Law 12527/2011 14. Videos were searched based on the following inclusion criteria: having been posted from March 20, 2020 (start of the pandemic) to May 2021 (start of vaccination of older people); address content related to ageism and covid-19; be available in Portuguese, English or Spanish; having been presented by older people, whether they are narrating their own experiences and/or those of third parties. Videos with reproduction difficulties, with duplicate content or of dubious character (checking the news channel and its content for veracity and reliability, giving preference to official channels and those of researchers that presented scientific references), as well as those that did not contain content referring to the repercussions of ageism on the covid-19 pandemic. The selection and data collection took place in February 2022 through the keywords: ageism; ageism in the pandemic; ageism in covid-19; prejudice against older people in the pandemic; ageism in the pandemic; age discrimination; stereotype; gerontophobia; old age; ageism; old phobia; old age; stigma; prejudice; and its correspondents in Portuguese and Spanish. These keywords were combined to create the expressions: "age<unk>smo pandemia"; "age<unk>smo covid-19"; "preconceito contra idosos na pandemia"; "preconceito de idade na pandemia"; "gerontofobia pandemia; etarismo pandemia"; "velhofobia pandemia"; "idosismo pandemia"; "violência idoso pandemia"; "ageism pandemic"; "old age pandemic"; "gerontophobia pandemic"; "ageism covid-19"; "edadismo pandemia"; "discriminación por edad pandemia e discriminación por edad covid-19". The content search and selection process was carried out by a researcher and is detailed in Figure 1. The information from the final corpus of the videos was organized in a table in Microsoft Excel and identified by title, access link, channel and date of posting and duration (Chart 1). Data analysis was guided by an in-depth study of the videos, in which an attempt was made to understand the reports narrated individually through Bardin's 15 thematic content analysis, which focuses on qualifying the subject's experiences, as well as their perceptions about an object and its phenomena, allowing the discovery of social processes still little known about specific groups and the adoption of new approaches, in addition to the revision and creation of new concepts and categories during the investigation 15. In the pre-analysis, the materials to be used and the keywords were chosen, the videos were searched and the material was selected. By watching all the videos, it was possible to know the content of each one of them, to obtain the first impressions and to constitute the corpus of the study of relevance for the research based on the inclusion and exclusion criteria. In order to explore the material, all the content of the videos was transcribed into text format in a Word file. Then, the material was read and possible errors were corrected. Videos in English and Spanish have been translated into Portuguese. Subsequently, the typed material was read exhaustively and the contents were codified by cutting out the recording units related to the theme of the repercussions of ageism in the covid-19 pandemic. This phase was validated by two researchers, doctor and master, with expertise in the subject and in the study of the Theory of Stigma 6. For the interpretation of the material, the recording units were grouped by similarities and differences, generating the categorization, whose interpretation was performed based on Goffman's Theory of Stigma 6, which discusses how society establishes means to categorize people and attributes considered common and natural for the members of these categories -as certain marks or characteristics that stigmatize the subjects -, and as derogatory attributes that can make the subjects react or accept the conditions that are imposed on them as "normal" or "abnormal". Such theory helps to identify central features of stigmatized people's life situations and how they affect social and personal identity. Each video was identified with a number from one to nine, and each excerpt relevant to the research was identified with the initials of the person who expressed themselves in the video, with the expression Without Identification (WI) being used for a person whose name was not revealed. --- RESULTS The selected videos are characterized in Chart 1, based on the categories: pre-pandemic expressions of ageism; expressions of ageism during the pandemic; and feelings and attitudes of the older person towards the repercussions of ageism. Data analysis revealed content related to ageism that was culturally accepted, albeit veiled, directed at older people even before the pandemic (Chart 2). The content of the videos presented findings that demonstrate ageism in the pre-pandemic period and the subsequent addition of new ageist elements, strengthened from the health, political, socioeconomic and cultural crises. The repercussions of ageism generated feelings and revealed attitudes of prejudice and discrimination experienced by the older population (Chart 4). --- DISCUSSION The netnographic findings made it possible to verify the configuration of the ageist manifestation that stigmatizes older people, by excluding this population from digital learning spaces, disregarding the ways of being an older person, and disrespecting the right to have access to public transport. Thus, the labeling and stereotype of "sick", "weak", "burdensome", "unproductive", "disposable", contributed to mistreatment/violence, marking as "subject of risk", disrespect for the right of priority in vaccination and the outbreak of negative feelings and attitudes to face the problem of ageism. The establishment of normative attributes to categorize people in what is considered common and natural imputes estrangement and deterioration of social identity 10, making it "different". The installation of these normative attributes can revert to stigma: what is negative about the moral status of a person in relation to another. Such normative determination imposes social categories of forced framing/fitting, permeated by stereotypes 11 about the older person, which implies prejudice/discrimination. The exclusion derived from stigma surprised men diagnosed with covid-19, marked by class and gender privileges, not used to being demoted in interactions when compared to other groups 16. Exclusionary attitudes can be implemented against older people, reverting to ageism 17. In this sense, stereotyped expressions about the perceptions one has about other people based on age are aggravated by the intersection of social markers of discrimination throughout life: when the stigmatized person starts to have the same beliefs about his identity as those who stigmatizes. In order to avoid negative experiences and feelings related to the deterioration of the social image, many stigmatized older people can assume behaviors/attitudes/practices in advance to respond and/or create barriers and defend themselves against ageism through withdrawal, social isolation or even aggressiveness. In view of this, it is essential to carry out actions that promote the self-care of the older person in order to avoid biopsychosocial deficits 18 ; inter-institutional strategies aimed at advocating and supporting the older population to know, recognize and establish effective measures to face ageism and its repercussions. The absence of effective responses and/or coping strategies includes not only those that can be taken by those who suffer stigmatization, but those that could be carried out by the entire apparatus of public devices, which makes many older people ignore their own wills, become depersonalized and abdicate their rights, favoring the growth of ageism as an inappropriate but common practice. However, there was a loss of hope, meaning/purpose in life, the imposition of marks of asexuality, mental illness and suicide, as they judged themselves to be inappropriate to live collectively in old age 4. Chart 4. Fragments of the feelings and attitudes of older people towards ageism on the YoutubeTM platform. Feira de Santana, Bahia, Brazil, 2022. ATTITUDES "[...]we seniors are disciplined, we take care of ourselves, we find different ways of living, we make handicrafts or masks, we cook, we practice gardening, we read and we connect with our emotions, to face discrimination". (V5_MT -Translated) Source: own authors The labeling of older people in the covid-19 pandemic was another significant finding in our study. It should be noted that the ageist label imputes the idea of being "incapable", favors discrimination 19, limits opportunities and reverberates in a feeling of indignation at the "impossibility" of learning to use technology, especially in the period of greater social isolation and lockdown, despite having the intellectual capacity to do so and showing a strong advance in the number of older people with internet access, especially in relation to the use of smartphones 20. Another important finding concerns the derogatory images and attitudes of life in old age, which constitute the pillar of support of ageism 4 and are manifested through expressions of "sick" and "burdensome" to the health system, which highlights a serious social problem installed, which can put the lives of the older population at risk, as seen in countries like Spain and Italy, which have established genocidal measures against older people in nursing homes 21. In some countries, protocols explicitly used age as a criterion for the allocation and non-allocation of treatment, with an age limit for access to intensive care and the use of ventilators 22. The establishment of purely age criteria strengthens labels that are harmful to health, which directly compromise access to health services and interfere with the quality of health care 23. This bad practice, through decision-making on whether or not to maintain the life that is breathing with the help of a mechanical ventilator, in the occupation of an Intensive Care Unit bed, continues to be perverse and takes many lives, as it takes into account, mainly, the age of the subject 17. Restrictions based only on chronological age reinforce discrimination and reduce human life to arbitrary numbers, which disregard values and choices. Thus, despite ethical recommendations aiming at fairer resource allocation protocols, it is still essential to educate health professionals to recognize institutional ageism 24. Negligence in care and the occurrence of physical/psychological violence in spaces of protection, such as Long Term Institutions (LTI), were not exempt from suffering from ageism. Both managers and professionals who work in these spaces are able to perceive the configuration of violence in some particular situations: (1) violence before institutionalization, motivating reason for sheltering; (2) institutionalization as an act of violence, when the family disregards the older person's autonomy regarding their desire to go to the institution or not (absence of any assistance/attention) or when they abandon the older person; and (3) absence/ limitation of public policies, lack of State actions, little effectiveness of existing legislation 25. In view of this, the institutionalized older population that already suffered from the effects of isolation and social negligence 26 saw itself as a victim of discrimination, through the media discourse that revealed exclusionary speeches, of social nonacceptance, provoking identity shame, self-hatred, self-deprecation and self-isolation 10. If, on the one hand, there was a narrative that the older population was the most affected by covid-19 3, on the other hand, there was the representation of the "vulnerable subject", "dangerous" and "disposable", becoming the "other" of the pandemic. In this sense, older people would be the only ones capable of dying from the disease or transmitting it, an idea that was perpetuated for a long period of disease dissemination 4. As a consequence, there was a lack of priority in investments in the health of these people 4, which led to the curtailment of the right and opportunity of the older population to benefit from therapeutic measures. In this sense, it is urgent to insert the principles of geriatrics/gerontology as a strategy to face ageism: clinical-functional assessment; implementation of individualized care for older people/families; combating the stigma of old age, aging and ageism 27 ; and investment in mental health literacy to recognize specific disorders and psychological distress and seek professional help 28. Combating ageism involves directing care to older people in terms of their physical, mental and social health needs; evaluate the specificities of the subject, its context, autonomy and independence, fulfillment of rights and duties and, mainly, respect for the individualities, limitations and potentialities of each subject. It also means establishing a social education pact as a pillar of intergenerational reconnection, respect and empathy. The contributions of this study to geriatrics/ gerontology are: highlighting the need to disseminate knowledge about ageism, the repercussions and ways to combat this phenomenon, which, although old, was originally evidenced in 1969 by the psychiatrist and gerontologist Butler 29, and strengthened during the covid-19 pandemic. In addition, it encourages the development/implementation of focal public policies, capable of including older people and respecting their rights. The limitations of the study are: search for videos on only one platform; and the time frame, since, due to the fact that the pandemic was not over by the end of this study, other videos continue to be published on the platform. In order to deepen these phenomena, future studies are needed, based on primary data, which listen to older people about the repercussions of ageism. The implications for the geriatric-gerontological practice lie in: recognition of situations of ageism and stigma that surround social relations; adoption of self-monitoring postures to avoid deleterious consequences; remediation of traumatic situations, including post-pandemic ones. Thus, older people actively seek well-being, to continue their lives in the best possible way, with the exchange of knowledge and experiences, various activities that help financially, relax and help in the redefinition of life, as they see themselves as capable subjects with high self-esteem and personal affection 30. --- CONCLUSIONS The repercussions of ageism directed at older people involve the social spheres generated from social isolation as a measure to contain the pandemic; feelings of worthlessness and self-deprecation; non-compliance with the rights of older people by institutions; generational conflicts between older people and the young; repercussions on lifestyle, as they fail to carry out their common activities of daily living because they feel incapable and because of the effort to use technology more and more as a means of communication; and repercussions on health, as older people are victims of negligence and recklessness within health institutions. These repercussions can cause physical, cognitive, social and psychic sequelae, whose permanence time and consequences require future investigations. The demands brought about by this study affirm the need to deconstruct the idea that aging is a painful and survival process, the need for greater socioprofessional and media inclusion of appropriate content, with a focus on health education to increase digital literacy. It is also essential to teach coping measures so that older people know how to handle prejudiced situations. Professional gerontologists need to act through an expanded clinic, focusing on the therapy of psychosocial repercussions in the face of social stigma and discrimination, which were enhanced throughout the pandemic, through the use of compassion, empathy and solidarity. --- AUTHORSHIP • Isis Bastos Barbosa-Conceptualization, Data Curation, Writing -First Drafting, Writing -Revision and Editing, Research, Methodology; • Pricila Oliveira de Ara<unk>jo-Project Administration, Formal Analysis, Conceptualization, Data Curation, Writing -Proofreading and Editing, Research, Methodology, Obtaining Funding, Supervision; • Vin<unk>cius de Oliveira Muniz-Formal Analysis, Data Curation, Writing -Proofreading and Editing; • Isabela Machado Sampaio Costa Soares-Formal Analysis, Data Curation, Writing -Proofreading and Editing; • Anderson Reis de Sousa-Formal Analysis, Data Curation, Writing -Proofreading and Editing; • Evanilda Souza de Santana Car valho-Project Administration, Formal Analysis, Conceptualization, Data Curation, Methodology, Supervision. Edited by: Yan Nogueira Leite de Freitas

Objective: To analyze the repercussions of ageism directed at older people during covid-19, through the content available on the Youtube™ platform. Method: Netnographic, exploratory and qualitative study, whose data were collected in videos on the Youtube™ platform; a thematic analysis of Bardin's content was performed and the elements were discussed in the light of the Theory of Stigma. Results: Three categories explain the repercussions of the investigated phenomenon: expressions of ageism pre-existing to the pandemic, with expressions of exclusion, disregard and disrespect; expressions of ageism during the pandemic from the risk group label that strengthens stereotypes of sick and incapable people; and feelings and attitudes of the older people towards the repercussions of ageism, which led to repercussions on social interactions, lifestyle and health of older people. Conclusions: The repercussions can cause physical, cognitive, social and psychic sequelae, and the fight against its impacts starts from the educational sphere towards a social pact that allows a respectful and empathetic coexistence between generations.

Introduction Journalism constitutes the systematic practice of collecting, editing, and disseminating news to the intended audience, with its primary objective being the provision of information to the public. This procedure is commonly referred to as the newsroom process. A robust newsroom possesses the potential to effectively establish, advocate for, and communicate specific agendas. Nevertheless, in light of the increasing prominence of social media, the effectiveness of the traditional newsroom is subject to change. Journalism is widely regarded as a paramount component within the field of Mass Media. As described by McQuail, "Mass Media" refers to the organized means of openly and distantly communicating with a multitude of receivers within a short timeframe. However, the emergence of the Internet has prompted a re-evaluation of the influence exerted by traditional Mass Media. These advancements in communication technology have profoundly impacted media assessment, including the fundamental concept of agendasetting. Agenda-setting, an inquiry into the media's role in shaping public discourse, has been a subject of scrutiny for over six decades. Continuous technological progress continues to reshape the character and structure of media, warranting a comparative exploration of agenda-setting within the domain of social media, the primary mass communication medium of the latest generation. Nepal's unique journey in mass communication spans centuries, with the printing press arriving in 1851, four centuries after its invention in 15th-century Germany by Johannes Gutenberg. In contrast to Western nations, where online news platforms emerged in the 1990s, Nepal embraced them in 1995, and social media has notably outpaced the growth of online journalism in the country. As of June 2023, the Nepal Telecommunication Authority reports 38.88 million fixed and mobile broadband users, representing 133 per cent of the population. This highlights the integration of internet usage into the daily lives of Nepali citizens, with social media platforms playing a prominent role and accounting for the majority of bandwidth usage. The COVID-19 lockdown in Nepal substantially increases internet consumption, placing strain on Internet Service Providers (ISPs) to meet heightened consumer demands. During this period, traditional newsrooms face challenges due to government-imposed lockdowns, leading to changes in audience habits. Many turn to social media as a primary source of information. The surge in internet users, combined with the dominance of social media, underscores the evolving landscape of media consumption and its impact on traditional media outlets, especially in extraordinary circumstances like the COVID-19 pandemic. --- Objectives Social media has become an inescapable communication medium that permeates every sector of human life, and journalism is facing its direct impact. This article aims to explore two specific objectives: <unk> Assess the impact of the rise of social media platforms on the dissemination of information and the integrity of traditional media. <unk> Evaluate the agenda-setting power of social media in Nepal. By examining these objectives, we can gain insights into the transformative effects of social media on journalism and understand its role in shaping public discourse and news consumption patterns. --- Theoretical Perspective The theory of 'agenda-setting' explores how the media influences public perception and emphasizes the importance of specific issues. This study builds upon the foundational work of Maxwell McCombs and Donald Shaw in the 1970s, who developed the 'agendasetting' theory with a focus on the influence of newspapers. Before their contributions, debates surrounding the media's effect ranged from theories emphasizing high media influence to those proposing lower levels of impact. --- The Decline of Traditional Media According to the World Economic Forum, from 2006 to 2016, newspaper circulation in India increased by an impressive 60 per cent, in stark contrast to the United Kingdom, which saw a 12 per cent decrease. In the United States, Germany, and France, newspaper circulation declined by 7 per cent, 3 per cent, and 3 per cent, respectively (Tharoor, 2017). In 2015-16, newspaper circulation in India peaked at an impressive 612,385,810 copies, as reported by the Registrar of Newspapers for India in 2022. Subsequently, data from the 'Office of Registrar of Newspapers for India' shows that during the 2020-21 fiscal year, newspaper circulation in all languages stood at 386,648,237 copies. However, unlike in India and other countries, specific data concerning the extent of this decline in Nepal is not readily available. Media executives do acknowledge a continuous decrease in newspaper circulation (Dahal, Shrestha, and Karki, 2078). The outbreak of COVID-19 further exacerbated the situation, resulting in a decline not only in newspaper circulation but also in the number of printed pages. This decline confirms the weakening circulation trend. Kantipur Media Group (KMG), holding the largest market share in the Nepali media industry, acknowledges the loss of its newspaper market. According to Mahesh Swar, the CEO of KMG, newspapers have experienced a substantial decline of at least 70 per cent in market share during this transition. He further stated, "We lost 70 to 80 per cent of the market due to COVID-19, and there is no possibility of returning to the previous situation once the pandemic is over" (M. Swar, personal communication, November 12, 2021). The decline in newspaper circulation is a global phenomenon, and Nepal is no exception. The impact of COVID-19 has accelerated this trend, necessitating a re-evaluation of the newspaper industry's future amidst the growing dominance of digital media. The introduction of radio marked the beginning of broadcasting, followed by the emergence of television as the subsequent "new media." However, with the rapid advancement of technology, television has now transitioned to the online realm. Local cable television networks have expanded their reach to a global audience, while terrestrial and satellite TV stations in Nepal have also made the shift to online platforms. The emergence of online television, alongside satellite, cable, and terrestrial TV, has transformed the concept of accessibility. Previously, it was challenging to determine viewership for specific programs, even when considering the ratio of televisions per population as stated in census data. Researchers used to rely on estimations based on ratings, which often included a margin of error. However, the introduction of Fiber to the Home, direct-to-home, and online streaming systems now enables real-time data on program popularity for television channels. Applications and video-sharing platforms provide live viewer counts, allowing anyone to track the number of viewers for live TV content. Furthermore, the rise of Over-the-Top platforms has revolutionized the production and distribution of cinema and television programs. These advancements have had a significant impact on print media. However, media operators express concerns about the potential for misinformation dissemination through social media, emphasizing the need to strengthen traditional media (Dahal, Shrestha, and Karki, 2022). As the landscape continues to evolve, striking a balance between the benefits of new media platforms and the integrity of traditional media becomes crucial for the industry's future. --- Patan Prospective Journal --- The Rise of Social Media as an Integral Component In recent times, social media has become an indispensable element for every media platform. This interdependence among different media outlets concerning news dissemination was not observed before. Rajendra Dahal, former president of Press Council Nepal and founding editor of Himal Khabarpatrika, shares his experience to illustrate this shift: "I listen to the newspaper on Radio Sagarmatha every morning. The radio broadcasts newspaper content, including editorials. I no longer need to read newspapers. Even through the radio, the content comes from newspapers. So, it doesn't matter if I read newspapers; it has also saved me time." (R. Dahal, personal communication, February 4, 2023) Radio stations now broadcast newspaper content in the morning, as do television channels. Furthermore, radio broadcasting has transformed into an audio-visual medium through social media platforms. Radio programs can now be watched by users on videosharing sites like 'TikTok', Facebook and YouTube. Just as newspapers began to be read on the radio, radio itself has evolved into a visual medium. As a result, the emergence of social media alongside traditional media necessitates a redefinition of mass media in the digital age. Presently, Kantipur Television is not solely reliant on its mobile application for broadcasting television content. Kantipur Television programs can also be viewed on videosharing sites like YouTube. As of June 5, 2023, Kantipur Television's YouTube channel has garnered 31 million subscribers. This significant viewership reflects the number of people who watch news and programs from Kantipur Television's video content shared on YouTube. Kantipur is not the only channel streaming traditional media content through social media. As of the study period, June 5, 2023, Nepal Television's YouTube channel has over 717,000 subscribers. Himalayan Television has surpassed 1.3 million subscribers, AP1 Television has amassed over 1 million subscribers, Avenues Television has gained more than 600,000 subscribers, and Sagarmatha Television has accumulated over 550,000 subscribers. The recently established television channel 'Galaxy 4K' has achieved an impressive 880,000 subscribers on its YouTube channel. through their Facebook page. Approximately 200,000 users also follow Kantipur Television on Twitter. Kantipur serves as just one example; other television channels and social media platforms like Facebook and Twitter are also extensively utilized. The reliance on satellite channels on social media platforms underscores the fact that traditional media cannot stay detached from the influence of social media. Most newspapers in Nepal are now available online, and it is rare to find news sites that do not integrate social media. Beyond media outlets, the ability to share personalized content has increased the number of online visitors engaging with social media platforms. Undoubtedly, as traditional media increasingly rely on social media, there is a transition in the role of agenda-setting to the new media. This shift is not solely due to the propagation of traditional media content on social platforms; rather, social media possesses distinct production and consumption attributes, constantly creating new influencers. Today, social media influencers wield more influence than television hosts, newspaper columnists, and radio presenters. Advertisers, who once favored traditional media, are now drawn to social media, underscoring the evolving impact of social media in its agenda-setting capacity. --- Social Media Dominates Social media has given rise to an influential brand in Nepal known as the 'Routine of Nepal Band' (RONB). Users across platforms like Facebook, Instagram, and TikTok take its content seriously, as it conveys various information and messages. According to its founder, Victor Poudel, RONB ensures that all content is uploaded only after undergoing multiple verifications, even though it is not a news media. In contrast, traditional media often presents news in a biased manner to serve certain interests. News outlets cater to numerous interest groups rather than prioritizing the public. RONB aims to provide a clear account of people's issues, which has fostered increasing trust among its followers (V. Paudel, personal conversation, 2023). Victor's argument is backed by the impressive reach of RONB's social media pages. As of June 5, 2023, Routine of Nepal Band has amassed 4 million followers on its Facebook page, 730,000 followers on Twitter, over 1.2 million followers on Instagram, more than 727,000 followers on TikTok, and nearly 200,000 subscribers on YouTube. The accessibility of diverse content through social media has rendered the need to seek information from original news sources obsolete. Furthermore, social media algorithms priorities topics of interest for users. Through the use of artificial intelligence, user preferences are determined, and technology itself determines which subjects will be presented to each individual (Dahal, 2023). --- Embracing an Alternative Path Traditional print and electronic media have often fallen short in addressing issues pertinent to the people. With the extensive scope of traditional media, not all subjects receive the attention they deserve, resulting in the filtering out of many important topics. Sudhir Sharma, the former editor of Kantipur Daily, argues that when social media, particularly YouTubers, pick up these filtered subjects, they gain popularity (S. Sharma, personal communication, February 11, 2023). This highlights the potential for social media to reach the same status as traditional media if it covers a wide range of sectors and genres. --- Patan Prospective Journal Since its inception, journalism through newspapers has served as a platform for exchanging ideas. However, the debates surrounding newspaper articles often failed to find space within the newspaper itself as a "public sphere." Similarly, radio and television discussions lacked room for dissenting thoughts in their studios. Audiences relied on these mediums to form opinions on various subjects, but there was minimal room for response or feedback within the one-way communication paradigm, known as the "Linear model." This is because, among the countless viewers or readers, only a few would have their voices acknowledged. The advent of the second-generation Internet, referred to as Web 2.0, introduced interactivity, challenging the established linear model of newspapers, radio, and television. This is the underlying reason why freely accessible social media pages like Routine of Nepal Bandh have become more influential compared to heavily invested traditional media outlets, including newspapers, radio, television, and online platforms. "If traditional media had provided free access to people's issues, the chances of social media becoming what it is today would have been very low" (V. Poudel, personal communication, June 2, 2023). As social media has become the primary channel for the exchange of ideas, individuals, organizations, political parties, and even leaders no longer wait for traditional means to convey their thoughts. During election periods, political activities are more prominent on social media than ever before, prompting the Election Commission to issue guidelines for social media usage. "The influence of social media has grown immensely. The guidelines were necessary as the uncontrolled spread of information became a concern. This issue is likely to become even more complex in the future" (D. Thapaliya, personal communication, February 7, 2023). --- Case Study 1: Campaign against Sexual Violence 'Occupy Baluwatar -2013' emerges as a groundbreaking "social media movement" against gender-based violence, setting an agenda that mainstream media fails to cover in Nepal. This movement highlights incidents ranging from financial exploitation of returning female migrant workers to rape cases. Microblogging platforms like Twitter and Facebook played a pivotal role in initiating this campaign, initially known as Occupy Baluwatar. Engaging young activists such as Jagannath Lamichhane, Vidushi Dhungel, Arpan Shrestha, Kashisdas Shrestha, Stuti Basnyat, Ishan, Sauvidhya Khadka, Ujwal Thapa, Pranika Koyu, the campaign aims to draw attention to the issue of gender violence (Shrestha, 2078 BS). According to activist Jagannath Lamichhane, Occupy Baluwatar was established in response to the government's failure to address the issue of gender violence, leaving a void that the movement seeks to fill, inspired by the persistent coverage by alternative media outlets. At the time of Occupy Baluwatar, only 25 per cent of the population had access to the Internet, and social media was still in its early stages. Although not as influential as it is today, social media connects a critical mass of urban-educated youth (J. Lamichhane, personal communication, February 23, 2023). The Occupy Baluwatar campaign symbolizes the collective passion of marginalized communities and draws inspiration from the social media-driven Occupy Wall Street movement in the United States. During the early stages of social media adoption, Occupy Baluwatar made a sensational impact in the realm of agendasetting. --- Patan Prospective Journal --- Case Study 2: Earthquake and Hashtag #GoBackIndianMedia The 2015 earthquake in Nepal showcases the diverse ways social media can be employed. During this period, social media served two main purposes. Firstly, it becomes a platform for coordinating rescue and relief efforts following the earthquake. Secondly, it plays a significant role in countering the aggressive portrayal of Nepal by Indian media. The hashtag "#GoBackIndianMedia" becomes a prominent case in point. Facebook, the most popular social media site at that time, hosted various groups dedicated to providing relief to earthquake-affected areas. People from all walks of life, including students, businessmen, and traders, joined these groups. Leveraging the strength of social media, these groups collected relief materials and distributed them in the affected regions. Simultaneously, a movement emerged to address the biased coverage of the earthquake by Indian media. As media content from India focused on sensationalism and ratings, a campaign against Indian mainstream media gained traction. This social media-driven campaign can be seen as a direct challenge to the mainstream media. The hashtag #GoBackIndianMedia originated organically on social media as individuals expressed their dissatisfaction. The campaign not only resonated within Nepal but also spread to India and Pakistan. On Twitter, the hashtag trended worldwide, holding the top position for a considerable duration. The significance of the campaign is evident from the fact that it remained a top trending topic on Twitter for 10 consecutive hours on World Press Freedom Day, May 3, 2015. The demand for the Indian media to leave Nepal stemmed from their biased, onesided, and insensitive reporting. By turning a tragedy into a television spectacle, Indian Prime Minister Narendra Modi's visit during the earthquake response was seen as a public relations exercise rather than a sincere endeavor to aid the country (Datta, 2015). Ramesh Aryal, a youth from Kathmandu, initiated the hashtag with the message "We love India but we hate Indian media" to warn the Indian media against misrepresenting the situation. The social media outcry compelled the Indian media to retreat. User-generated social media content has effectively set robust agendas and successfully challenged the influence of the powerful Indian media. During the local elections held in 2022, all eyes were on the Kathmandu Metropolitan City. It was during this time that an online news article highlighted the controversy surrounding the use of the national flag by Balendra Shah, the mayoral candidate for the Kathmandu metropolis. The article raised questions about the compliance of Balendra's actions with Nepal's laws regarding the national flag. Being a popular rapper with a significant following on social media, Balendra attracted considerable attention. --- Patan Prospective Journal Following the publication of the article, Balendra's supporters became actively engaged in an online campaign against the news outlet. They worked to diminish the number of Facebook likes for the news organization. Balendra's social media supporters responded aggressively on various platforms, including the mainstream media, even resorting to sharing news articles favouring Balendra to counter the attack. The trend of unfollowing on Facebook has surged to the extent that over one hundred thousand followers have unfollowed the Onlinekhabar Facebook page. This impact has also rippled into the newsroom. To mitigate the ongoing damage, Onlinekhabar has initiated the practice of publishing stories that support Balen Shah. The use of social media played a significant role when Balendra secured a resounding victory over candidates from the Nepali Congress and CPN-UML parties. Two prominent social media groups, Routine of Nepal Bandh and Meme Nepal, were instrumental in Balendra's electoral success. Despite his non-political background, these groups effectively promoted his candidacy. Given the ongoing shutdowns and strikes by political parties in Nepal, the Facebook page Routine of Nepal Banda emerged as a crucial platform for establishing the electoral agenda for the 2022 local elections. Additionally, the Meme Nepal Facebook page, with over 1.4 million followers, actively campaigned for Balendra Shah by creating videos, songs, and satirical content targeting opposition candidates. Apart from these two prominent groups, Balendra's election campaign extensively utilized organized and unorganized social media platforms such as TikTok, Twitter, and YouTube. The election results demonstrate the influence of social media and its ability to shape the agenda in the Kathmandu Metropolitan City elections, showcasing the power of online platforms in political campaigns. In the case of Balen Shah, Nepali traditional media fell short of effectively gauging his popularity. The discernible impact of social media on the agenda-setting process came to the forefront during this election. Source: Agenda-setting study, 2023. --- Can journalism serve as an alternative to agenda-setting? The case study sheds light on this question. While social media demonstrates its strong influence in agenda-setting, it raises an important and sensitive question about the role of mainstream journalism in this context. Experts involved in the study are asked to provide their insights, and they collectively agree that social media content may not undergo the rigorous editing process associated with journalism. Despite its agenda-setting function, social media is not purely a journalistic medium. It is concluded that while social media can disseminate information to the public, it does not necessarily provide news in the true sense. All the experts acknowledge that social media gains significance because mainstream media often fails to directly cover issues closely connected to the people. The "gap" left by the mainstream media's limitations is filled by social media platforms, particularly YouTube. Paudel, the founder of Routine of Nepal Bandh, criticizes mainstream media for conveying one-sided messages and becoming a tool for propaganda, a sentiment that resonates with other participants to some extent. It is not uncommon for media outlets Patan Prospective Journal Volume: 3 Number: 1 June 2023 Rishikesh Dahal 126 to face scrutiny when there is an imbalance in the flow of news and ideas. When social media highlights such issues, it provides an opportunity for mainstream media to improve. In other words, social media can be seen as a "social auditor" of mainstream media. However, there is a risk associated with social media in terms of promoting incorrect agendas due to the presence of raw and unverified content. In recent times, the rapid spread of disinformation, misinformation, and misleading messages through social media has become a concern. The erosion of credibility within the news media landscape is a multifaceted phenomenon, primarily attributed to political predisposition, corporate encroachments, and instances of self-imposed censorship. Within this milieu, notable political actors, including KP Sharma Oli, Rabi Lamichhane, and Balen Shah, have undertaken concerted endeavours to discredit conventional newsrooms, often harnessing the amplifying capabilities of social media platforms. Concurrently, newsrooms find themselves ensnared in a crisis of professionalism, contending with challenges to their integrity and objectivity, while influential political figures and social media influencers mount assertive campaigns against their legitimacy. --- Conclusion Simultaneously, traditional media outlets have been compelled to embrace social media in response to the growing reach and impact of technology. Organized social media groups have demonstrated their ability to wield greater influence than mainstream media, as exemplified by the mobilization surrounding Balendra Shah's election as the mayor of Kathmandu Metropolitan City. Social media has become the primary platform for addressing public concerns and shaping the agenda based on people's needs. Consequently, there arises a necessity to redefine the role of media as a whole. Just as the Fourth Estate monitors the three branches of government, social media has the potential to function as a "watchdog of the watchdogs." There have been inquiries on social media regarding the content produced by mainstream newsrooms. This scrutiny has prompted the newsroom to heighten its vigilance. Such monitoring via social media serves as an inspiration for journalism to fortify itself. Given these dynamics, it appears that social media could be positioned as a fifth estate. However, it is crucial to acknowledge the inherent risks of misinformation, as disinformation poses a constant threat to democracy. To harness the potential of social media as a catalyst for positive change, comprehensive reforms within traditional media are imperative. By doing so, social media can be integrated as a facilitator of constructive transformation, ensuring the dissemination of accurate and reliable information while maintaining democratic values. Political party leaders have placed significant emphasis on social media. The news sector has been utilizing content sourced from social media platforms. This underscores the increasing effectiveness of social media in its agenda-setting role. However, there is a pressing need for refinement in social media content. It is essential for all stakeholders within the media ecosystem to

This article examines the influence of social media on traditional media's role in shaping public opinion and agenda-setting in Nepal. Social media has emerged as a powerful medium, surpassing traditional media in terms of influence and reach. Drawing on the theoretical framework of agenda-setting, this study explores the current state of social media in Nepal. Using case studies and interviews with experts as primary sources and considering social media's purpose, use, and impact, the article presents a comprehensive analysis.The findings reveal that social media increasingly plays a stronger role in agenda-setting, while traditional media's ability to shape opinions and facilitate debates is diminishing. With its fast-paced dissemination, affordability, and visible impact, social media has overtaken traditional media in setting the agenda. However, the unrestricted production of content on social media poses risks, as it lacks an editing process. Traditional media, now relying on social media, faces intensified competition. To remain relevant and avoid weakening, news media must invest in content research and adapt to changing usage patterns. Upholding journalistic standards while leveraging the strengths of social media is crucial for traditional media in Nepal.

in the individual life course. Whereas the major theoretical frameworks that have been used to study adjustment to retirement (role theory, continuity theory, and the life course perspective) assume that retirement processes are related to experiences in the past, empirical insights regarding earlier life experiences and retirement adjustment are limited. The central question of this study is: To what extent and how can variation in retirement adjustment be explained by earlier life experiences? In the literature on retirement adjustment (see reviews by Van Solinge, 2012;Wang, Henkens, & van Solinge, 2011), several qualitative studies have pointed at the importance of life histories for understanding perceptions of retirement and adjustment (Barnes & Parry, 2004;Kloep & Hendry, 2006;Nuttman-Shwartz, 2004;Price, 2003). Earlier life experiences in the work, family, leisure, and health spheres seem to be associated with the ease of adjusting to retirement. However, insights regarding earlier life experiences and retirement adjustment based on quantitative studies are scarce. Only few studies explicitly pay attention to more distal life experiences. These studies examine the impact of either work histories (i.e., employment continuity) or family histories (i.e., marital stability) on retirement quality (Price & Joo, 2005;Quick & Moen, 1998) and retirement adjustment problems (Van Solinge & Henkens, 2005). This study aims to contribute to the literature on retirement adjustment in three ways. First, compared with earlier studies on life histories and retirement adjustment, we will build to a greater extent on the life course proposition of "multispheral development" (Settersten, 2003). Consistent with this proposition, we will not solely focus on earlier life experiences in one life sphere but simultaneously test the impact of earlier life experiences in the work, health, and family spheres on adjustment difficulties. Given that predictors of retirement adjustment might differ between men and women (Barnes & Parry, 2004;Calasanti, 1996;Szinovacz, 1992), we will pay attention to gender as a potential moderator of life history effects on retirement adjustment. Second, the retirement transition involves two developmental challenges: adjustment to the loss of the work role and the development of a satisfactory postretirement lifestyle (Van Solinge & Henkens, 2008). Most retirement adjustment studies are based on general measures of psychological comfort such as happiness (Calvo, Haverstick, & Sass, 2009), morale (Kim & Moen, 2002), life satisfaction (Calasanti, 1996;Hershey & Henkens, 2013), or retirement satisfaction (Quick & Moen, 1998), which do not distinguish between these developmental processes. This study aims to improve our understanding of the first developmental challenge-adjustment to the loss of the work role-by directly asking retirees about the extent to which they miss aspects of work since they retired. Missing work has been studied as a predictor of postretirement morale (e.g., Martin Matthews & Brown, 1987), satisfaction with retirement (McGoldrick & Cooper, 1994), and intentions to unretire (Schlosser, Zinni, & Armstrong-Stassen, 2012), but relatively little is known about the factors that predict this developmental facet of the postretirement process itself. Third, instead of using a general measure of missing work after retirement (cf. Skoglund, 1979;Szinovacz, 1992), we will pay attention to the multidimensional nature of the adjustment process. The loss of the work role might imply multiple changes, such as the loss of income, social contacts, status, daily structure, and purposeful activity. Not only might the ease of adjustment differ across these dimensions (Van Solinge, 2012) but also predictors might differ. As Taylor, Shultz, Spiegel, Morrison, and Greene (2007) argue, "a composite criterion that simply combines different dimensions may mask more complex relationships between the predictors of adjustment and particular facets of adjustment" (p. 1702). In this study, we focus on three work-related aspects that retirees might miss after retirement-money/ income, social contacts via work, and status-which resemble the dimensions that Van Solinge andHenkens (2005, 2008) distinguish in their measures of preretirement anxiety regarding the loss of the work role. Especially when examining the role of earlier life experiences in the adjustment process, it is important to study these dimensions separately, given that the direction of some relationships can be hypothesized to differ between dimensions. This article is based on panel data collected in 2001, 2006-2007, and 2011 among 1,004 Dutch older persons, who were all employed at the first wave of data collection and fully retired within the observation period. Retrospective information on earlier life experiences provides the possibility to study the relationships between life history experiences and adjustment. Resources and retirement transition characteristics-which are established correlates of retirement adjustment (Donaldson, Earl, & Muratore, 2010;Pinquart & Schindler, 2007;Wang, 2007;Wong & Earl, 2009)-will also be taken into account in the analyses. In the Netherlands, all individuals are covered by a flat-rate basic public pension scheme, and about 91% of employees are covered by earnings-related occupational pension plans in which participation is mandatory. Income replacement rates are relatively high (OECD, 2011). In recent decades, there has been a strong "early exit culture" in the Netherlands (De Vroom, 2004, p. 120) --- Theoretical Background The main theoretical perspectives that have been used to study variation in retirement adjustment are role theory, continuity theory, and the life course perspective (Van Solinge, 2012). Role theory assumes that the transition into retirement might be especially difficult for individuals who are highly invested in their work role and for whom the work role is central to their self-identity (Ebaugh, 1988). Continuity theory generally suggests that most adults will be able to achieve positive results adapting to life transitions because during their earlier life they have developed relationships, activities, frameworks of ideas, and adaptive skills that create continuity in their lives when making these transitions (Atchley, 1999). The life course propositions of lifelong and multispheral development imply that specific life periods cannot be understood thoroughly without information on preceding experiences in different life spheres (Settersten, 2003). To integrate these theoretical frameworks, Wang and colleagues (2011) propose a resource-based dynamic perspective for studying adjustment to retirement. In this perspective, adjustment is conceptualized as a process, which is dependent on individual resources and changes in resources. The extent to which retirees miss money/income, social contacts, and status can also be expected to be dependent upon the amount of financial and social resources offered by work, changes in these resources due to retirement, and the availability of alternative resources. Moreover, the importance individuals attach to specific work-related resources may play a role. --- Work History In the literature, two main arguments can be found that link work histories to retirement adjustment. Based on a financial argument, it can be expected that employment histories characterized by continuity and upward mobility are positively related to retirement adjustment (Quick & Moen, 1998). Given that pension benefits are dependent upon income and years of service, retirees with these work histories are likely to have an advantageous postretirement financial situation, which might facilitate adjustment to retirement (Donaldson et al., 2010;Wong & Earl, 2009). We therefore hypothesize that retirees who have worked continuously, full-time, or followed an upward career path are less likely to miss the money/income provided by work than those who had a more discontinuous career (Hypothesis 1a). Via a nonfinancial argument, adjustment to retirement can be expected to be relatively difficult for retirees who followed a continuous or upward work trajectory. These retirees may be highly attached to their jobs and might have had fewer opportunities to invest in alternative roles over the course of their working life (Barnes & Parry, 2004;Quick & Moen, 1998). In that respect, they might perceive the social changes associated with retirement as troublesome. We hypothesize that retirees who have worked continuously, full-time, or followed an upward career path are more likely to miss work-related social contacts (Hypothesis 1b) and status (Hypothesis 1c) than those who had a more discontinuous career. --- Health History The health situation of retirees is often found to be an important resource that enables retirement adjustment (Donaldson et al., 2010;Pinquart & Schindler, 2007;Wang, 2007). Insights regarding the effects of health problems earlier in life are limited though. The experience of severe health problems earlier in life can be expected to increase expenditures (e.g., on health care and medication) and suppress earnings (e.g., due to constraints in work capabilities), which might affect retirees' financial situation and adjustment negatively. We hypothesize that retirees who experienced severe health problems in midlife are more likely to miss the money/income provided by work than those who did not experience these health problems (Hypothesis 2a). Workers who have had health problems earlier in life might experience more difficulties adjusting to the social dimensions of the retirement transition as well. During midlife, they might have had fewer capacities to develop alternative roles, activities, and relationships next to work compared with those who did not experience health problems. Furthermore, persons in poor health might be less capable of replacing lost relationships (Broese van Groenou, Hoogendijk, & Van Tilburg, 2012) and sources of status by new ones, which might make the retirementrelated loss of these social resources relatively difficult. It can be expected that retirees who experienced severe health problems in midlife are more likely to miss work-related social contacts (Hypothesis 2b) and status (Hypothesis 2c) than those who did not experience these problems. --- Family History In studies on retirement adjustment, it is generally hypothesized that married retirees experience less adjustment problems than unmarried retirees (e.g., Donaldson et al., 2010;Reitzes & Mutran, 2004;Wong & Earl, 2009). The broad categories of whether retirees are married capture, however, a lot of diversity in terms of marital histories, which might be associated with retirement experiences (Price & Joo, 2005). Individuals who have ever been divorced have been found to have significantly lower wealth in preretirement years than the continuously married group, although remarriage partly offsets the negative divorce effects (Holden & Kuo, 1996;Wilmoth & Koso, 2002). A divorce earlier in life might also result in a relatively large drop in terms of income after retirement for the partner that earned the most during the marriage because of pension sharing. We hypothesize that retirees who have ever been divorced-both those who repartnered and those who remained single-are more likely to miss the money/ income provided by work than the continuously married group (Hypothesis 3a). Divorces are often accompanied with changes in social networks (Terhell, Broese van Groenou, & Van Tilburg, 2004). Although divorced persons are more involved with friends than persons in their first marriage, divorces negatively affect neighborhood contacts, participation in clubs (for women only), and outdoor recreation (Kalmijn & Broese van Groenou, 2005). Repartnering, however, seems to reverse negative effects of divorce on social integration. Moreover, having a partner can be expected to offer access to relation-specific resources (Van Solinge & Henkens, 2008) and to offer a stable role or identity (Reitzes & Mutran, 2004;Wang, 2007). Especially for divorced persons who remained single, therefore, the social contacts and status provided by the work role can be expected to be highly relevant. We hypothesize that divorced retirees without a partner are more likely to miss work-related social contacts (Hypothesis 3b) and status (Hypothesis 3c) than those who have continuously been married or repartnered after divorce. --- The Role of Gender In the literature on retirement adjustment, two main arguments can be found on the role of gender (see review by Van Solinge, 2012). On the one hand, women might experience less difficulties adjusting to the loss of the social dimensions of work than men, given that they have more experience in terms of role transitions and career interruptions, and might be more inclined to perceive the family role as their primary role. On the other hand, it can be expected that women experience more financial adjustment difficulties when leaving the work role compared with men, given that they might be more financially vulnerable due to their more interrupted work careers, employment in secondary labor market positions, and lower likelihood of being married. However, given that the previously discussed life history factors will capture many of these differences between men and women, gender differences in terms of adjustment to the loss of the work role-net of the life history effects-are expected to be limited. It might be the case, however, that the impact of certain earlier life experiences on adjustment differs between men and women. Previous research has shown that the financial status of women in later life is more strongly affected by prior marital dissolution than the financial status of men and persists until remarriage (Fokkema & Van Solinge, 2000;Wilmoth & Koso, 2002). Therefore, it can be hypothesized that the effect of being divorced and single on missing the money/income provided by work is stronger among women than among men (Hypothesis 4a). With respect to the social contacts dimension of missing work, the impact of being single and divorced can, however, be expected to be stronger among men than among women (Hypothesis 4b). The experience of a divorce has been found to have a significant positive effect on support from colleagues and acquaintances among men but not among women (Kalmijn, 2012). This suggests that colleagues are particularly an important source of social support for divorced men, which might make the social changes due to retirement challenging. --- Design and Methods --- Sample The NIDI Work and Retirement Panel data are three-wave panel data collected by the Netherlands Interdisciplinary Demographic Institute. In 2001 (Wave 1), data were collected among (a) a random sample of civil servants aged 50-64 years working for the Dutch central government and (b) all workers aged 50-64 years of three large Dutch multinational private sector organizations (active in information and communication technology, retail, and manufacturing). A mail questionnaire was sent to 3,899 older workers; in total, 2,403 questionnaires were completed (response rate 62%). In 2006-2007, a follow-up study was carried out among surviving and traceable participants of the first wave. A total of 2,239 questionnaires were mailed out, of which 1,678 were returned (response rate 75%). The third round of data collection took place in 2011 among all 1,638 surviving and traceable respondents of the second wave. The Wave 3 questionnaire was returned by 1,276 respondents (response rate 78%). The base sample for the analyses consists of 1,080 respondents who shifted from being in paid work at Wave 1 to being fully retired at either Wave 2 or Wave 3. Given that this study focuses on adjustment to retirement, those who did not make use of an (early) retirement arrangement but stopped working because of unemployment or disability (N = 47) were excluded from this base sample. Respondents for whom information on the dependent variables is missing (N = 54) or who did not answer the central questions regarding mid-career experiences (N = 22) were eliminated from the sample. This results in an analytic sample of 1,004 retirees. On average, respondents were retired for 2.5 years when they answered the adjustment questions. --- Measures --- Dependent Variables To measure adjustment to the loss of the work role across dimensions, fully retired respondents were asked during Waves 2 and 3 to report to what extent they miss various aspects of work since they stopped working. We used the responses provided at the study wave immediately following the respondent's full retirement. Missing money/income and missing social contacts via work were both measured by one-item indicators. Missing status was measured by a two-item scale (Cronbach's alpha =.79), which was constructed by taking the mean score of items that ask about the extent to which respondents miss self-esteem and prestige/status since they stopped working (Van Solinge & Henkens, 2005, 2008). Response categories ranged from 1 (very much) to 5 (not at all) but were reversely coded in the analyses. High scale scores indicate that respondents miss the specific work aspect very much. Social contacts are the work-related aspect that respondents are most likely to miss (M = 2.56, SD = 1.07), followed by financial resources (M = 2.38, SD = 1.05) and status (M = 1.56, SD = 0.78). In the multivariate analyses, we standardized the dependent variables to obtain effect sizes (Cohen's d) for the dummy variables. --- Independent Variables To measure continuity of the work career, respondents were asked to indicate the age at which they started working and for how many years in total they have been out of the labor market after that (if applicable). This information was used to calculate the number of years spent in the labor market at retirement. Specific work and health experiences in midlife were measured by two questions that asked for several life experiences-such as employer change, part-time work, and severe health problems-whether respondents had these experiences before age 40 and between ages 40 and 50. We constructed a dummy variable per life experience, indicating whether the respondent has had the particular experience before age 50 (cf. Damman, Henkens, & Kalmijn, 2011). Information about upward mobility was acquired via the question "how would you characterize the course of your career between ages 40 and 50" (1 = no upward mobility; 2 = gradual upward career path; 3 = steep upward career path). To measure marital histories, information about the marital and partner status (i.e., whether the respondent lives with a partner) is combined with retrospective information about whether respondents have ever been divorced. The following categories were distinguished: (1) married/cohabiting, never divorced; (2) married/cohabiting, ever divorced; (3) no partner, never married; (4) no partner, ever divorced; (5) no partner, widowed. In the analyses, we control for the respondent's gender, the study wave at which the dependent variables were measured (Wave 2 or 3), and the time elapsed since the respondent made use of an (early) retirement arrangement. In addition, given that resources and retirement transition characteristics are established correlates of retirement adjustment, we take preretirement financial resources, preretirement perceived satisfaction with life, subjective health, voluntariness of the retirement transition, and age at retirement into account. Table 1 presents the means, standard deviations, coding, and wording of survey questions for all variables. In general, item nonresponse was low (maximum 4.4% on the wealth variable) and was dealt with by using multiple imputation procedures (STATA 12: mi impute chained). The variables with missing cases were imputed 25 times using information from the dependent, independent, and control variables. Thereafter, the regression models are estimated for all these 25 data sets and the results are combined (STATA 12: mi estimate). --- Analyses The relationships between earlier life experiences and the different dimensions of missing work after retirement were analyzed by estimating linear regression models and combining the estimation results by seemingly unrelated estimation (SUE). SUE is an appropriate technique when estimating different equations based on the same data. It combines the parameter estimates and (co)variance matrices of the separate regression models (StataCorp, 2007), thereby allowing to test cross-equation differences between coefficients (see Van Solinge & Henkens, 2008, for an application). To deal with the structure of the data (employees of four organizations nested in organizational departments), we control for organization in the analyses and used standard errors that allow for intradepartmental correlation (cluster option in SUE). --- Results Table 2 presents the SUE results for the different adjustment dimensions. The models are estimated in two steps. In the first step, the relationships between earlier life experiences and missing money/income (1a), social contacts via work (1b), and status (1c) are examined. In the second step (Models 2a-2c), resources and retirement transition characteristics are added to the equations. --- Life History Experiences In Model 1a, the extent to which retirees miss money/ income is regressed on information about earlier life experiences and control variables. The results show that experiences in both work and family spheres are associated with missing financial resources after retirement. As predicted in Hypothesis 1a, those retirees who experienced an upward career path-either a steep or a more gradual upward trajectory-are less inclined to miss money/income after retirement than those who did not experience upward mobility. Examination of interaction effects with gender (not presented in the table) suggests, however, that the effect of gradual upward mobility is significantly stronger for men than for women (b(Gender <unk> Gradual) =.35, t = 2.39, p =.017). The steep upward mobility effect does not differ significantly by gender. As shown in Model 1a, the coefficients of years in the labor market, midlife employer change, part-time work, and severe health problems are not statistically significant. Regarding marital histories, the findings indicate that retirees who repartnered after divorce are more likely to miss financial resources than those who have continuously been married, as expected in Hypothesis 3a. Divorced retirees who remained single do not differ significantly from the continuously married group in terms of missing financial resources. The results regarding missing work-related social contacts after retirement are presented in Model 1b. None of the effects of the studied work and health history experiences is statistically significant. Marital histories, however, are found to be associated with missing work-related social contacts. As expected in Hypothesis 3b, divorced retirees without a partner are more likely to miss work-related social contacts than their continuously married and repartnered (b =.43, t = 2.57, p =.010) counterparts. Moreover, they are more likely to miss work-related social contacts than single never married retirees (b =.55, t = 3.08, p =.002). Whether we used the scores provided at Wave 1, 2, or 3, is dependent upon the type of variable and the moment at which the respondent shifted into full-time retirement. For those who were already fully retired at Wave 2, we used the Wave 2 measures of partner status, health, and retirement transition characteristics. For those who transitioned into full retirement between Waves 2 and 3, we used the Wave 3 measures of these variables. The earlier life experiences, preretirement financial resources, and preretirement perceived satisfaction with life were measured at either Wave 1 or 2. --- SE Coef. --- SE Coef. --- SE Coef. --- SE Coef. --- SE Coef. statistically significant. Regarding marital histories, the results show that single divorced retirees are more likely to miss work-related status than continuously married, single never married (b =.59, t = 2.26, p =.024), and single widowed (b =.69, t = 3.70, p <unk>.001) retirees. The difference with the repartnered group (b =.40, t = 1.70, p =.089) is in the expected direction but not statistically significant at the 5% level. --- SE With respect to gender, the results show that men and women do not differ significantly in their likelihood of missing money/income, social contacts, and status after retirement. Inspection of interaction effects suggests that the impact of marital experiences differs between men and women on some dimensions. As expected in Hypothesis 4b, the effect of being divorced and single on missing social contacts is smaller for women than for men (b(Gender <unk> No partner, ever divorced) = -.45, t = -1.92, p =.055) but is strictly not significant. For the other adjustment dimensions, the impact of being single and divorced does not differ between men and women. The effect of being repartnered after divorce on missing status is significantly smaller for women than for men (b(Gender <unk> Married/cohabiting, ever divorced) = -.39, t = -2.30, p =.022). F tests of cross-equation differences between coefficients show that the effect of a steep upward career path differs significantly across all three studied dimensions [money/ income vs social contacts (F = 5.95, p =.015), money/ income vs status (F = 15.54, p <unk>.001), and social contacts vs status (F = 5.51, p =.019)]: Those retirees that experienced a steep upward career path are less likely to miss money/income after retirement but more likely to miss status, whereas no association is found with missing social contacts. The coefficient of being single and divorced is significantly larger for missing status than for missing money/income (F = 10.15, p =.001). Another noteworthy result is the role of the control variable time elapsed since retirement, which differs significantly between the money/ income and social contact dimensions (F = 7.10, p =.008). The findings show that the more years have elapsed since retirees made use of an (early) retirement arrangement, the less likely they are to miss work-related social contacts. For the financial dimension, this effect is not statistically significant. --- The Role of Resources and Transition Characteristics In Models 2a-2c, resources and retirement transition characteristics are added to the equations. Preretirement financial resources are negatively associated with missing money/ income after retirement. For preretirement satisfaction with life, a negative effect on missing financial resources is observed as well. Those who had more financial resources and were more satisfied with life in preretirement years are less likely to miss financial resources after retirement. For the social contacts and status dimensions, these effects are not statistically significant. The perceived health situation of the retiree is relevant for all studied adjustment dimensions. Retirees in good health are less likely to miss work-related money/income, social contacts, and status compared with those in poor health. Also, a voluntary retirement transition is related to fewer adjustment difficulties on all studied dimensions. Those who retired at a relatively older age are less likely to miss money/income than those who retired earlier. For the social adjustment dimensions, the effect of age at retirement is not statistically significant. Comparing the effects of earlier life experiences between the life history models (Models 1a-1c) and the expanded models (Models 2a-2c) provides insights into the extent to which the effects of earlier life experiences are mediated by the established correlates of adjustment. The results show that the effects of career path and marital history generally remain statistically significant when taking resources and retirement transition characteristics into account, suggesting that these life history effects cannot be fully explained by the established correlates of adjustment. --- Discussion The difficulties retirees experience when adjusting to the loss of the work role are often assumed to be dependent upon experiences earlier in life. In line with the life course notion of multispheral development (Settersten, 2003), this study shows that earlier life experiences in both work and family spheres are associated with missing work after retirement. Regarding work histories, the findings show that retirees who had a steep upward career path in midlife are less likely to miss money/income, equally likely to miss social contacts, and more likely to miss status compared with those that did not experience upward mobility. These findings clearly point out that retirees can miss work for different reasons, depending on their career path in midlife. Probably, mid-career pathways "set the stage" (Settersten, 2003, p. 29) for experiences during late careers and one's postretirement situation-either by limiting or promoting resources and opportunities-and consequently shape retirement experiences. Marital histories were found to play a role as well. This study shows that divorced retirees without a partner are most likely to experience difficulties adjusting to the social changes accompanied with the loss of the work role. They were not only more likely to miss social contacts and status compared with continuously married retirees but also compared with single never married retirees, suggesting that among those living without a partner it is important to take diversity in terms of marital histories into account. Also, the long-term negative financial consequences of divorce experiences (Holden & Kuo, 1996;Wilmoth & Koso, 2002) are reflected in the data. Those retirees who repartnered after divorce were found to be more likely to miss financial resources after retirement compared with continuously married retirees. Generally, men and women did not differ in terms of their difficulties adjusting to the loss of the work role, although the implications of marital experiences were found to differ slightly by gender. As expected, being divorced and single has a slightly stronger impact on missing work-related social contacts for men than for women. Paying attention to the multidimensional nature of adjustment appears to improve our insights into the postretirement process. The results show differences across dimensions in terms of the incidence of adjustment difficulties and processes over time. Moreover, predictors were found to differ across adjustment dimensions, suggesting that some effects (e.g., career path) might have been overlooked when using a combined measure of missing work after retirement. Generally, social contacts were found to be the work-related aspect that retirees are most likely to miss. The longer individuals are retired, the less likely they are to miss work-related social contacts, which might either suggest that retirees compensate work-related contacts by other contacts or perceive work-related contacts as less important over time. For financial resources and status, the incidence of adjustment difficulties is lower and no time effect is observed. This may indicate that for many persons-at least in our Dutch sample-retirement is not necessarily associated with an important loss of financial resources or status. The lack of a time effect could suggest, however, that for those retirees who do miss financial resources or status, the likelihood of experiencing difficulties does not decline the longer they are retired. Probably, income and status remain important needs among retirees (Steverink & Lindenberg, 2006), which may be relatively difficult to compensate for after retirement. No support was found for the hypotheses regarding various work and health history factors (years in labor market and midlife employer change, part-time work, and health problems). These findings may suggest that not the amount of time employees have spent in the work role but rather the investments they made within the work role (reflected in upward mobility) shape their retirement experiences. For the interpretation of the research findings, it is important, however, to take the Dutch country context into account. With regard to retirement savings and income, much more is organized at a collective level in the Netherlands than, for example, in the United States where individual workers mainly carry the risks and responsibilities (see Van Dalen, Henkens, & Hershey, 2010, for a comparison of the Dutch and U.S. pension systems). Replacement rates are relatively high and the income poverty rates among the elderly are low (OECD, 2011). In this respect, especially adjustment to the loss of the money/income provided by the work role might be relatively easy in the Netherlands, and its relationships with earlier life experiences might be relatively weak. Whether the incidence and predictors of the different dimensions of missing work after retirement are similar in other countries is an important question for future research. Studying other routes of exiting the labor market, such as disability or unemployment, might also be a relevant venue for future research. Leaving work due to disability or unemployment is likely to result in much less favorable outcomes than the (early) retirement experiences examined in this study, given its relatively poor prospects and inherently involuntary character. Three limitations of this study should be kept in mind when interpreting the findings. First, we used rather broad retrospective questions to measure work and health histories, which might not have captured the meaning of the work role in sufficient detail. Moreover, several life history measures focus on the period before age 50 and therefore did not capture the years between age 50 and retirement. It might be the case that the impact of midlife experiences cumulates during one's late career and that these late-career experiences are more influential for shaping postretirement experiences. In future studies, it would be interesting to examine the role of both mid-and late-career experiences to disentangle their relative importance for explaining postretirement adjustment. Second, even though the retirees in the study sample form a highly diverse group in terms of earlier life experiences, resources, and retirement transition characteristics, they were all employed at four organizations. Therefore, the sample is not representative for Dutch older workers. Third, even though availability of information about the extent to which retirees miss work-related aspects is an important strength of the data, it should be noted that missing financial resources and social contacts were both assessed by single-item measures. For future research, it is advisable to develop multi-item scales to measure the three adjustment dimensions examined in this study, as well as other adjustment dimensions (e.g., adjustment to the loss of a daily structure). Despite these limitations, this study shows that adjustment to the loss of the work role is a multidimensional process embedded in the individual life course. The findings of this study raise important issues for policy and practice. For policymakers, the findings point out that changing life course experiences might have important implications for retirement quality of future cohorts. Whereas the lives of Dutch men and women born between 1931 and 1940 generally reflected the standard life course, life courses destandardized among cohorts born after 1950. Variation in behavior increased, for example, divorces became more common (Liefbroer & Dykstra, 2000). These developments might have important implications for the retirement experiences of future cohorts, given that divorced retirees were found to be most likely to experience difficulties adjusting to the loss of the work role. For retirement counseling, the results highlight the importance of not solely focusing on the current situation of older individuals but to view retirement as an integral part of the individual life course.

Although the process of adjustment to retirement is often assumed to be related to experiences earlier in life, quantitative empirical insights regarding these relationships are limited. This study aims to improve our understanding of adjustment to the loss of the work role, by conceptualizing retirement as a multidimensional process embedded in the individual life course. Design and Methods: Analyses are based on panel data collected in 2001, 2006-2007, and 2011 among Dutch retirees (N = 1,004). The extent to which retirees miss aspects of the work role (money/income, social contacts, status) is regressed on information about earlier life experiences, resources, and retirement transition characteristics. Results: The incidence of adjustment difficulties varies across dimensions. Predictors differ as well. A steep upward career path is associated with fewer financial adjustment difficulties but with more difficulties adjusting to the loss of status. Compared with continuously married retirees, divorced retirees without a partner are more likely to miss the social dimensions of work and those who repartnered are more likely to miss financial resources. The longer individuals are retired, the less likely they are to miss work-related social contacts. Implications: Changing life course experiences might have important consequences for retirement processes of future retirees.

Introduction Humanity's awareness of the growth of dangers and risks in all spheres of life determines the search for ways of minimizing and preventing them. The XXI century is marked by the problem of confrontation between the two worlds. One is formed by nature, without the participation and influence of man. The other is an artificial world formed as the result of human activity. Modernity is associated with fundamental changes in the functioning of the artificial environment, which separates man and begins to develop its own laws. As a result, the artificial is replacing the natural. An important role in the invasion of the artificial is performed by consumption. The special importance of studying consumption is emphasized in the report of the Stiglitz Commission (UN, 2009), which strongly recommends that in the assessment of socio-economic development and progress, the emphasis should be made on the measurement of production (GDP), but on the assessment of wealth, income and consumption. In this regard, the study of the characteristics of consumption and the identification of factors that determine their crisis dynamics become relevant. The sustainable development project makes one take a fresh look at the causes of the crisis and look for ways out in the sphere of consumption. The world community has identified social responsibility as the most influential lever on the path to sustainable development and provided its legal formalization through the international standards ISO 26000, ISO 14000, ISO 9001:2000, the UN Global Compact, etc. Ukraine has committed itself to the implementation of sustainable development. In Ukrainian society, social responsibility has not taken its proper place in the system of social relations, and has not become a conscious and used norm. And the need for it is growing rapidly. In this context, the relevance of the search for effective forms of social management on the social responsibility basis to consolidate social order is increasing. The aim of the study is the analysis of socially responsible consumption as a possible option to overcome the crisis caused by the transformation of technology into a determining factor in systemic changes in modern society. To achieve this goal it is necessary to perform the following research research tasks: 1) analyze the essence and place of social responsibility in the system of public relations; 2) consider the essence of the natural-artificial crisis in the context of ontology and the theory of dialectics; 3) show the relationship between consumer lifestyle and technocratic society; 4) assess the prospects for the use of socially responsible kinds of behavior in overcoming the naturalartificial crisis. --- Research methods The main provisions of the system of social responsibility and socially responsible relations were developed in the works of H. Jonas, I. Panarin, X. Lenk, and others. Various aspects of the formation and manifestation of social responsibility are covered in the works of E. Giddens, V. Windelband, T. Parsons; a close relationship between social cohesion and social responsibility is in the works of E. Durkheim, the search for the most effective means of goal-oriented behavior -M. Weber. T. Adorno, J. Delgado, K. Lorenz, H. Marcuse, M. Heidegger, M. Horkheimer, K. Jaspers laid the foundations for the crisis in the technocracy of modern civilization, the unevenness of the processes of material and spiritual development. The idea of "technohumanitarian balance" and the consideration of civilizational crises as its violation, associated with the acceleration of scientific and technological progress, is formulated in the works of V. Vinge, R. Kurzweil, A. D. Panov, A. P. Nazaretyan and others. A. Adler, A. Gehlen, H. Plesner, and others find the roots of the crisis in human biological insufficiency, for which social progress serves as compensation. The constantly renewing diversity of the world of technology, and its connection with natural and social problems requires reliance on the philosophical principle of complementarity, which makes it possible to carry out methodological synthesis in the process of studying the phenomenon of technology. The basis of the study is the ontological characteristics of technology given by M. Heidegger, showing the possibilities of technology in the unity of man, society, and culture. --- Research results Responsibility as a philosophical category defines the objectively necessary relationship between the individual and society on the basis of their mutual obligations, which are realized in conscious and volitional behavior and activities, regulatory mechanisms. In a broad sense, responsibility is one of the universal ethical regulators and principles of any social interaction and organization. Socially responsible relations are correlated with the processes of effective democracy, which is represented by the self-organization of the citizens themselves, their ability to make responsible consensus decisions and the logic of coordinated collective actions regarding the public good, harmonization of the interests of different social groups (Stepanenko, 2009: 358). Social responsibility is a category determining the degree of free manifestation by a social subject of his duty and right to choose, under specific conditions, the best option relating to reality, based on the progressive interests of society (Plakhotnyy, 1981: 8). There are three most important foundations-characteristics of social responsibility: the social subject, his freedom, and its degree. The social subject in this definition implies an individual, a social community, society, and, in the end, humanity as a whole. The object of social responsibility is various acts of activity and behavioral practices that are implemented in the system of social relations. Public awareness of the importance of social responsibility is the key to certainly expected achievements in this area. Due to the peculiarities of this category, which is inherently multifaceted, its understanding is not limited to any one definition or concept. Social responsibility penetrates the entire system of social relations, characterizes a certain type of behavior, and recreates the level of culture and moral qualities of a person and society. The desire for a systematic vision of social responsibility and its manifestations necessitated the orientation of scientific research towards the simultaneous study of the features of the social responsibility of an individual, society, business, and state, applying to the natural and the artificial. For the first time, the ratio of "artificial and natural" as a philosophical problem arose in Antiquity. In particular, Aristotle defined some existing objects as those that exist by nature, and others -due to other reasons. Everything formed "by nature" has the beginning of motion and rest in itself. On the contrary, what is artificially formed does not have an innate impulse for change. In Antiquity, the idea dominates, according to which the natural (nature, cosmos) is an ontological value, and the artificial -only as a "derivative" of it -is "secondary". At the same time, nature and space are divine, animated, and sacred. In the Middle Ages, the idea of the "creature" of nature prevails, which loses the halo of divinity, acting as a peculiarly understood "product" of God. Starting from the 15th century the idea of replacing "short-lived" natural nature with artificial "nature" becomes one of the fundamental components of technogenic civilization. By the XX century, the artificial world has become so significant, influencing nature, that mankind began to understand that the natural world must be protected. There is no single technological complex on planet Earth. However, within the framework of philosophical studies, the artificial world is considered as a single object (V. S. Stepin, A. P. Nazaretyan, E. S. Demidenko, others), referring to the fact that the global level of some technogenic changes has been reached. Technogenic impact on nature proceeds in three directions: -direct technological modification of natural processes and systems for the purpose of their economic use (depletion of natural resources, territorial displacement of biocenoses, etc.); <unk>сник <unk>. <unk>ер<unk>: <unk>лосо<unk>. <unk>ул<unk>туроло<unk>. -2022. -No 1 (35) -indirect (unpredictable and almost uncontrollable) impact of the technogenic environment on the biosphere through climate transformation (through technogenic changes in the background radiation, chemical environment, etc.); -impact on living beings through a change in biospheric cycles and interactions caused by the extinction of other biological species (which triggers biospheric mechanisms of self-regulation). The technosphere as a manifestation of the artificial, expanding farther and farther, steps on the natural and thereby displaces man himself. An attack on nature in general is associated with an attack on the moral nature of man (Drotianko, 2021: 12). Technocracy marks the beginning of the post-human era, in which there is less and less of man and nature. Human consciousness does not keep pace with progress. The dangers of the technosphere are growing faster than man is getting smarter. E. Toffler's work "Future Shock" describes a production cycle that establishes a cycle of death-rebirth, accelerated renewal of things, thanks to which fashion is created and its mobility is affirmed. The standards for using things are changing towards one-time use or shortterm use, and then being replaced by a newer model, which gives rise to a "throw-away culture". A whole chapter is devoted to the issue of using a thing -"Things: the throw-away society", in which he describes a new type of relationship with things that do not imply getting used to them: shopaholism, consumerism and throwing away. The category of "old", which dominated in the traditional culture is being replaced by the category of "new." The new is precisely the permanently new, the minimal new is the "other" at the moment of its appearance, and the period of interaction with things becomes as short as possible and is increasingly signified only by the phase of familiarization. Hence there is the growth of the pathos of disposable things, although their quality and their price are often not commensurate with a one-time appeal to them. The phase of parting with things also undergoes similar changes: "... if the period of getting used to a new environment is compressed in time, then the period of weaning from the old conditions is also reduced" (<unk>оffler, 2003: 122). J. Baudrillard states: "We are experiencing the time of things: I want to say that we live in their rhythm and in accordance with their continuous sequence. Today we see how they are born, improved and die, while in all previous civilizations there were things, tools or durable monuments that lived longer than generations of people" (Bodriyyar, 2006: 5). On the one hand, things reach moral faster than physical obsolescence, which makes it impossible to become attached to a thing, and on the other hand, consumer products are often deliberately intended to be short-lived, that physical aging occurs in a much shorter time than its counterparts. "It is often more profitable to replace a thing than to fix it. Therefore, it makes more economic sense to produce cheap, nonrepairable disposable products..." (<unk>оffler, 2003: 68). Consumption also contributes to the further growth of production, because the needs (real or constructed by the consumer system) determine production. Direct functionality, the high quality of a thing associated with it, and, accordingly, its long-term use completely contradict the discourse of fashion and consumer culture, and therefore only symbolic functionality is acceptable for this discourse. Quality is compensated by quantity and symbolic utility. Today, the man -thing relations are characterized by an ever-increasing interest in the consumption of symbols and signs, a kind of virtualization of a thing, which is noted by many researchers of modern culture. That interest in the thing, which has been known for many centuries of human history, is now being modified into an interest in the symbol of the thing. If a thing of the past demonstrated status, class affiliation, or anything else of that kind, today this function is not fixed in a thing: the meaning can be anything, including negative, and the absence of meaning is also possible. The thing turns into a text that, according to the laws of postmodernism, is not obliged to educate, contain or appeal to any intelligible idea at all. The essence of the sign and symbol conveyed by the thing can be understood only by the author of the idea, or by some group associated with it: the thing as a text is of interest in the light of the game process, which includes fragments of texts from other cultures or subcultures. It is no longer necessary for man to own a thing, he only uses it, not trying to keep it for a long time, but changes it immediately, as soon as a newer thing appears. An illusion arises that the suffocation of traditional culture with its hoarding is being replaced in our world by the antisuffocation of free consumerism. Thus, the destabilization/degradation of the natural environment is only one side of the coin of the problem: the other is the formation of an integrated environment of a new type. This is evidenced by the data that the "techno-substance" in terms of annual mass turnover exceeds the bio-substance of land by 1-2 orders of magnitude, and the energy capacities of technoprocesses have already caught up with geological ones (Balandin, 2005). In such conditions, the adaptive apparatus of man is under double pressure, and in our opinion, we are talking not only about the tension of existing mechanisms but also about the need to develop new ones. So, if the expansion of "classical" industrial factors in the technosphere has been gradually unfolding for quite a long time, then the modern rapid development greatly complicates the preservation of the natural and adaptation to the new technized reality. In the sphere of the general public, various forms of protest against consumerism are brewing. Further searches within the framework of this topic can be focused on the study of socially responsible attitudes in the individual and public consciousness as a type of social responsibility. In order to introduce the principles of sociallyresponsible consumption into everyday life, it is necessary to make a comprehensive effort for the whole society. First of all, it will be necessary to form socially responsible thinking for all participants: the state, business, and citizens. In this regard, the study identified the main methods for the formation of socially-responsible consumption from the standpoint of these three levels. In order to prevent an increase in the anthropogenic load on the environment, the state must control the activities of economic entities and create the necessary conditions for the formation of socially responsible consumption. Regulation of the activities of companies by the state can be both voluntary and mandatory. The main methods can be the following: legal regulation; development of national standards; development of social advertising. In order for a business to fully express itself as a supporter of socially responsible consumption, it needs to: raise standards in the industry, review business models and processes by major manufacturers, implement circular economy models and increase supply chain transparency (observance of ethical principles throughout the supply chain). For civil society, the following are the main methods of forming socially responsible consumption: downshifting, freeganism, anti-consumerism, primitivism, and enathism. The ideas of rationalizing home space are becoming very popular: minimizing things, and the possibility of transforming them in order to increase functionality. Another option is to go into creativity, allowing one to shift personal interests, and not external relations with things. The efforts of anti-consumer (highly artistic, highly intellectual, humanistic, etc.) tendencies are absorbed by what these efforts are directed against. The world of consumption appropriates the subversive movements of thought and action, makes them serve its own purposes, subjecting them to recoding, commodification, that is, turning into a market commodity, as a result of which the former subversiveness disappears from them. It is able to neutralize not the social ideas and slogans themselves that call for specific actions, but their image, a symbol, from which the ideological potential that was once inherent in them is eventually forced out. Using the example of the creation of a "capsule wardrobe" (S. Faux), one can see how the legalization of anti-consumer ideas ends with a real consumer: from the idea of limiting the number of things in the wardrobe, this movement goes all the way to a clearly fixed set of clothing items, with specified brands and terms of operation. All of these features strictly correspond to the ideology of consumerism, and the individual himself is deprived of the need for self-criticism, forming another element in the series of consumers who manifest latent consumerism disguised as anti-consumerism. The same thing happens in the choice of styles. So, minimalism, which seems to limit the number of things in the interior, actually illustrates the same consumer-type behavior, having at its disposal clearly marked objects, brands, budget, and other features for its implementation. It is the illusion of anti-materialism that becomes a part of modern fashion. A paradoxical situation arises, where consumerism is hidden under the mask of non-attachment to things. All this gives rise to a situation in the modern world that one would like to call anti-suffocation because formally its requirements are met: there is no getting used to the thing, and the desire to possess fades into the background. The modern technocratic is insatiable in consumerism. Therefore, the forecasts of scientists about the coming ecological catastrophe are quite justified. The united planet can seriously react to insane consumption in an attempt to attract the attention of a greedy human consumer who, armed with the idea of anthropocentrism, neglecting ecology and turning nature from a thing-in-itself into a thing-exclusively-for-us, ceased to be a reasonable person and began to feverishly use resources outstrip the viability of the ecosystem. Nature began to be presented as an area that resisted purposeful human activity, and the tasks of science and technology were reduced to finding ways to overcome this resistance. --- Discussion Permanent innovationism, expressed in the cult of revolutionary continuity, is extremely harmful since with it the new serves the development of culture and the sociosystem, but their complete denial in favor of the invented. The focus on progress should not be limited to itself. It needs to have some kind of socially useful metagoal, a super-task, in relation to which progress is a means, an instrument of achievement. The correct formula is new is not for its sake, but "new is for society". Any innovations require an assessment in relation to themselves from the standpoint of the prospects that they are able to give to man and society. The new should not destroy the old, but improve or supplement it because any socio-cultural development is limited by certain limits. In this focus, the way is being paved for social responsibility, which is not associated with a destructive trend of cardinal destruction of the past culture and sociosystem, but involves its systematic improvement. It is necessary to move not forward to the progress of technology, which turns into its intellectual, moral, environmental, etc. costs, but upward movement, toward the improvement of man, society, and culture. According to the apt expression of V. Kutyrev, if progress is not stopped, and death is not avoided, there is no need to push it, but to rush it (<unk>utyrev, 2012: 86-96). Society is called to develop, not to stand still, but the process of development cannot be frozen by superconservatism, nor given complete freedom by boundless innovation. Responsibility for the future is becoming one of the key conditions for modern people to preserve the future for future generations, given the threat of possible environmental disasters. Gradually, information about environmental degradation is becoming a more and more public concern, and the issue of socially responsible consumption is becoming interesting and relevant not only for consumers but also for businesses and the state, which provide goods and services to citizens. Socially responsible consumption is those actions and decisions on a purchase that are connected with problems of depletion of an ecological resource. The transformation of the consumption model involves awareness of the environmental, social, and economic consequences of decisions made in the process of consumption (Skyba, 2021: 150); the desire to eliminate or minimize any harmful effects associated with the consumption of certain goods and maximize any beneficial, positive effects; taking into account the requests of stakeholders and society as a whole when making appropriate decisions; willingness to assume certain obligations and follow certain restrictions. --- Conclusion The modern relationship between man and the environment is in a state of extreme disequilibrium. This is due both to the growth of loads on its natural part and to the hypertrophy of the technogenic component. The challenge of our time is the harmonization of the development of the artificial world with the natural environment. Processuality, flexibility, omnipresence (penetration in all areas of human activity) of modern technologies change the ways of production and ways of consumption. Socially responsible consumption involves the purchase, use, and disposal of products based on the desire of the consumer to minimize or eliminate any harmful consequences of his choice and to have the maximum beneficial effect on society. Socially responsible consumption is comprehensively formed by raising the level of responsible behavior of the state, business, and individuals. --- <unk>. <unk>. <unk>исова --- <unk>-<unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk>ннота<unk>и<unk>. <unk>тат<unk> <unk>осв<unk>ена анали<unk>у со<unk>иал<unk>но-ответственно<unk>о <unk>отре<unk>лени<unk> как вида со<unk>иал<unk>но<unk> ответственности, о<unk>условленно<unk>о <unk>урн<unk>м ростом те<unk>нос<unk>ер<unk>, т.е. инте<unk>ра<unk>ии те<unk>ноло<unk>и<unk> в о<unk>ество и кул<unk>туру. <unk>он<unk>тие «те<unk>нос<unk>ера» отра<unk>ает сво<unk>ство те<unk>ники не остават<unk>с<unk> в виде локал<unk>н<unk> у<unk>равл<unk>ем<unk> о<unk>ектов, но <unk>ормироват<unk> <unk>елостну<unk> среду. <unk>овременное состо<unk>ние те<unk>но<unk>енно<unk> <unk>ивили<unk>а<unk>ии мо<unk>но на<unk>ват<unk> кри<unk>исом и<unk>-<unk>а в<unk>теснени<unk> естественно<unk>о искусственн<unk>м. <unk>е<unk>но<unk>енное о<unk>ество, как ква<unk>и<unk>риродное о<unk>ра<unk>ование, вос<unk>ринимает норм<unk> те<unk>ни<unk>еско<unk> де<unk>тел<unk>ности как естественн<unk> <unk>ори<unk>онт ра<unk>вити<unk> со<unk>ти<unk>. <unk>олитика со<unk>иал<unk>но-ответственно<unk>о <unk>отре<unk>лени<unk>, <unk>ротиво<unk>оставленна<unk> де<unk>стви<unk>м коммер<unk>ески<unk> кор<unk>ора<unk>и<unk>, <unk>реследу<unk>и<unk> <unk>инансово-<unk>кономи<unk>еские <unk>ели <unk>а с<unk>ет о<unk>ественно<unk>о <unk>ла<unk>ососто<unk>ни<unk>, в <unk>астности в во<unk>роса<unk> о<unk>ран<unk> окру<unk>а<unk>е<unk> сред<unk>, со<unk>иал<unk>но<unk> страти<unk>ика<unk>ии, <unk>а<unk>вл<unk>ет о се<unk>е как <unk>орма <unk>ра<unk>данско<unk>о и <unk>олити<unk>еско<unk>о де<unk>стви<unk>. <unk>л<unk>ев<unk>е слова: искусственное, естественное, со<unk>иал<unk>на<unk> ответственност<unk>, со<unk>иал<unk>но-ответственное <unk>отре<unk>ление, усто<unk>ивое ра<unk>витие, те<unk>но<unk>енна<unk> <unk>ивили<unk>а<unk>и<unk>. --- <unk>. <unk>. <unk>исова --- <unk>-<unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk>сту<unk>. <unk> стол<unk>тт<unk> <unk>о<unk>на<unk>ене <unk>ро<unk>лемо<unk> <unk>ротисто<unk>нн<unk> дво<unk> св<unk>т<unk>в. <unk>дин створени<unk> <unk>риродо<unk>, <unk>н<unk>и<unk> -<unk>ту<unk>ни<unk> св<unk>т, <unk>о утворивс<unk> в ре<unk>ул<unk>тат<unk> д<unk>л<unk>ност<unk> л<unk>дини. <unk>ето<unk> статт<unk> <unk> анал<unk> со<unk>ал<unk>но-в<unk>д<unk>ов<unk>дал<unk>но<unk>о с<unk>о<unk>иванн<unk> <unk>к мо<unk>ливо<unk>о вар<unk>анту <unk>одоланн<unk> кри<unk>и, викликано<unk> <unk>еретворенн<unk>м те<unk>ноло<unk> на один <unk> ви<unk>на<unk>ал<unk>ни<unk> <unk>актор<unk>в системни<unk> <unk>м<unk>н у су<unk>асному сус<unk>л<unk>ств<unk>. <unk>л<unk> реал<unk>а<unk> дано<unk> мети нео<unk>дно вир<unk>ити так<unk> досл<unk>дни<unk>к<unk> <unk>авданн<unk>: <unk>роанал<unk>увати сутн<unk>ст<unk> <unk> м<unk>с<unk>е со<unk>ал<unk>но<unk> в<unk>д<unk>ов<unk>дал<unk>ност<unk> в систем<unk> сус<unk>л<unk>ни<unk> в<unk>дносин; ро<unk>л<unk>нути сутн<unk>ст<unk> кри<unk>и <unk>риродно<unk>о-<unk>ту<unk>но<unk>о <unk> <unk>о<unk>и<unk> теор<unk> д<unk>алектики; <unk>ока<unk>ати в<unk>а<unk>мо<unk>в'<unk>ок с<unk>о<unk>ива<unk>ко<unk>о с<unk>осо<unk>у <unk>итт<unk> та те<unk>нократи<unk>но<unk>о сус<unk>л<unk>ства; о<unk>нити <unk>ерс<unk>ективи використанн<unk> со<unk>ал<unk>но-в<unk>д<unk>ов<unk>дал<unk>ни<unk> вид<unk>в <unk>овед<unk>нки дл<unk> <unk>одоланн<unk> кри<unk>и <unk>риродно<unk>о-<unk>ту<unk>но<unk>о. <unk>етодоло<unk> досл<unk>д<unk>енн<unk>. <unk>номан<unk>тн<unk>ст<unk> св<unk>ту те<unk>н<unk>ки, <unk>о <unk>ост<unk>но оновл<unk>т<unk>с<unk>, <unk> <unk>в'<unk>ок <unk> <unk>риродними та со<unk>ал<unk>ними <unk>ро<unk>лемами вима<unk>а<unk> <unk>верненн<unk> до <unk>лосо<unk>с<unk>ко<unk>о <unk>рин<unk>и<unk>у в<unk>а<unk>модо<unk>овн<unk>ваност<unk>. <unk>е<unk>ул<unk>тати досл<unk>д<unk>енн<unk>. <unk>о <unk> стол<unk>тт<unk> <unk>ормуванн<unk> <unk>ту<unk>но<unk>о <unk>л<unk>сно<unk>о середови<unk>а <unk>ри<unk>вело до деста<unk>л<unk>а<unk>/де<unk>рада<unk> <unk>риродно<unk>о середови<unk>а. <unk>л<unk> в<unk>ровад<unk>енн<unk> <unk>рин<unk>и<unk>в со<unk>ал<unk>но-в<unk>д<unk>ов<unk>дал<unk>но<unk>о с<unk>о<unk>иванн<unk> у <unk>овс<unk>кденне <unk>итт<unk> нео<unk>дно докласти ком<unk>лекс <unk>усил<unk> <unk> <unk>оку дер<unk>ави, <unk>несу та <unk>ромад<unk>нс<unk>ко<unk>о сус<unk>л<unk>ства. <unk>е<unk>ул<unk>ванн<unk> дер<unk>аво<unk> д<unk>л<unk>ност<unk> ком<unk>ан<unk> ма<unk> в<unk>д<unk>уватис<unk> на до<unk>ров<unk>л<unk>н<unk> та о<unk>ов'<unk>ков<unk> основ<unk> <unk>а до<unk>омо<unk>о<unk> <unk>равово<unk>о ре<unk>ул<unk>ванн<unk> та ро<unk>ро<unk>ки на<unk>онал<unk>ни<unk> стандарт<unk>в. <unk> мето<unk> <unk>ере<unk>оду <unk>несу на стандарти со<unk>ал<unk>нов<unk>д<unk>ов<unk>дал<unk>но<unk> д<unk>л<unk>ност<unk>, нео<unk>дним вида<unk>т<unk>с<unk> <unk>дви<unk>енн<unk> стандарт<unk>в в <unk>алу<unk> виро<unk>ни<unk>тва та с<unk>ер<unk> наданн<unk> <unk>ослу<unk>; <unk>ере<unk>л<unk>д <unk>нес-моделе<unk> та <unk>ро<unk>ес<unk>в виро<unk>ни<unk>тва <unk> <unk>верненн<unk>м до <unk>ерева<unk> в<unk>ровад<unk>енн<unk> <unk>иркул<unk>рно<unk> економ<unk>ки. <unk>л<unk> <unk>ромад<unk>нс<unk>ко<unk>о сус<unk>л<unk>ства <unk>д в<unk>ливом со<unk>ал<unk>но<unk> реклами ма<unk>т<unk> <unk>осил<unk>ватис<unk> антис<unk>о<unk>ив<unk> тренди. <unk>оворенн<unk>. <unk>осеред<unk>ен<unk>ст<unk> на <unk>ро<unk>рес<unk> не ма<unk> <unk>а<unk>навати а<unk>сол<unk>ти<unk>а<unk>. <unk>отр<unk>на сус<unk>л<unk>но корисна мета-<unk>л<unk>, над<unk>авданн<unk>, <unk>о в<unk>дно<unk>енн<unk> до <unk>ки<unk> <unk>ро<unk>рес висту<unk>а<unk> <unk>асо<unk>ом, <unk>нар<unk>дд<unk>м дос<unk>ненн<unk>. <unk>равил<unk>на <unk>ормула -<unk>е «нове не <unk>аради ново<unk>о», а «нове дл<unk> сус<unk>л<unk>ства». <unk>исновки. <unk>ро<unk>есуал<unk>н<unk>ст<unk>, <unk>ну<unk>к<unk>ст<unk>, <unk>роникненн<unk> в ус<unk> с<unk>ери л<unk>дс<unk>ко<unk> д<unk>л<unk>ност<unk> су<unk>асни<unk> те<unk>ноло<unk> <unk>м<unk>н<unk>т<unk> с<unk>осо<unk>и виро<unk>ни<unk>тва та с<unk>осо<unk>и с<unk>о<unk>иванн<unk>. <unk>о<unk>ал<unk>но-в<unk>д<unk>ов<unk>дал<unk>не с<unk>о<unk>иванн<unk> <unk>еред<unk>а<unk>а<unk> ку<unk>вл<unk>, використанн<unk> та утил<unk>а<unk> <unk>родук<unk>, ви<unk>од<unk>и <unk> <unk>а<unk>анн<unk> с<unk>о<unk>ива<unk>а м<unk>н<unk>м<unk>увати а<unk>о усунути <unk>уд<unk>-<unk>к<unk> <unk>к<unk>длив<unk> насл<unk>дки <unk>о<unk>о ви<unk>ору <unk> максимал<unk>но <unk>ла<unk>отворно в<unk>ливати на сус<unk>л<unk>ство. <unk>о<unk>ал<unk>но-в<unk>д<unk>ов<unk>дал<unk>не с<unk>о<unk>иванн<unk> ком<unk>лексно <unk>орму<unk>т<unk>с<unk> <unk>л<unk>ом <unk>дви<unk>енн<unk> р<unk>вн<unk> в<unk>д<unk>ов<unk>дал<unk>но<unk> <unk>овед<unk>нки дер<unk>ави, <unk>несу та окреми<unk> ос<unk>. <unk>л<unk>ов<unk> слова: <unk>ту<unk>не, <unk>риродне, со<unk>ал<unk>на в<unk>д<unk>ов<unk>дал<unk>н<unk>ст<unk>, со<unk>ал<unk>но-в<unk>д<unk>ов<unk>дал<unk>не с<unk>о<unk>иванн<unk>, стали<unk> ро<unk>виток, те<unk>но<unk>енна <unk>ив<unk>л<unk>а<unk>.

Вступ. В статті обґрунтовується теза, що з одного боку, правові інститути виконують конкретну законодавчо-правову функцію. З іншого боку, сила закону може блокуватися з політичних, економічних чи інших умовних причин. У сучасному глобальному правовому соціумі сформувався загальний образ правових інститутів, який, як єдина модель, «накладається» на інші, існуючі в ньому, моделі, нібито «підганяючи» їх під себе. «Правовий інститут», як такий, виконує свою класичну функцію як механізм та сукупність правил, що регулюють ту чи іншу сферу діяльності, як спеціальний, закріплений у нормативно-правових актах різного рівня, порядок регулювання суспільних відносин, заснований на встановлених та забезпечених державою правових засобах. Глобальний правовий інститут регулює суспільні відносини, засновані на встановлених та забезпечених тим чи іншим об'єднанням держав правових засобах. Метою даного дослідження є концептуалізація ключових детермінантів розвитку глобальних правових інститутів та експлікація даного терміна в рамках сучасного соціально-філософського та філософськоправового дискурсу. Ключовим завданням стало осмислення феномену глобальних правових інститутів та його впливу на сучасний глобальний правовий соціум. Соціально-філософський та філософсько-правовий методологічні принципи дозволили: розглянути глобальні правові інститути, їхню структуру, механізми формування соціальних зв'язків крізь призму сучасного суспільства, людини, культури, релігії, права; виявити зв'язки глобальних правових інститутів з іншими явищами права; зафіксувати когерентність сформульованих та кодифікованих правових норм з базовими ідеями та моральними цілями, що лежать в їхній основі; оновити понятійний апарат соціальної філософії та філософії права в частині трактування правових інститутів. У результатах дослідження доведено, що ключові детермінанти глобальних правових інститутів є відображенням глобальної системи права з точки зору її структури, а також логіки її розвитку. Логічні зв'язки між структурними ланками глобальних правових інститутів встановлюються за умови створення найстійкішої глобальної наддержавної правової системи. Такий логічний зв'язок визначається характером, обсягом, якістю та змістом суспільних відносин, на перший погляд опосередкованих правом. У дискусії підтверджено, що глобальні правові інститути можуть сформуватися на стику різних наднаціональних та наддержавних утворень, об'єднань, спілок, альянсів. Вони представлені як сукупність юридичних норм, що регулюють відносини усередині цих утворень. У висновках доведено, що ключовими детермінантами глобальних правових інститутів є: правове регулювання норм та протоколів через наявність множини глобальних несхожих правових систем; несиметричність норм юридичної відповідальності, де теоретична та практична моделі юридичної відповідальності часто не корелюють через складність конструкції цілісної глобальної правової системи.

Introduction Groups of people who are systemically marginalised within a society have poorer health outcomes than those who have access to safe living conditions, non-hazardous work, a living wage, and educational, health and social welfare institutions (Wilkinson & Marmot 2003). These types of resources are frequently considered to be'social determinants of health' (SDH), a term that broadly encompasses 'the conditions in which people are born, grow, develop, live, work, and age' (Viner et al. 2012). Importantly, the constellation of SDH that disadvantages a specific group's health may also make its members unable or unwilling to engage in research: residential mobility, fear of arrest, non-comprehension of a national language, or a lack of transportation can all be barriers to optimal health and to research participation (George, Duran & Norris 2014). This has the potential to more deeply entrench health inequities as populations that go unstudied cannot benefit from interventions, treatments and services tailored to their needs (Dodgson & Struthers 2005;Wilson & Neville 2009). To build a comprehensive body of knowledge about how SDH operate within a specific social context, researchers must begin by considering how various vulnerabilities and oppressions may affect people's experiences of being recruited, interviewed and retained in a study. For example, members of a population that have suffered threats of deportation may be wary of interacting with people from outside their community and thus be challenging to reach through standard recruitment and retention channels (Teedon et al. 2015). Likewise, a longstanding history of exploitation of low-resource communities by researchers who were not members of those communities could be another barrier to people's willingness to participate (Cacari-Stone et al. 2014;Sudhinaraset et al. 2017) Wallerstein et al. 2014, Sudhinaraset, Ling et al. 2017. Such exploitation by outsiders can have a negative impact that reverberates far beyond the research study itself. For example, the disclosure of the infamous Tuskegee Study of Untreated Syphilis in the Negro Male, conducted by the United States Health Service from 1932 to 1972, has been found to be correlated with 'increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men' (Alsan & Wanamaker 2018). A local population's sense of distrust or wariness about exploitation can also arise in the context of community-based organisations if they are perceived as being overly accountable to political funding sources or other outside interests (Marwell 2004). If populations underrepresented in research choose to enrol in a study, research or survey questions developed for mainstream populations may not resonate with them or adequately allow for their experiences, which may lead to discomfort, frustration or distress, as well as a perception among community members that research is unhelpful. A lack of consonance between a population and the questions being asked also could result in incomplete or poor quality data, and potentially an investment of funds in research that yields few results of interest or improvements in population health. Under these circumstances, the risk of further stigmatisation and negative labelling of communities through the research process is all too real, and a problem-based approach can create a pathologising lens for researchers that obfuscates the strengths of communities. In this article, we discuss the A Crecer ('To Grow') study, which examines SDH among Latino youth living in an agricultural community. We undertook this study with the knowledge that factors which potentially make these youth vulnerable to poor health outcomes may also pose specific challenges to enrolling them as research participants. We therefore understood that it was imperative from the outset of the study to develop methodological strategies that actively addressed these challenges in ways that were culturally responsive, community engaged and inclusive. As we set ourselves to this task, we interpolated our own identities in order to be reflexive about how members of this community would see us as 'outsiders', or different from them, as well as our shared experiences and commonalities. Within this article's authorship team (hereafter referred to as 'our team'), which was responsible for the design and leadership of the study, two of us identify as Mexican American and two as children of immigrants. Some of our families struggled to make ends meet during our childhoods, including by working in the agricultural field economy, while others of us had the privilege of financial security. Prior to attending college, a few of us lived in neighbourhoods or attended schools that experienced elevated levels of teen pregnancy and violence. None of us grew up in the community where we conducted our research, although one author has lived and worked there for over 30 years and another was raised in a similar community in California. In designing our approach, we understood that the youth we sought to enrol in our study and their families would consider us to be outsiders, and therefore our methodological strategies needed to address issues of building trust and rapport. With this in mind, we generated a series of questions about best practices for conducting research with rural Latino youth that shaped our research development and implementation: (1) How can we best develop and strengthen community relationships and community engagement in the research? (2) What considerations are important when staffing our study, and how can we best support staff to do this work? (3) How can we engage youth's perspectives in this study? (4) How can we develop culturally appropriate research protocols? Below we present the methodological strategies developed in response to these questions and used in A Crecer to recruit and retain a longitudinal cohort of 599 youth. We begin with a review of the literature to situate our work methodologically within other efforts to engage marginalised and oppressed populations in health research, as well as conceptually at the junction of adolescent health, SDH and rural Latino youth. Next, we provide an overview of the study purpose and settings to contextualise the community in which we work. We then detail our methodological strategies as they relate to our best practice questions. We conclude by reflecting on our experiences undertaking this research, including the importance of sustaining a focus on community strengths and implications of this process for future studies. --- Methodological approaches to engaging marginalised populations in health research Research with members of marginalised populations has a long and troubled history that emphasises the importance of thoughtful engagement with such groups. Certain populations may be difficult to recruit and enrol in health studies because of well-founded misgivings about the trustworthiness of researchers, but others may be elusive because 'public acknowledgement of membership in the population is potentially threatening' (Heckathorn 1997). This frequently includes people who are at risk of arrest, harassment or violence due to a specific activity (e.g. drug use or sex work) or characteristic (e.g. undocumented immigration status). Under these circumstances, participating in research may take on additional risk either because the topic of the study identifies someone as having a vulnerable status, or because being involved in a study could make someone easier to find or to prosecute if there were a breach of confidentiality. Multiple methodological approaches have been developed in epidemiologic research to grapple with such challenges. Respondent-driving sampling (RDS), for example, constitutes one strategy that engages participants through their trusted social networks, a design that uses structured incentives and chain-referral methods to reach 'hidden populations' (Heckathorn 1997). As its name implies, RDS offers a recruitment strategy, yet does not necessarily address issues of marginalisation or vulnerability at other stages of the research process (e.g. study staffing, research instruments). Another methodological approach that has been adopted for public health research is community-based participatory research (CBPR). A defining feature of CBPR is the cultivation of inclusive partnerships with shared decision-making and ownership of the research process (Israel et al. 2013). Building trust and respect between researchers and communities is foundational to successful CBPR work, yielding research that addresses locally identified needs, recognises a community's assets, supports co-learning between diverse partners and is positioned to address health disparities (Minkler & Wallerstein 2008). CBPR is particularly effective in informing the development of interventions that address SDH (de Sayu & Sparks 2017), and CBPR methods have been applied to numerous public health issues, with successful examples found in areas ranging from chemical exposure for nail salon workers (Quach et al. 2013) to hepatitis B vaccination (Ma et al. 2017). For research on adolescents, youth participatory action research (YPAR), is a form of CBPR that aims to engage youth directly (Berg, Coman & Schensul 2009;Langhout & Thomas 2010). Several YPAR publications have focused on the opportunities for, and challenges encountered in, building empowerment and leadership development with youth, as well as defining a feasible and actionable research agenda (Madrigal et al. 2016;Ozer et al. 2013). In this article, we describe our approach to designing and implementing the A Crecer study as guided by best practices in community-engaged research inspired by CBPR. The processes of CBPR have been explicated in detail, and there are manuals guiding the use of CBPR approaches (Minkler & Wallerstein 2008). However, applications of the CBPR framework may vary across stages of the research, and some research teams may not be equipped to fully adopt CBPR methods -which can be intensive -at all phases. We recognise that we did not follow the CBPR framework to the extent necessary to exemplify this methodology in its fullest sense. However, through our awareness of our positionality as outsiders to the community and the concomitant need to build trust and rapport, we understood the benefit of incorporating the principles of respect for community stakeholders and responsiveness to community needs. Despite increased use of community-engaged methods in research, there are few examples in the literature outside of CBPR-specific studies that explore how to establish multi-sectoral partnerships, build trust and engagement among partners, and advance a thoughtful research agenda that integrates the insights of local perspectives with research expertise (Farquhar et al. 2014;McQuiston et al. 2005). Our goal in this article is to elucidate our efforts in these domains. Before providing an overview of our study purpose and setting, we situate our work conceptually within the literature on Latino youth in agricultural communities. --- Adolescent health, social determinants, and rural populations The health of adolescents is strongly shaped by SDH, including proximal SDH, such as family, education, employment and peers, as well as structural factors such as city ordinances, local criminal justice policies and national legislation. There is global and national recognition that the health of young people has generally been neglected, leading to young adults''surprisingly poor health' in the words of the Institute of Medicine (Institute of Medicine and National Research Council 2014;Resnick et al. 2012;United Nations Secretary-General 2015). The Lancet Commission Report on Adolescent Health and Wellbeing highlights the importance of addressing 'inequalities in health and wellbeing in socially and economically marginalized adolescents, including ethnic minorities', among other groups (Kleinert & Horton 2016). Eliminating health disparities in the United States constitutes a national goal reflected in Healthy People 2020, and addressing SDH is a core strategy for achieving this goal (Satcher 2010). The ability to improve adolescent health is limited by a lack of technical knowledge and capacity to intervene, including a dearth of evidence regarding the effects of SDH on youth and a shortage of evidence-based interventions and policy. The scarcity of research is most evident among the youth who are most affected by inequities, including ethnic minorities, lowincome youth and the children of immigrant parents (Auerswald, Akemi Piatt & Mirzazadeh 2017). Latino youth living in rural areas lie at the intersection of these categories. Most of these youth grow up in immigrant families, whether as immigrants themselves or as children of immigrants (Economic Research Service 2017) and frequently one or more members of these families is involved in low-paid seasonal agricultural labour (Lopez & Velasco 2011). The existing research on Latino youth has focused primarily on urban Latino populations (Raffaelli, Iturbide & Fernandez 2016), but the few studies that have focused on rural youth in the United States have reported similar or higher levels of risk behaviour, particularly alcohol and other substance use, as well as lower uptake of preventive sexual health services compared to urban youth (Roberts et al. 2017;Vielot et al. 2017;Wang, Becker & Fiellin 2013). These studies indicate a clear need for in-depth longitudinal research focused specifically on rural Latino youth. While proximal individual-level factors associated with risk behaviours may be similar among rural youth to those found in urban populations, current intervention approaches do not address SDH specific to Latino adolescents living in rural areas, such as the influences of the agriculture-based economy and the dominance of Mexican (im)migration. Understanding these underlying contexts and how they might be contributing to health disparities is recognised as vital to achieving substantive improvements in health outcomes (Bronfenbrenner 1994;Krieger 2012;Marmot 2005). Notably, the Centers for Disease Control and Prevention has identified addressing urban-rural health disparities related to health care access as a national priority (Healthy People 2020). The relationships of structural and interpersonal factors in rural environments to poor health outcomes for Latino adolescents therefore constitute a largely unexamined but vitally important research area. However, conducting rigorous research with rural youth presents numerous challenges that are common to working with other populations facing health disparities. Our goal in A Crecer, from a methodological perspective, was to address these challenges by developing a set of best practices for engaging the local community and being inclusive in our approach to conducting rigorous research that would yield knowledge that was useful and actionable. We turn now to the study purpose and setting, followed by a discussion of our methodological strategies and innovations for developing and strengthening community relationships, staffing the study, engaging youth's perspectives and developing culturally appropriate research protocols. --- Study purpose, setting and sample A Crecer was designed to examine the multi-level factors that influence Latino adolescents' wellbeing (including resilience, future orientation and educational engagement), as well as the onset of youth violence and sexual health risks associated with teen child-bearing. The study, which began in 2014, focuses on the transition from middle school to high school, a critical developmental period, thus examining trajectories through middle adolescence. Recruitment began in November 2015 and the full sample was enrolled by March 2017. Data collection is ongoing with a cohort of 599 youth. Study participants complete a questionnaire at baseline and then every six months over the course of two years. All study procedures, including written consent provided by study participants, were approved by the RTI International Institutional Review Board. A Crecer is being conducted in Salinas, California, which offers a vibrant environment for a community-engaged study of the protective factors that influence rural Latino adolescent trajectories. Salinas is a migration destination for agricultural sector employment and is home to multiple generations of immigrants. Eighty-nine per cent of Salinas public middle school students identify as Latino, nearly all of Mexican origin (Salinas Union High School District 2017). Salinas has a strong history of community organising for farmworker rights, engaged families and rich cultural ties. However, alongside these assets, youth experience high rates of entrenched poverty (82 per cent of middle school youth are considered socioeconomically disadvantaged), gang exposure and teen child-bearing A Crecer's approach to the cultivation of community partnerships, study staffing, engagement of youth perspectives and development of research protocols contributed to the successful recruitment of our targeted study sample. Figure 1 presents a diagram of enrolment efforts, starting with recruitment of 1099 8th grade youth from the four middle schools that comprise the school district with which we partnered for this study. Youth were approached on school campuses by bilingual research staff members (see 'Staffing the study' below) under the leadership of the Project Coordinator (Marisol Chavez). With input from youth advisers engaged during the formative research stage, staff created a brief, interactive 'pitch' for the study that they could deliver in classrooms and to small groups of students in schoolyards. During recruitment, eligible youth were asked to provide contact information for a parent who could provide permission for them to enrol in the study. The telephone-based verbal parent permission process was directed by a script that allowed for an interactive conversation with the study staff member initiating the permission process. These conversations were held in English or Spanish, depending on the parent's preferred language. As depicted in Figure 1, study staff successfully made contact with 870 of the 1081 households. A parent gave permission for their child to participate in 92 per cent of cases. The 600 youth who enrolled in the study did so with an average of 4.9 contact attempts from recruitment through enrolment (median=4; range=1-29). As presented in Table 1, the staff recruited a sample of youth that met the study objectives of balance between male and female youth, geographic distribution of residence within the community and variation in sociodemographic indicators. Nearly all youth identified as Latinx (94 per cent), mostly of Mexican origin. Half (49 per cent) of participants had at least one parent employed as a farmworker, 60 per cent resided in crowded housing conditions (based on the US Census definition) and 42 per cent had mothers who did not complete high school. 1 Percentages add to >100% as participants may have more than one origin. Given these multiple vulnerabilities, we see the robust number of youth interested in study participation, the willingness of their parents to permit children to be enrolled and the achievement of an ambitious sample target as evidence that our efforts to undertake best practices for community-engaged and inclusive research were well received. We turn now to describing those efforts. --- Conducting research with rural Latino youth: A Crecer's approach As noted, from the outset of A Crecer we challenged ourselves to respond to a series of questions about best practices for conducting community-engaged and culturally inclusive research with Latino youth living in Salinas. Understanding our status as people who were not members of this community, we firmly believed in the importance of undertaking research that respected community norms, listened to community voices and addressed questions of community concern. In the following sections, we detail the methodological strategies and innovations we generated and implemented in our efforts to build trust and rapport throughout the design of the study, development of the research protocols and recruitment of the study sample. We begin with our approach to the first question: How can we best develop and strengthen community relationships and community engagement in the research? --- COMMUNITY RELATIONSHIPS AND ENGAGEMENT: DEVELOPMENT OF THE PROPOSAL The A Crecer study developed as a partnership between the Principal Investigator (PI, Alexandra Minnis), who is based in San Francisco (roughly 145 kilometres north of Salinas), and the Monterey County Health Department's Youth Violence Prevention Coordinator (YVPC, Linda McGlone), who has coordinated teen pregnancy prevention, youth violence prevention and other prevention efforts in Salinas for over 20 years. Through her work, the YVPC has established relationships with diverse leaders and agencies working to improve adolescent health in the community. In 2011, she learned of the PI's research with Latino youth in San Francisco and invited her to present at the Natividad Medical Center Grand Rounds. This initial meeting led to interest in developing a collaborative research proposal that could examine the intersection of sexual health and youth violence in Salinas. Over the subsequent 18 months, the PI and YVPC established regular professional interactions, exchanging research articles, discussing the community environment in Salinas and planning the grant proposal. As a long-time and well-known Health Department employee with extensive professional network ties in the community, the YVPC was able to actively facilitate early support for the project locally and build connections between the PI and a diverse range of local leaders, including identifying a local co-investigator (Co-I) for the study at Natividad Medical Center. To inform the research design and refine the research questions in the grant proposal, the PI and YVPC met to discuss potential study objectives and the types of community perspectives that could provide ground-level insights into the core issues and concerns affecting youth in Salinas. In order to learn about those perspectives, they decided to conduct a set of informational interviews with community stakeholders. Drawing on the YVPC's decades of work in Salinas and strong relationships with community leaders and organisations, they identified key individuals and groups, including directors of youth leadership and gang prevention programs, a middle school teacher, former gang members working to stem gang involvement, a local city council leader, community health clinicians and social service providers. When conducting the initial interviews, they adopted an iterative strategy of asking the key informants to whom they spoke whom else they should approach to discuss the study. In total, they conducted 12 informational interviews. Some of these individuals joined the study's Community Advisory Board (CAB) and many agreed to support A Crecer as partner organisations to facilitate parent engagement and local visibility. The PI and YVPC also solicited youth input through a discussion with peer leaders at a local high school. In addition to these joint meetings, the YVPC helped to mobilise support with the school district, the mayor, the local congressman and the Community Alliance for Safety and Peace, a coalition comprised of over 50 agencies working to reduce violence in Salinas. This process was crucial to the design of the study as the research questions and approach reflected ideas and reactions offered by the individuals interviewed. Most importantly, the research concept resonated with community stakeholders and stimulated great interest in supporting an effort to generate high-quality data to guide future prevention policies and programs. Many stakeholders discussed community-level influences on youth's trajectories, including gender and family norms; housing instability and employment structures for farmworker families; intergenerational gang involvement; and differences in access to community resources by immigrant generations. These factors informed our approach to identifying protective and risk factors in youth's social and structural environments. The A Crecer grant proposal was first submitted to the National Institutes of Health in 2012, resubmitted in 2013, and funding commenced in August 2014. --- COMMUNITY RELATIONSHIPS AND ENGAGEMENT: SCHOOL DISTRICTS AND COMMUNITY STAKEHOLDERS Once A Crecer funding began, the PI and YVPC focused on strengthening partnerships with the school district and community stakeholders. They jointly attended multiple meetings with school district administrators, during which they presented the project, emphasising how the study goals were aligned with those of the school district for supporting student success. They also met with individual school site teams, including principals, counsellors and parent liaisons (who were responsible for parent-school coordination). The process of soliciting input from a diverse set of community leaders at the proposal design stage established foundational relationships that supported the development of A Crecer's CAB. Convened by the YVPC and the Co-I, the CAB has met quarterly since the inception of the study. When recruiting members for the CAB, the YVPC and Co-I contacted a variety of colleagues working in youth development, teen pregnancy and violence prevention who were well respected within the community and known to be credible and trusted among local groups. Tapping their networks accelerated development of the CAB, attracting engaged and enthusiastic members. Current CAB membership mirrors the racial and ethnic demographics of Salinas and includes parent representatives, school representatives, a grassroots organiser of women working in agriculture, Salinas service providers, the local hospital's Co-Director of Community Medicine, and teen radio coordinator of the local bilingual radio station, among others. The CAB advises the study on outreach strategies to parents, as well as recruitment and retention approaches. For example, CAB members suggested the development of a website featuring the logos of member organisations in order to strengthen the perceived legitimacy of the study and deepen community connections; subsequent feedback from participants' parents indicated that these endorsements boosted A Crecer's credibility as a study that was genuinely invested in the local community. In addition, A Crecer data are presented to the CAB for input on interpretation and analysis, which is a particularly important 'validity check' for the members of our team who are not based in Salinas. To achieve language inclusivity at the meetings, simultaneous translation in Spanish is offered. --- STAFFING THE STUDY: COMMUNITY-ENGAGED PROFESSIONAL DEVELOPMENT In addition to valuing the importance of grounding research in community partnerships, we asked ourselves : What considerations are important when staffing our study, and how can we best support staff to do this work? A focal point of our approach to this question has been our commitment to employing young adults from the local community as research staff, particularly because none of the senior staff members grew up in Salinas and we felt it was important to include local voices in our daily work. By bringing community members to the table as salaried employees, encouraging dialogue and soliciting input, we hoped to increase accountability of the research to the people it would ultimately affect. Furthermore, it was congruent with our ultimate goal, as a study seeking to support resilience and opportunities for youth, to invest research funds in creating jobs that could provide exposure to career paths in public health research to current undergraduates and recent graduates from the community. To maximise visibility, A Crecer job announcements were listed online, posted on local community college and state university job websites, sent to the youth collaborative of Monterey County and disseminated by CAB members. In an effort to reach potential applicants who might not otherwise have considered working in research, job descriptions emphasised the desirability of skills such as knowledge of local culture and ability to establish rapport with youth. During the period from the study launch to enrolment of the full cohort, A Crecer employed a total of seven Salinas-based staff members, including five originally from the broader Salinas Valley and two from similar communities in California. Six of the seven members of the staff identified as Latinx, and all were bilingual in Spanish and English. Five staff members had attended a local college or university. For five staff members A Crecer was their first job upon completion of an undergraduate or Masters program as well as their first experience working in research. Extensive training in research methods was provided to the A Crecer research staff. Inperson sessions facilitated by San Francisco-based staff were valuable not only in terms of building capacity and skills among the newly hired junior members, but also in providing opportunities for the junior members to share knowledge about youth in Salinas with the more senior members, and for team bonding. Trainings included topics such as ethics and adherence to Institutional Review Board protocols; effective recruitment techniques; quantitative interview administration; in-depth qualitative interviewing; adolescent development and health issues; SDH research; and how to provide facilitated referrals for distressed participants. Several presentations of local public health data by Monterey County Health Department staff strengthened knowledge of adolescent health inequities. Trainings were ongoing and responsive to the needs of the junior research staff. For example, when staff members remarked that numerous participants were worried about firearm incidents that had taken place in town, an adolescent health physician from the research team (Marissa Raymond-Flesch) conducted a session on techniques for supporting youth exposed to violence and self-care for staff working with vulnerable youth. --- INCORPORATING YOUTH'S PERSPECTIVES The question, How can we engage youth's perspectives in this study?, has been central to A Crecer from its inception. As a means of learning about youth's perspectives early in the study, we convened eight focus groups with youth recruited from participating middle schools as well as from Salinas youth leadership programs. (Findings from these focus groups have been published elsewhere; see Raymond-Flesch et al. 2017) Recruitment for these groups was conducted using strategies developed with input from the Principal or Vice-Principal at each school, as well as the CAB. Information sessions, held on campus at lunch, offered students an opportunity to learn about A Crecer, sign up for a focus group and talk informally with members of the research staff. To secure parental support for the focus groups, we solicited input from local implementers of family-based prevention programs and met directly with parents during regularly scheduled parent meetings at each of the middle schools where the focus group recruitment was to be conducted. At each parent group, the study staff introduced A Crecer and its objectives; modelled a focus group discussion with the parents, having them role play the activities that would be conducted with participants during the group; discussed parent permission approaches; solicited input on what parents saw as the greatest needs for youth in the community; and offered an interactive educational session on adolescent health issues at a future date. These presentations were either bilingual or conducted in Spanish. Each presentation was led by one member of the San Francisco-based team or the local Co-I and a bilingual and bicultural field coordinator who was from the Salinas community. A total of 42 youth participated in the eight focus groups, which followed an innovative structure. Rather than posing questions to the entire group, youth were engaged in a series of activities aimed at generating conversation. In the first activity, participants used stickers to rank their relative agreement or disagreement with statements about family, gender and relationships (e.g. 'It is very important for a guy to get respect from others', 'A woman must be a source of strength for her family'). They were then encouraged to discuss why and how strongly they agreed or disagreed with each statement. In the second activity, participants drew maps of their community, with prompts to include their home, school, recreational areas and transportation methods, and to indicate places where they felt safe and unsafe. Participants then presented their maps to the group, indicating points of interest and providing further details (see Figure 2). Focus group findings informed questionnaire development and recruitment strategies. For example, youth's strong orientation towards family as their primary source of health guidance and modelling pathways to adulthood, prompted us to expand the scope of measures related to family included in our questionnaires. In response to requests from parents of focus group participants to have an opportunity to learn more about the research and to contribute to the design of the parent engagement and permission procedures for the cohort study, the Salinasbased Co-I led a meeting for eight parent leaders from two middle schools, two of whom subsequently joined our CAB. We also convened a Youth Advisory Board (YAB) to provide guidance on study activities. In addition to conducting activities to engage youth in understanding the purpose of the research, the YAB served to inform the development of the study name (A Crecer) and logo through an art workshop, the design of study flyers, the development of recruitment messages that would resonate with youth, and the development of the referral guide for youth services and activities in Salinas that is distributed to all participants during their study visits. --- DEVELOPMENT OF CULTURALLY APPROPRIATE RESEARCH PROTOCOLS Our final best practices question, How can we develop culturally appropriate research protocols?, is of utmost importance to our team. We aim to conduct rigorous research that will yield knowledge that is useful and actionable to those directly concerned with the health and wellbeing of youth in Salinas and similar agricultural areas. It is therefore tremendously important that youth and their parents feel comfortable with, and preferably enthusiastic about, participation in the study. To this end, the A Crecer team actively solicited and incorporated information regarding local culture, terminology and norms to inform recruitment and interviewing procedures for the cohort study. We drew heavily on the knowledge and insights of the Salinas-based staff members, led by the Project Coordinator, particularly regarding how to best approach youth and their parents about study participation. Staff framed the study as exploring 'what it is like to be a teen in Salinas', and encouraged students to consider participating as a way to'share your voice' and contribute to the community. The staff also noticed that peer leaders could quickly set the tone for whether youth would express interest in study participation, and they consciously adopted strategies of'matching the tone' of exuberant students, generating a sense of shared enthusiasm, while also telling students that they could join the study with friends and come to interview appointments together. As recruitment proceeded, the staff noted that they had developed ways of adjusting recruitment to different environments (schoolyards vs classrooms), groups ('popular' kids as compared to quieter youth who kept to themselves) and even schools (noting that students in some schools wanted many details about participation, whereas in others the main focus was on concerns about confidentiality). Early on in their recruiting, the Salinas-based staff discerned that both youth and their parents had concerns about what was meant by a'research interview'. Realising that many people think of an interview in terms of what is seen on television news or talk shows, the staff began proactively explaining the quantitative interview more concretely. For example, they described the survey as'multiple choice' and reiterated that youth could skip any questions they did not want to answer. They also specified that the answers were entered directly into a computer, which youth and parents alike found reassuring, often telling staff that they had been concerned that youth would be asked to write down responses. These explanations also helped parents understand A Crecer as a research study, as opposed to an after-school program. In addition, the staff learned that parents were sometimes hesitant to enrol their children in A Crecer because they feared negative consequences for their child if they were unable to bring him or her to an interview appointment. The staff therefore made sure to explain to parents that children were never penalised for missing appointments. They also clarified that parents did not need to stay on site during the interview, recognising that many parents had multiple responsibilities and could not spare the time to wait. These efforts to assuage parents' concerns yielded not only higher numbers of enrolled study participants, but also a sense of pride among students and their parents who began to see study participation as a way of contributing to the community and benefiting youth. Building on this perspective, we partnered with local school officials to arrange for youth to receive community service hours for their participation in A Crecer. Focus group findings also informed procedures for recruitment and obtaining parent permission for the cohort study. Based on parent feedback obtained through recruitment for the focus groups, the staff developed a telephone-based verbal parent permission process that ensured parents had opportunities to talk privately by phone and also to meet staff in person, either at our study office or at one of the five community-based interview locations, in advance of having their child enrol in the study. Concerns about literacy were also raised by youth during the focus groups, which confirmed our decision to use audio computer-assisted self-interviewing (ACASI) for the more sensitive questions, and staff emphasised during recruitment that youth were not required to read or write on their own in order to participate. Finally, we made use of multiple opportunities to build legitimacy within the community. For example, on two occasions, Salinas-based staff members were interviewed by a teen-led youth radio show that aired on a bilingual radio station as a means of raising awareness about the study and demonstrating engagement with the community. --- Discussion When conducting studies on SDH in communities that experience inequalities and marginalisation, researchers must be mindful of how the same conditions that may shape health disparities may also affect whether and how community members engage with research. We take A Crecer's ability to engage parents and school partners, achieve enrolment targets and sustain high retention to date as indicators that our approach has been successful, not only by research but also by community standards. Importantly, this engagement has also helped us to ensure that our research focus is well aligned with parents' and youth's priorities and community objectives regarding the promotion of adolescent wellbeing. While A Crecer brings attention to challenges faced by youth in Salinas and an evidence base for tailored solutions to address these challenges,

The health of adolescents, perhaps more than in any other period of their life, is shaped by the social determinants of health (SDH). The constellation of SDH that disadvantages a specific group's health may also make members of that population unable or unwilling to engage in health research. To build a comprehensive body of knowledge about how SDH operate within a specific social context, researchers must design studies that take into account how various vulnerabilities and oppressions may affect people's experiences of being recruited, interviewed and retained in a study. In 2014, we initiated a prospective cohort study with Latino youth DECLARATION OF CONFLICTING INTEREST The author(s) declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

staff emphasised during recruitment that youth were not required to read or write on their own in order to participate. Finally, we made use of multiple opportunities to build legitimacy within the community. For example, on two occasions, Salinas-based staff members were interviewed by a teen-led youth radio show that aired on a bilingual radio station as a means of raising awareness about the study and demonstrating engagement with the community. --- Discussion When conducting studies on SDH in communities that experience inequalities and marginalisation, researchers must be mindful of how the same conditions that may shape health disparities may also affect whether and how community members engage with research. We take A Crecer's ability to engage parents and school partners, achieve enrolment targets and sustain high retention to date as indicators that our approach has been successful, not only by research but also by community standards. Importantly, this engagement has also helped us to ensure that our research focus is well aligned with parents' and youth's priorities and community objectives regarding the promotion of adolescent wellbeing. While A Crecer brings attention to challenges faced by youth in Salinas and an evidence base for tailored solutions to address these challenges, the study team has been cognisant of the potential for reinforcing a negative image of Salinas through the study findings. In focusing research on two of the most pressing public health problems facing Salinas teens (teen pregnancy and risk of violence), we have strived to also acknowledge the importance of understanding resilience among adolescents who are engaged in school, volunteer in a community to which they feel attached and are connected to families with whom they share strong bonds. It has been a priority of the A Crecer team to be vigilant about slipping into a problem-based characterisation of 'at-risk' youth in a disadvantaged community, and instead choosing to align with a growing movement to investigate what helps a community thrive, building on the strengths of its residents and a proud cultural heritage. Collaboratively, the research team has challenged itself to incorporate protective factors such as school connectedness, resilience and a future orientation towards the measures of influences that lead to a positive trajectory. This focus grew naturally out of the strong communityresearch linkages forged by intentional community engagement during the formative stages of the study. This more balanced approach respects and nurtures growing community pride and has been welcomed by CAB members, YAB members and local stakeholders. Our team is fully committed to the approach described in this article. We recognise that such engagement requires time, resources and a willingness of all parties to listen, be transparent and remain open-minded. It has been important -and meaningful -in A Crecer for the San Francisco-based researchers to spend entire days in Salinas in an effort to better understand the context in which the study takes place, meet face to face with community partners and problem-solve on site with the local staff. Likewise, the Salinas-based research staff have worked evenings and weekends in order to maximise their ability to connect with parents, teachers and other community members, shared their observations and experiences in order to inform the aspects of the research that can be adapted to the local culture, and maintained the research protocols that need to be standardised with equanimity and good humour. Within a study that focuses on rural Latino youth, many of whom contend with immigration, acculturation, poverty and other issues that could potentially affect health outcomes, such efforts to create community-level trust and buy-in are key conditions for the production of high-quality data that can be used to support resources, solutions and paths forward. --- Conclusion Work that will meaningfully affect SDH must be conducted in ways that not only acknowledge community challenges but also recognise and build upon resilience. Taking this approach promotes a growing community awareness of the barriers resulting from SDH and the drive to address these factors to further the development of a safe and thriving community. In the case of our research with rural Latino youth, building in the active participation of the actors in charge of the settings where adolescents live, such as educators and parents, was crucial. Indeed, developing these community partnerships and working to maintain them through accountability and transparency helped expand the reach of our study to a greater number of residents, thereby promoting community engagement and expediting participant recruitment. Likewise, we found that by engaging local opinion leaders -including youth -early in the research process, support for the study spread through multiple channels, minimising the barriers that could have arisen for community members who feel wary of outsiders and instead prompting parents to come forward and enrol their children in what was perceived as a positive community-focused activity. Despite their importance, building community partnerships and providing avenues to hear the voices of a study population is not sufficient. In order for research among vulnerable groups to be as relevant and ethical as possible, community perspectives and expertise must be deeply integrated into the study itself. Two channels for this are research staff and protocols, the heart and soul of a study. By hiring young people from the local community and valuing and building their knowledge, we hope not only to improve the quality of our current work, but also to help train the next generation of scholars. Similarly, by designing protocols that are culturally appropriate and respectful, we aim to broaden the community's understanding of research, degree of comfort engaging with it, and expectations that it should lead to solutions that will be feasible and effective. In working towards these goals, we hope that A Crecer will live up to its namesake by providing opportunities not only to learn, but for all of us involvedyouth, community and researchers -to grow.

The health of adolescents, perhaps more than in any other period of their life, is shaped by the social determinants of health (SDH). The constellation of SDH that disadvantages a specific group's health may also make members of that population unable or unwilling to engage in health research. To build a comprehensive body of knowledge about how SDH operate within a specific social context, researchers must design studies that take into account how various vulnerabilities and oppressions may affect people's experiences of being recruited, interviewed and retained in a study. In 2014, we initiated a prospective cohort study with Latino youth DECLARATION OF CONFLICTING INTEREST The author(s) declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

INTRODUCTION The life of this world is not concurrent, often changing, as well as social life. This change can be a fundamental social shift, as happened in the relationship between men and women. The roles and status of the husband and wife in the family that society has accepted and believed in have changed and shifted (Zahra, 2022). The husband, thought to be the leader, can be replaced by his wife to lead the family. This shift not only changes or even replaces the tradition that previously existed. Among the indicators of this shift is the emergence of the phenomenon of the Household Father or Stay at Home Dad (SAHD) (Rici, 2021). Several studies have been conducted on husbands' leadership, including those seen from a gender perspective. From a gender perspective, leadership is not the husband's absolute right, but the wife also has the opportunity to become a family leader. Husband's leadership is considered a product of a patriarchal culture that is not gender-fair (Nurmila, 2015). Thus, the concepts and manifestations of gender relations are dynamic and flexible, considering the changing socio-cultural conditions. Zamroni Ishaq researched husband and wife leadership in the family from the point of view of classical and contemporary mufassir. In his research, he said that the husband's leadership over his wife is based on two theological matters, meaning that it is an innate trait given by Allah SWT that one should not envy one another, because each has been given their specialties (Ishaq, 2014). Other research is regarding the permissibility of wife's leadership in the family from a gender perspective (Rahim, 2016). Meanwhile, Basyar's research focused on the relationship between husband and wife in a review of Islamic Law and Law Number 1 of 1974. His study found that the husband's role as the head of the family has not changed, while the wife's role has shifted because her role has increased in the public sphere (Basyar, 2020). Meanwhile, Marta Widyawati focuses her research on the impact of a shift in earning a living on the crisis of her husband's masculinity, such as loss of independence, self-confidence, courage, assertiveness, and emotional control (Widyawati & Widyawati, 2021). Muhammad Amanuddin, in his research, emphasizes that the husband's leadership can be eroded if he does not carry out his obligations. So, to anticipate, the husband must be able to carry out their obligations properly (Amanuddin, 2021). Meanwhile, Chaula Luthfia found multiple and unequal roles for a wife, namely being a housewife and earning a living (Luthfia, 2021). Ikhma Zurani, in his research, found that businessmen's wives have the power to decide business and family financial affairs (Zurani, 2020). Siti Khoirotul Ula discusses leadership in the family with the theory of mubilah. The research shows a mutual relationship between husband and wife in carrying out their obligations, so there is no dominant relationship between husband and wife (Ula, 2021). Meanwhile, Agus Hermanto, in his research, criticized feminist thinking about the rights and obligations of husband and wife. He concluded that what was put forward by feminists was not absolute but casuistic, and the genuine concept of Islam would bring problems if implemented correctly (Hermanto & Ismail, 2020). All of the research that has been described above has an object of study that is different from what the author will do. This paper is focused on answering a question on what are the negative consequences of a shift in husband's leadership in the family on household goals. --- METHOD This qualitative research uses the descriptive analysis method. The approach used is a normative and sociological legal research approach. Data was collected using a literature study technique. Then, the data were analyzed using qualitative data analysis techniques: studying, reducing, correcting, tabulating, categorizing, interpreting, and drawing conclusions (Silverman, 2015). --- RESULTS AND DISCUSSION Economic problems in the family often cause shifts in husband's leadership. Husbands, in this case, cannot earn a living, while wives have the opportunity to work and even have a more significant income. Finally the husband decided to become a housewife (Simatupang, 2021). According to psychologists, a householder, from a psychological perspective, will feel that he is a man who has had bad luck for several reasons, one of which is because he has just been fired from a job or has been ill for a long time. In addition, being a housewife creates pressure or being cornered, frustrated, and useless, sometimes leading to suicide. The wife's more money and career skyrocketed often trigger a fight. The fame or success of a wife, accompanied by a lot of money, will intimidate the husband (Saman & Dewi, 2012). Coupled with the arrogant attitude of the wife, who feels she has a better career and a lot of income, it often becomes a psychological problem for the husband. When I finally met my in-laws, my husband became embarrassed (Rahmawati, 2016). In addition to the psychological problems above, household leadership will also be problematic. Husbands whose actual status and role as leaders in the household are questioned and their status is challenged. Carrying out the part of the household's father as if he were a leader is considered illegitimate. As a result, the husband is no longer confident (self-confidence) that he is a leader. Under these conditions, it is challenging for the husband to be able to carry out his role and function as the head of the household. On the other hand, wives who work and pursue careers outside the home with large incomes seem to have a basis for legitimacy to be able to take over leadership status and determine the direction and decisions of the household. In other words, leadership status shifts from husband to wife. or at least between husband and wife have the same and equal status (Ishaq, 2014). When household leadership shifts, or is problematic and does not function as it should, it is certain that all rules and laws relating to the household will not be implemented properly, there will be overlapping rights and obligations as well as noble and noble ideals from the household. will not be achieved (Putung & Azahari, 2020). In other words, the household will be a household that is not sakinah mawaddah wa rohmah. Another negative consequence is the lack of harmony in the relationship between husband and wife. a wife who is busy with activities outside the home with all her problems and burdens at work often runs out of energy and energy to be able to serve her husband well. Not to mention that there are assignments out of town for days on end that the husband's needs cannot be served properly and optimally. Coupled with the problems faced that are not resolved at work and then brought home. Wives with tired conditions, with a myriad of work problems tend to be emotional, as a result the relationship with their husbands becomes less harmonious and they are always bickering (arguing), it is not uncommon for quarrels to end in divorce (Andriyani, 2014). Research conducted by the international organization WHO in 2005 showed that the number of female heads of household (PKRT) has increased from year to year. In the Caribbean the number of female heads of household is (35%), Latin America (21%), Sub Saharan Africa (20%), Central Asia (17%), North Africa, West Asia and South Asia (12%-13%), India (11.7%), even in Central America as many (90%) of refugee families are supported by women (Ernawati, 2014). This is confirmed by data from the Central Bureau of Statistics in 1999, which stated that 13.2% of households in Indonesia were headed by women (Ernawati, 2014). The data presented above indicates that there has been a shift in the husband's leadership among some households. This is indicated by the exchange and shift of roles between husband and wife. The husband, who previously had the role of earning a living, now takes care of the domestic affairs of the house, and vice versa, the wife, who previously carried out the domestic role at home, carries out the role of the husband in earning a living. This exchange of roles can eventually lead to a shift in the husband's leadership. In some cases, the father of the household, the inability of the husband to meet the economic needs of the family is the reason someone decides to become a father of the household. Such is the case in TKW families where the role of the husband as the main breadwinner in family needs is replaced by the wife while the husband is in charge of taking care of the children and doing household chores. Another case is experienced by Mr. Sri Mahamat Maaji, a graduate of Yogyakarta State University who has decided to switch roles with his wife since 2002 in order to maintain the continuity of family life, while his wife has a career as an office employee (Simatupang, 2021). --- Functional Structural Theory According to the functional structural theory as proposed by Parsons that the family will be in a state of harmony and balance if family institutions or institutions are able to maintain stability in the family members. A family structure that can carry out its functions properly while maintaining the values and norms that are upheld by family members will create stability in the family itself (Haris, 2021). Parsons believes that there are several conditions that must be possessed by a social system, namely; First, structured (organized), that is, a system must be well organized and able to work harmoniously with other systems. Second, there is support from other systems. Third, it can meet the needs of the actors proportionally. Fourth, create a participative atmosphere from the members. Fifth, controlling negative behavior. Sixth, being able to control conflicts that lead to chaos. Seventh, there is language (Ritzer, 1985). Among the social systems that are important and also determine the pros and cons of social life in society is the family. A good family will have a positive impact on the good social condition of the community, on the other hand when a family has a problem, it will have a negative impact on the social damage of the community (Suarmini et al., 2016). The family as a system has established accepted norms and values. When a family carries out its functions properly, it means that the family adheres to the values, norms and rules that apply. However, families who are unable to carry out their roles and functions properly will cause conflict, friction and other negative impacts. Among the established values accepted in society, especially Muslims, is regarding the husband's leadership status in the household. --- The Husband's Leadership Shift and Its Negative Consequences The shift in husband's leadership that occurs amid some people is the impact of a change in the way of thinking among them, especially regarding the relationship between husband and wife in the family. They believe that family leadership is not the husband's prerogative, but the wife also has the same rights and opportunities (Utamidewi, 2017). In addition, the economy is also one factor that encourages exchanges and shifts in the role and status of leadership in the family. A husband who, for one reason or another, cannot make a living and is replaced by his wife, while he carries out his wife's domestic role (Andriyani, 2014). This shift has negative social and psychological consequences for the family. The failure or dysfunction of the role of the family institution causes this. The powerlessness of family institutions in solving problems due to deviations committed by leaders and or family members from the status and roles that have been regulated and determined. For a family to function optimally, it must have a structure. Structure is an organized set of social relations involving members of a society or group (Ritzer, 1985). --- a. Structural Aspect In the family structure can function to unite families in one container. There are three main things, which are related to each other in the family structure, which is: 1) Social Status: This can be breadwinners, homemakers, toddlers, school children, or teenagers. 2) Social Function: the role of parents in the family, namely the instrumental role expected to be carried out by the husband or father, and the emotional role usually held by a wife or mother figure. This role has the function of fulfilling the love, tenderness, and affection needed by family members. If there is a shift and division of functions that are not firm and clear (overlapping), it will disrupt family integrity and harmony. Functionalism theory seeks to explain how the system always functions according to the role that exists in society. 3) Social Norms: Social norms are rules that describe how a person behaves in his social life, as well as social functions, social norms are standards of behavior expected by each actor. The nuclear family, like other social systems, has characteristics in the form of role differentiation and a clear organizational structure. --- b. Functional Aspect Functionality of the structure can be implemented if there are: 1) Role differentiation. Each family member should have a clear role to play. 2) Allocation of solidarity. Division of relationships between family members based on love, closeness of relationship, and strength. 3) Economic allocation. Distribution of goods and services within the family. The division of tasks must also exist in the family financial sector, especially in production, distribution, and consumption. 4) Political allocation. The distribution of power allocation in the family. These conditions will be fulfilled if each actor carries out his role following the provisions of the organization in which he is located Based on the structural-functional theory above, structure in the family is one of the most important things. Because of the importance of its existence, it will affect the functioning of the family. According to scholars such as Zamakhsyari, Alusi and Sa'id Hawa, the husband is a leader for his wife in the family (Ilyas, 1997). This husband's leadership is based on Al-Qur'an Surat An-Nisa (4) verse 34 and some hadiths of the Prophet SAW. When the husband carries out his status, role, and function as a family leader, while the wife and other family members carry out their respective status, roles, and functions, harmony will grow amid the family. Also, sakinah, mawaddah wa rohmah will be realized. It becomes a problem when there is a shift in status, roles and functions, especially in matters of family leadership. The husband's leadership status is questioned and even sued because his wife makes a living for the family. If this happens, dysfunction can occur, namely the husband is no longer confident in carrying out his status and functioning as a leader. The husband's lack of self-confidence can cause the roles and functions that should not be carried out. This can result in overlapping roles and functions and impact other family members' status, roles and functions. Ritzer said that the family is a social system consisting of parts that are connected in a balanced unity. Changes in one will affect the changes in the other (Ritzer, 1985).This shift in the husband's leadership can cause instability in the family system and impact the family's failure to carry out its functions, namely socialization and affection. One of the causes of failure in carrying out family functions is the existence of a particular situation in the family, including because the wife works and longs for a higher position than the husband and the husband and wife often leave the house because they are busy outside (Zahrok & Suarmini, 2018). Similarly, Kartini conveyed that several cases of juvenile delinquency were caused by the failure of the mother's role as educator and protector in the family. The shift in husband's leadership is a form of not working the division of roles properly amid the family, which in the end has some negative consequences both psychologically; the husband loses his self-confidence and sociologically where the relationship between husband and wife becomes disharmonious which ultimately has an impact on reduced parental affection for children and conflict between husband and wife. These negative consequences eventually lead to not achieving the household's goals to the fullest (Utami & Mariyati, 2015). There are several functions that a disharmonious family cannot carry out, among others: a. Socialization Function. It is the function of education, namely educating children from childhood to form a noble personality in children. However, because of the busyness of their parents, sometimes they are negligent in carrying it out and rely more on other parties in carrying it out (Pandin, 2016). b. Protection Function. The function of protection serves to protect all family members from various hazards that threaten both physically and psychologically (Zahrok & Suarmini, 2018). c. Affective Function. The function of affection must be given by parents to children. They will vent it elsewhere without warm communication between family members (Anggraini, 2018). d. Recreation Function. The function of recreation is that the family must function as a place of entertainment for its family members. However, because it is rare to meet among family members, this function does not work (Wahidin, 2017). The shifting of the four family functions above is a factor causing the family's goals and aspirations to be not achieved. One of them is the presence of juvenile delinquency in the family. Another negative consequence of the husband's shift in leadership is the less harmonious relationship between husband and wife (Ogura & Forwell, 2023). The wife, after work, runs out of energy to serve her husband properly and optimally. In addition, another negative consequence is the opening of opportunities for infidelity (Tang et al., 2022). Husband and wife who are not harmonious and have no warmth at home seek escape outside, plus meetings with other men that are so intense that location love occurs. --- CONCLUSION The shift in husband's leadership among several families is a social reality of Indonesian society. This has several consequences, including giving birth to several adverse effects psychologically and sociologically so that the ideals and goals of household cannot be achieved optimally.

This study aims to understand more deeply the shift in husband's leadership and its negative impact on the family. This qualitative research uses the descriptive analysis method. The approach used is a normative and sociological legal research approach. Data was collected using a literature study technique. Then, the data were analyzed using qualitative data analysis techniques: studying, reducing, correcting, tabulating, categorizing, interpreting, and drawing conclusions. This study found that social changes caused a shift in the husband's leadership, harming the family psychologically and sociologically.

Introduction The health of Brazilian children has constantly and significantly improved in recent decades. Data from the 2010 Census recorded that infant mortality in the first year of life had nearly halved in ten years. In 2000, for every thousand live births, 29.7 babies died before their first birthday, while the figure in 2010 was 15.6. Regarding anthropometric indices, stunting decreased during the period between 2003 and 2009 from 15.7% to 9.7% among white children and from 20.5% to 11.7% among blacks (Reis, 2012). This is an important achievement for the advancement of human capital investment as it is well known that early life conditions have persistent and profound impacts on an individual's later life in terms of chronic diseases, education and wages (see Barker, 1990;Almond andMazumder, 2005, 2011;Almond and Currie, 2011;Currie and Vogl, 2012;Lin and Liu, 2014;among others). The progress in maternal and child health that Brazil is achieving is the result of important changes over the last three decades in several domains. Brazil has experienced major economic growth with an increase in Gross National Income (GNI) per capita of 47.2% only between 2004 and2012 (according to World Bank data). The financial gap between rich and poor has become less pronounced and cash transfer schemes (particularly Bolsa Fam<unk>lia) have increased family income among the poorest groups. From an educational point of view, the major investment in elementary schooling during the 1990s has increased educational attainment among Brazilian mothers. In parallel, Brazil has experienced an important decline in its fertility rate. The country has also seen great improvements in terms of urbanization (access to water and sanitation). Specifically in terms of health policy, in the late 1980s, a three-tiered healthcare system of private security, social security and charitable institutions was replaced by a universal, tax-funded, national health system. Primary health care became the cornerstone of the system, and the geographical targeting of care led to the setting up of family health teams in the neediest areas of the country. Moreover, maternal-child health policies in Brazil underwent profound change: a vertical health program that started in the 1980s, PAISM, for the promotion of breastfeeding, oral rehydration and immunizations, as well as the implementation of many national and statewide programs have improved children's health and nutrition (Paim et al., 2011;Barros et al., 2010). Despite all the progress, the prevalence of stunting (1 out of 10 children) is much higher than in well-nourished populations, indicating that there is still room for improvement. Moreover, even if the Brazilian case can be thought of as a successful example, the speed of the improvement has not been uniform and important differences still remain. On a geographical level, differences between rural, urban and metropolitan areas continue to exist, which are mainly explained by the heterogeneity in sanitation and access to or quality of the health system. Despite convergence to a national standard level, the prevalence of stunting has been historically much higher in the poorest (North and Northeast) regions than in the wealthier Southeast. Also, although the racial gap in nutritional indicators has clearly decreased, white children still receive better nutrition than blacks (Reis, 2012). While acknowledging regional and racial disparities, the main focus of this paper is to study the importance of family structure as a source of inequalities in children's health outcomes. Our hypothesis is that children raised by a lone mother are more likely to have lower height-for-age z-scores after controlling for other socio-economic and demographic characteristics than children growing up with both parents. Several mechanisms may be at play. Lone mothers may suffer higher levels of stress because of the difficulties dealing with the role of sole carer and primary breadwinner. At the same time, lone mothers cannot count on the help and monitoring of a cohabiting partner. Similarly, they may have more difficulties obtaining care for their children because of a smaller extended family. All these mechanisms may explain the poorer health outcomes for children raised by a lone mother. As far as we know, this is the first time that family structure has been taken explicitly into account when analysing children's health inequalities in the case of Brazil. If our hypothesis is confirmed, our results have important implications both for social and health policy. According to data from Brazilian Censuses, the number of children under the age of 14 that did not live with their father multiplied almost fourfold from 1980 to 2010. Indeed, in Brazil, nearly 1 out of 5 children between 0 and 13 years of age were raised by a lone mother in 2010. Historically, Brazil has had a high level of informal unions (which account for 36% of all unions in the most recent data). Also, it is common to have a child in each new union to fulfil the idea of having a proper family -this being particularly true for men who leave their children from previous relationships with the mothers (Greene, 1992). To this situation, we can add the violent context of high male homicide and incarceration rates (Murray et al., 2013;Reichenheim et al., 2011), which increase the probability of women rearing their children alone. The isolation of a causal effect between family structure and children's health requires an econometric strategy that accounts for selection into marital status. We estimate a treatment-effects model that uses male preference for firstborn sons (as opposed to firstborn daughters) to instrument the probability of a woman becoming a single mother. Family economics literature has well established that firstborn children are more likely to cohabit with a father figure if they are boys than if they are girls (see Dahl and Moretti, 2008;Ananat and Michaels, 2008;Ayllón, 2014a). Assuming that the sex of a child is random and that there is no sex-selection abortion in Brazil (Chiavegatto Filho and Kawachi, 2013), the gender of the firstborn in a household allows us to implement an instrument variable strategy that, to the best of our knowledge, is used for the first time in the context of children's health analysis. Our results indicate that children raised by a lone mother in Brazil have a height-forage z-score that is 0.31 points lower than that of children of the same characteristics that cohabit with both parents. These findings are robust to different specifications that control for socio-economic and demographic characteristics. Moreover, the number of children in the household below the age of 10 and the mother's lack of schooling are factors associated with lower height-for-age z-scores. In turn, the mother's height and body-mass index are positively related with children's height (indicating to the importance of controlling for the genetic code). Our results confirm that family structure should not be overlooked when designing health policy in Brazil: lone motherhood may become a real challenge for future maternal-child health programs in Brazil (much more than racial or regional disparities). After this introduction, the following section describes the acute consequences of malnutrition in early life. Section 3 discusses the relationship between children's malnutrition and family structure according to previous literature. Section 4 describes the dataset used and presents some descriptives while section 5 details the econometric strategy. Section 6 contains our main results and Section 7 concludes. --- Malnutrition in early life Malnutrition is typically caused by a combination of inadequate food intake and infections that impair the body's ability to absorb or assimilate food. It encompasses stunting, wasting, and deficiencies of essential vitamins and minerals, with obesity or over-consumption of specific nutrients as another form. From an economic perspective, infant nutritional status can be seen as the output of a health production function, where nutrient intake is a very important input. However, in addition to that and to the particular genetic variation, there are other relevant variables: appropriate care, household conditions (including food insecurity), parental education, access to quality health care and living environment. There are two commonly used anthropometric indicators for children's nutritional status: wasting and stunting, which distinguish between short-term and long-term physiological processes (WHO, 1986). The first indicates a low weight-for-height and reflects current nutritional problems (diarrhoea, insufficient dietary intake and other childhood diseases). The weight loss associated with wasting can be restored quickly under favourable conditions and is generally seen as a short-lived problem. 1 The stunting index is measured by height-for-age and shows children's cumulative linear growth or a chronic restriction on their potential growth. It thus reflects the child's present and past inadequate nutrition and/or frequent illnesses, expressing a long-run health condition and is not usually reversible. The WHO recommends it as a reliable measure of overall social deprivation (WHO, 1986).2 These indicators are measured in terms of a standard deviation z-score which accounts for the difference between the value for an individual and the median value of the reference population (same age and sex) divided by the same reference population's standard deviation. Extensive epidemiological literature has focused on the early childhood environment, nutrition in particular, and its relationship with health outcomes in adulthood.3 It emphasizes that linear growth failure is largely confined to the intrauterine period and the first years of life, and is caused by inadequate diet and frequent infections. Malnutrition in the early years of life may also cause later deficiencies in cognitive development. There is some disagreement as to whether the effects of malnutrition on cognitive development are more acute when the child is a baby (0-6 months), as Dobbing (1976) argues, or a toddler (6-36 months), but there seems to be a consensus that the first two years are very important (Waber et al., 1981;Pollitt et al., 1995;Martorell, 1995;Glewwe and King, 2001). Early growth failure will lead to reduced adult stature unless there is compensatory growth in childhood (so-called catch-up growth), which is partly dependent on the extent of maturational delay that lengthens the growth period. Because maturational delays in low-income and middle-income countries are usually shorter than 2 years, only a small part of growth failure can be compensated. Individuals who remain in the setting where they developed childhood malnutrition tend to become short adults (Martorell et al., 1994 and2005). 4The epidemiological literature reveals that the nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome (Kramer, 1987;Kramer and Victora, 2001). Short maternal stature is a risk factor for caesarean delivery and low maternal body-mass index is associated with intrauterine growth restriction (WHO, 1995;Fishman et al., 2004;Ronsmans et al., 2006). In the short term, the results of maternal/child malnutrition are mortality, morbidity and disability. In the long term, the consequences are adult size, intellectual ability, economic productivity, reproductive performance, and metabolic and cardiovascular diseases (Black et al., 2008). Regarding academic achievement, particularly in developing countries, the economic literature has found that childhood malnutrition is a significant determinant of delayed enrolment and low test scores (Glewwe and Jacoby, 1995;Glewwe et al., 2001;Alderman et al., 2001;Wisniewski, 2010;Monk and Kingdon, 2010). Malnutrition in childhood can also undermine labour outcomes in adulthood because of the probability of low school attainment being greater for unhealthy children than for those who were well-nourished (Deaton, 2008). In the Brazilian case, Machado (2008) showed that for children between 7-14 years old and from the Northeast and Southeast regions, low height-for-age status increases the chances of late entry into school. The study by Gomes-Neto et al. (1997) uses data from a major education intervention program, EDURURAL (conducted in three Northeastern states in the 1980s), which measured students' health. This program was designed to reduce low achievement and high drop-out rates in these rural areas. The authors studied the complementarities between health and educational attainment/cognitive proficiency of children and found that changes in nutritional status play an important role in explaining cognitive differences among children (but do not have an impact on the final degree of schooling). More recently, Gigante et al. (2006) used a large cohort of data from all children born in the city of Pelotas (on the country's Southern region) in 1982, with follow-ups in adulthood (21-23 years old) to analyse various later health and economic outcomes. This study confirms that height-for-age predicts school or cognitive test performance in later life, and stunting between 12 and 36 months of age predicted poorer cognitive performance and/or lower school grades attained in middle childhood. So, the previous literature has reached a strong consensus on the acute consequences of malnutrition during the first years of life across the whole life cycle. This paper assesses whether stunting (measured by height-for-age z-score) can be partly explained by family structure in Brazil. 3 Family structure and infant health: a review Studies that have analysed the impact of marriage on health systematically find a positive association between the two. In general, the literature indicates that married people live longer, have fewer problems related to alcohol, engage in fewer risky behaviours and have better mental health (see Lillard and Panis, 1996;Espinosa and Evans, 2008;Rendall et al., 2011;Curran et al., 1998;Duncan et al., 2006;Umberson, 1992;among others). The literature has established that the marriage-health relationship can be explained by selection, causation or both.5 According to the selection framework, healthier people are more prone to marriage because they are more desirable in the marriage market (e.g. physical attraction, mental well-being, higher income, greater self-sufficiency, likely longevity, etc.). In this case, it is not possible to attest that marriage itself provides a better health condition. So, the advantages observed in the health status of married people (compared to those without a partner) only reflect selection (Goldman, 1993). On the other hand, the causation alternative advocates that marriage does cause benefits to the health of the people involved (adults and children). This is known as the marriage protection hypothesis, which sees marriage as a mechanism that protects people's health through: (i) social channels as integration, (ii) accomplishment of some social roles, (iii) support, (iv) financial resources and economies of scale, and (v) joint and full monitoring between spouses. The most common view is that marriage leads to emotional support: it is seen as an institution that gives a sense of meaning (or purpose) of responsibility/commitment to others, as well as closeness. 6 It also works as a sign of fulfilment of an adult social role, which together with parenthood reduces the chance of health-harmful and risk-taking attitudes (Ross et al., 1990;Waite, 1995;Hibbard and Pope, 1993;Rendall et al., 2011). Other factors include family income/wealth and economies of scale that may increase access to medical care and the purchase of better nourishment and housing (Becker, 1991;Hahn, 1993). Despite the difficulties disentangling the influence of selection and protection, studies that have dealt with the issue are consistent regarding a marriage premium. They generally find that the association between marriage and health is a combination of both (Lillard and Panis, 1996;Murray, 2000;Rendall et al., 2011), so marriage affects and is affected by its members' health status. Consequently, the positive results of marriage on health are also extended to the children living in two-parent families. The monitoring mechanism is especially relevant when there are children in the household because they are treated as a collective good by both parents (Weiss and Willis, 1985). 7 In this case, any opportunistic behaviour by one of the parents is avoided by the monitoring between them, which may encourage both to invest in the common good. Theoretical models provide intuition for the empirical studies that have evaluated the effect of marriage on children's health through specific inputs, for example, quality/time of prenatal care, nutrition and/or abstention from tobacco, alcohol or illegal substances during pregnancy (Currie and Gruber, 1996;Joyce, 1999;Evans and Lien, 2005;Abrevaya and Dahl, 2008;Almond and Mazumder, 2011;Evans and Ringel, 1999). The findings indicate that the quality of care during the prenatal period, including the significance of the mother's nutrition, is very important for ensuring that the infant is born in healthy conditions, thus affecting the child's subsequent ability to accumulate human capital. Moreover, despite the increased diversity of family arrangements, women are still disproportionately the primary caregivers for children in Brazil. As a result, women are more likely than men to be faced with the dual role when unmarried: that of sole caregiver and primary breadwinner. This situation affects access to resources and psychological well-being and must have an impact on the quality of care provided to children (Osborne et al., 2012). A mother's stress (or depression) has a negative impact on her child's health, not just in key periods such as pregnancy and breastfeeding but also during early childhood (Chung et al., 2004). 8 Regarding the father's involvement, some research suggests that it plays a role in linking family structure to children' health outcomes. Married and cohabiting fathers are more likely to be involved with their children by virtue of proximity, while men who are not married to or living with their child's mother find it harder to be involved, and hence participate less (Furstenberg and Cherlin, 1991). Besides, when a union dissolves, the father's involvement drastically declines (Tach et al., 2010), especially if the relationship ends when children are very young. In general, the literature suggests that fathers may have an impact on infant health by encouraging (or not) women to seek prenatal care and refrain from unhealthy behaviours, such as smoking and consuming alcohol while pregnant (Teitler, 2001). Misra et al. (2010) have suggested that the father's involvement may improve birth and infant health outcomes by reducing maternal stress. The relevance of each aforesaid mechanism is difficult to evaluate since they depend on the interaction between family members. 9 Therefore, no empirical study of the impact of family structure on children's development has succeeded in isolating each mechanism. A significant number of empirical studies have examined the potential effects of family structure on children's development, and these generally confirm the disadvantage of children from households led solely by women. 10 Most of the literature focuses on cognitive and educational factors, as well as factors that are relevant during youth (early pregnancy, smoking, anxiety and economic inactivity). Studies that specifically analyse the impact of family structure on children's health indicate that unmarried mothers invest less in prenatal care and, consequently, their children have poorer indicators at birth. Thus, their children are at a disadvantage to others in terms of prematurity, birth weight and mortality (Bennett, 1992;Bennett et al., 1994;Bird et al., 2000;Peacock et al., 1995). However, few of these studies have addressed a causal relationship. The challenge for disentangling the effect of family structure on children's outcomes resides in the difficulty finding exogenous variations in the mothers' marital status. Ribar (2004) argues that in most studies the identification strategies used to address the issue of selectivity into marriage are unconvincing. 11 One of the most common methods used is that of instrumental variables, and it is usually found that exclusion restrictions reduce the association between family structure and well-being (which is consistent with selectivity) but do not eliminate the association (which is consistent with causality). Such is the case with Buckles and Price (2013), who measure the effect of marriage on four child indicators: low birth weight (<unk> 2, 500 grams), prematurity (<unk> 37 weeks), mortality in the first year of life and the Apgar test. They use a sample of siblings to show that accounting for selection with regard to observable and time-invariant characteristics significantly reduces estimates of the marriage premium, but the positive causal effect remains. This paper uses the instrumental variable method to analyse the causality between family structure and children's malnutrition (measured by height-for-age z-scores) by 8 See Amato (2005), Fomby and Cherlin (2007) and Wu (1996) for further studies that have documented the adverse associations of family instability and child outcomes. 9 Note, for example, that lone-mothers may also be exposed to some degree of monitoring by other family members (parents, siblings, etc.). 10 For a literature review see Ribar (2004) and Sigle-Rushton and McLanahan (2004). 11 It seems that the literature that analyses the impact of family structure on child outcomes (such as education or early adult results such as teenage pregnancy, tabacco or drug consumption) address causality more often. Some examples are Ermisch and Francesconi (2001), Finlay and Neumark (2010) and Craigie (2008). proposing a new exclusion restriction that has not been previously used for a similar research question. --- Data, definitions and descriptives Data is from the Brazilian Consumer Expenditure Survey (Pesquisa de Orçamentos Familiares, POF) relative to the 2008-2009 period. The survey contains 190,159 individuals from 55,970 households and is representative of the population living in private households in Brazil. Our working sample is restricted to all (single-birth) children under 60 months of age that are sons or daughters of the head of household (or spouse), whose mothers are between 20 and 44 years of age (both inclusive) and did not have their child as teenagers. This last restriction is imposed because we do not want to confound the effect of teenage biological immaturity (which may have consequences on children's health outcomes) with that related to lone motherhood. Moreover, in the POF, family ties are defined in relation to the head of household: (i) spouse/ partner, (ii) child (son/daughter), (iii) another relative, or (iv) non-relative. Such a survey structure allows us to link 89.3% of the infants in the sample to their mothers. Children classed as 'another relative' (10.5%) or 'nonrelative' (0.2%) cannot be linked to their mothers even if they are in the household. 12 As explained above, the 60 month threshold seems most appropriate when seeking to capture early-life health. In total, 10,072 records have been used. The POF data contains anthropometric measures for all individuals (weight, height and length) as well as information on such characteristics as age, race, education, position in the family, availability of a private health insurance plan for each person in the family, household income, governmental cash transfers, living conditions (sanitation, street paving, public lighting, health facility in the community, quality of public services, violent area, etc.) and geographic variables (state and urban/rural areas). Despite its importance, the raw anthropometric data collected by the POF is of limited value as an indicator of malnutrition in its own right, partly because weight and length/height depend on both age and gender. So, in order to assess the adequacy of a child's growth it is necessary to compare these indicators with their distribution in a "healthy" reference group and identify "extreme" or "abnormal" departures from the reference values. 13 To do this, the Anthro software created by the World Health Organization (WHO) was used, which requires input of each infant's sex, age in months, weight and length/height data. 14 From this data, z-scores for height-for-age have been calculated. Table 1 shows that the average height-for-age z-score is zero with a standard deviation of 12 Strickly speaking, this means that our sample is not representative of all children under the age of 60 months in Brazil. However, it is also true that about 5% of children in this age group do not live with their mothers (according to the 2010 Census data) so, we are not missing as many mother-child links as it may seem. Also note that the restriction of mother's age is also related to survey structure limitations. By only using the sample of women between 20-44 we disregard the possibility of considering grandmothers that are rearing their teenage daughter's child. 13 A total of 101 observations were considered extreme cases and were deleted from the final analysis. 14 Anthro can be consulted at the web page http://www.who.int/childgrowth/software/en (June 2014). This software also provides the WHO Child Growth Standard measures for weight-for-age (WAZ), weightfor-height (WHZ) and body-mass index for age (BMI). Since 2006, the WHO has used new curves to assess the growth and development of children around the world. This new standard was obtained by combining longitudinal follow-ups from birth to 24 months and a cross-sectional survey of children aged 18 to 71 months. The sample has information from 8,440 healthy breastfed infants and young children from a wide variety of ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA). 1.70 and a minimum and maximum value of -5.99 and 5.92, respectively. Indeed, descriptives indicate that 11.2% of children in the sample suffer chronic malnutrition (stunting). On the other hand, 15.7% are obese. Regarding family structure, a child's mother is considered to be a lone mother if none of the registered members of the household is her partner. This means that the lone mother may be divorced, separated, never married or widowed. As a matter of fact, the POF data does not make it possible to distinguish the mother's marital status. 15 In total, 9.6% of the children in the sample cohabit with a lone mother. As in many other parts of the world, lone motherhood has become an increasing phenomenon in Brazil as shown in Graph 1, which uses data from the Censuses from 1970 to 2010 to create a sample with the same characteristics as those explained above. A thorough analysis of this trend goes beyond the scope of this paper but two explanations stand out in the case of Brazil. Firstly, the analysis by Greene and Rao (1995) indicates a squeeze in the Brazilian marriage market (a shortage of men) driven by a decrease in mortality rates. As, on average, men marry younger women, the simple reduction of mortality in younger cohorts increases the supply of women in relation to men. The result of this compression would be an increase in cohabitation, with men going through various unions during their life cycle. 16 Secondly, it is important to take into account how the Brazilian context of violence also increases the probability of a woman having to raise her children alone. Each year the country loses approximately 45,600 men lives due to homicides, according to data from the Ministry of Health ( 2010), which particularly affects young men. The same is true for incarceration rates. The other rows in Table 1 show summary statistics for the groups of variables that will be used as controls when modelling the effect of lone motherhood on children's height-forage z-scores: other demographic factors, children's and mothers' characteristics, household economic status, and regional/urbanization descriptives. As for other demographic characteristics, summary statistics indicate that there are between 1 and 4 children in each household under 60 months of age (average 1.32) and that 43% of the children in the sample have at least a brother or sister between the ages of 5 and 10 and 24% between the ages of 11 and 15. Regarding children's characteristics, 48.9% of the sample are girls; 51.1% are black, half-caste or indigenous and, on average, they are 32 months old. As for mothers' characteristics, mean age is 29.6 and mean age at birth is 27.4. Mothers' average height is 158 centimetres, their body-mass index is 24.8 and, they have been to school for an average of 8 years. 4% of the mothers have never been to school and nearly 18% of them did not complete primary education. At least two of the mothers' characteristics are particularly important for the children's health: height and age at birth. Regarding mother's height, extensive literature highlights its correlation with some reproductive outcomes. Taller mothers tend to have easier births (Liljestrand et al., 1985), heavier babies at birth (Kirchengast et al., 1998), fewer stillbirths (Pollet and Nettle, 2008) and higher survival rates among their children. Thus, the mother's height carries direct information on genetic inheritance and indirect information about her own past situations of malnutrition and poverty. The information on the mother's age at birth is a measure of her biological maturity, which is another relevant factor for the child's health outcomes. Finlay et al. (2011) analyse the effect of the mother's age at first birth on infant mortality, its anthropometric failure (stunting and underweight), diarrhoea and anaemia. Using data from Demographic and Health Surveys (conducted from 1990 to 2008) for 55 low and middle-income countries, these authors found that the risk for the child's health is lower for women who have gave birth for the first time between the ages of 27 and 29. The risk of infant mortality in firstborn children from mothers below 27 and above 29 is higher, although the effect is only statistically significant for women below the age of 18. The variables referring to household economic conditions are poverty status and being a Bolsa Fam<unk>lia beneficiary. Poverty is defined using the same concept applied by the government cash-transfer program, Bolsa Fam<unk>lia, which has been operating since 2003. This study uses the values that were established from June 2008 onwards: families with an income per capita up to 30 USD (monthly) are considered "extremely poor" and families with an income per capita above 30 USD but below 60 USD are considered "poor". Here the sum of these two groups defines a poor family. In the sample, 16.5% of the children live in a poor family and 23.1% receive the cash transfer. It is important to note that the Bolsa Fam<unk>lia is a secondary indicator of household poverty but also works as a health input control. Its inclusion was necessary for two reasons. First, because of its conditionality regarding the health of children up to 7 years old, which requires beneficiary families to monitor the vaccination card and make frequent visits to the doctor to follow-up the children's growth and development. This condition exposes all children whose families are beneficiaries (partially) to the same health input: access to medical services (prescriptions and monitoring). 17 Second, the Bolsa Fam<unk>lia and poverty status are both included (despite being based on the same criteria) because not every poor family receives this cash transfer (and vice versa). In order to control for the level of urbanisation, we also consider the variables "piped water" and "paved street". The first is used as an indicator of sanitation conditions and the second as a proxy for the public services that come with urbanization. In the sample, 87.8% of the children live in an area with piped water and 59.5% with a paved street. As for regional characteristics, the Brazilian territory is divided into five areas (North, Northeast, Southeast, South and Central West). Most children live in the Northeast region of the country, followed by the Southeast and South. --- Econometric strategy The simplest modelling strategy to capture the relationship between family structure and child malnutrition would be an OLS regression accounting for changes in the outcome of interest according to a set of observable characteristics. Formally, haz i = <unk> 0 + <unk> 1 singlemother i + <unk> 2 X i + i (1) being haz i the height-for-age z-score. As already explained above, among nutritionists, height-for-age is a widely recognized index to identify malnutrition. Among economists, it is the most useful indicator of a child's health and welfare in developing countries and is widely recognized as a good predictor of many later-life outcomes. Moreover, <unk> 1 is the coefficient for lone motherhood which we expect to be negative thus indicating poorer health outcomes among children being raised by a single mother. X i is the vector of explanatory variables, and finally, i is the usual white noise error term. However, a simple linear regression holds the assumption that the mother's marital status is an independent variable and that there is no correlation between the error term of the model that gives rise to the choice of mother's marital status and the error term in our equation of interest ( i ). As a matter of fact, there are various channels by which the mother's marital status may be thought of as endogenous, and therefore, the estimates from equation 1 are inconsistent. As explained in the literature review, people choose whether they will partner or not and with whom, so marital status is a selection-intotreatment. Moreover, there are unobservable factors related to mothers' health that make an unhealthier woman more likely to be a single mother and which, in turn, affect children's health. If the error term in a model for becoming single mother is correlated with poor mothers' health, and the error term in equation ( 1) is correlated with this, the error terms are correlated. In this case, we have an omitted variable problem that yields biased OLS estimates. In order to account for the bias, we fit an instrumental variables estimation, a treatmenteffects model that will also restore consistency under the hypothesis of selection of unobservable factors. This is achieved with at least one instrumental variable that must be (directly) correlated with marital status and, at the same time, (directly) uncorrelated with the child's height-for-age z-score (the so-called exclusion restriction hypothesis). Thus we are interested in fitting the model: haz i = <unk> 0 + <unk> 1 singlemother i + <unk> 2 X i + i(2) out pre-natal tests and monitor their health and the baby's health. singlemother * i = <unk> 0 + <unk> 1 IV i + u i(3) where singlemother * i = 1, singlemother* > 0, i.e., mother is single, separated, divorced 0, otherwise and IV i is the instrumental variable that needs to assign exogenous variation to the relation between mother's marital status and child's height-for-age. Expressed differently, we need at least one variable that influences the probability of a woman becoming a single mother that, at the same time, exerts no influence on her child's height-for-age z-scores. In this paper, the instrumental variable is "firstborn girl". The family economics literature has shown the existence of a relationship between the probability of divorce or lone motherhood and the sex of the firstborn in a family. Dahl and Moretti (2008), Ananat and Michaels (2008), Bedard and Deschênes (2005) and Ayllón (2014b) have shown for the United States that firstborns are less likely to cohabit with a father figure if they are girls. In other words, firstborn girls (as opposed to firstborn boys) increase the probability of divorce or separation among natural parents and decrease the probability of their mother finding a new partner after dissolution of a

This paper studies the relationship between lone motherhood and children's height-for-age z-scores in Brazil. In order to isolate the causal effect between family structure and children's condition, we estimate a treatment-effects model that uses male preference for firstborn sons (as opposed to firstborn daughters) to instrument the probability of a woman becoming a single mother. We find that children being raised by a lone mother have a height-for-age z-score that is 0.31 points lower than that of children of similar characteristics that cohabit with both progenitors. We argue that the increasing trend of lone motherhood in Brazil should be treated as a major concern in health policy design.

.e., mother is single, separated, divorced 0, otherwise and IV i is the instrumental variable that needs to assign exogenous variation to the relation between mother's marital status and child's height-for-age. Expressed differently, we need at least one variable that influences the probability of a woman becoming a single mother that, at the same time, exerts no influence on her child's height-for-age z-scores. In this paper, the instrumental variable is "firstborn girl". The family economics literature has shown the existence of a relationship between the probability of divorce or lone motherhood and the sex of the firstborn in a family. Dahl and Moretti (2008), Ananat and Michaels (2008), Bedard and Deschênes (2005) and Ayllón (2014b) have shown for the United States that firstborns are less likely to cohabit with a father figure if they are girls. In other words, firstborn girls (as opposed to firstborn boys) increase the probability of divorce or separation among natural parents and decrease the probability of their mother finding a new partner after dissolution of a partnership. 18Several hypotheses have been used to explain the association between partnership stability and firstborn males. First, it could be that men are (simply) gender biased and have a greater preference for raising boys than girls, which would explain why they are more likely to cohabit with their male offspring. Second, the role model hypothesis argues that fathers may believe that their sons are more in need of a male role model (than daughters) and that is why they are more likely to stay. Third, the technological reasons or differential costs hypotheses assume that men could be more efficient at raising boys than girls so, since it is easier for them, they are more likely to cohabit with their male children. This is similar to the idea that girls could be more costly in terms of money and time. Finally, the compensatory behaviour hypothesis assumes that boys have more health problems and are harder to look after than girls, so fathers are more likely to stay in the household to compensate. We hypothesize that, like in the United States, "firstborn girls" (and all their brothers and sisters) are more likely to live without their father in Brazil than children in families where a boy is born first. Indeed, a simple regression probit with the dataset at hand confirmed that this is the case: firstborn girls are more likely than boys to live with a lone mother (with a significance level of 5%). We have confirmed these results with data from the five Brazilian Censuses from 1970 to 2010 extracted from the International Integrated Public Use Microdata Series (IPUMS-International) (see Minnesota Population Center, 2013). The significance level for the gender effect was even higher, which is readily explained by the fact that the Census contains a huge number of observations compared to the POF and therefore the gender effect can be more easily captured (Ayllón, 2014a). It is important to note that results from the simplest regression model indicated that "firstborn girl" has no influence on the height-for-age z-score equation, which allows us to implement an instrumental variables strategy. To the best of our knowledge, this is the first time that such an instrument has been used in the context of child health analyses. Mothers's previously imposed age limitations help us to ensure that the child observed to be the eldest really is the mother's firstborn. In Brazil, mean age at leaving home is above 20, so it is unlikely for the firstborn in a family to have already left the parental home while the mother has a child that is younger than 6. Median spacing between children of the same mother below the age of 20 is 3 years (with an average of 3.4) according to Census data from 2010. Moreover, we assume that child sex is random (women cannot induce the sex of their babies) and that there is no sex-selection abortion in Brazil as confirmed by Chiavegatto Filho and Kawachi (2013). --- Empirical results Table 2 shows the results of the treatment-effects regression model. The first row clearly indicates that, controlling for other observable factors, being raised by a single mother is associated with lower height-for-age z-scores or, phrased differently, with a higher probability of suffering malnutrition, among children under the age of six in Brazil. The coefficient for lone mothers is statistically significant at 1%. Moreover, post-estimation results indicate that, conditional on being in a lone mother household, a child's expected height-for-age z-score is 0.31 points lower than for children in households with both parents. This is, for example, equivalent to the effect of being raised by a mother that never attended school. The results of the second equation indicate the validity of the instrument variable used. Having a firstborn girl in the family increases the probability of a mother raising her children alone (statistically significant at 2%). The Wald test (shown at the bottom of the table) establishes that we can reject the hypothesis that the two error terms are uncorrelated. Moreover, a likelihood-ratio test of an over-identified treatment-effects system of interest against a just-identified version indicated the validity of the instrument used. Indeed, the "firstborn girl" dummy was not significant in the main outcome equation in any of the specifications we tried. As for the other variables for family structure, the number of children in a household up to 10 years of age is associated with lower height-for-age z-scores in the studied sample, but not in the case of older siblings (11-15 years). It is reasonable to believe that malnutrition is more prevalent in families with a large number of children since food needs to be shared among more members. Regarding the other explanatory variables, we focus first on children's characteristics. Being a female infant is positively related with higher height-for-age z-scores while being black, half-caste or indigenous does not have any explanatory power. Our results indicate that the nutritional racial gap is closing in Brazil once controlling for the endogeneity of family structure. Children's age (in months) is negatively associated with height-for-age z-score, which indicates that younger children are (in relative terms) taller than older children. The mothers' characteristics offer some of the factors with the greatest explanatory power. Mothers' height is associated with higher children's height-for-age z-scores and the same is true for body-mass index. Both variables are keys in our specification as they control for the child's genetic code. As for the mother's age at birth: the older the mother was when she gave birth to the child, the higher her children's scores. 19 This association slightly reverses at older ages, following the usual inverted-U shape. 20 A mother's lack of schooling is another key variable for understanding children's height-for-age z-scores in Brazil. Compared to a child whose mother holds a University degree, a child with a mother that never went to school has a z-score that is 0.30 points lower. Note that no differences are observed between mothers that went to school (even for a short period). Moreover, children with an employed mother have higher than average height-for-age z-scores, although the coefficient is only statistically significant at 10%. Household economic status was controlled by building a categorical variable that combined poverty status and receipt of Bolsa Fam<unk>lia (BF). Poor children in Brazil that live in households that receive Bolsa Fam<unk>lia are still suffering consequences for their health condition because their family cannot provide sufficient economic resources. Despite the Bolsa Familia's success at fighting poverty in Brazil, poor children in beneficiary households have lower height-for-age z-scores compared to those not receiving the transfer. 21 Also, household income per capita was considered (in logs) but was not statistically meaningful. 22 19 Note that despite our initial hypothesis that taller women could have had better chances in the marriage market (and, therefore, be less likely to be a lone mother), the variable "mother's height" was not statistically significant in explaining single motherhood. 20 Mother's age was not included in order to avoid multicollinearity problems. 21 If households are no longer considered poor thanks to the BF transfer, this would indicate major success of the program, by not only helping families out of poverty but also their children out of malnutrition. 22 We also tried to include household income quintiles but this made no difference to the results so they were left out of the final specification. In terms of the level of urbanization, the results show that living in an area with paved streets is positively related with higher height-for-age z-scores while piped water does not have any explanatory power. As for regional characteristics, and unlike the previous literature, we do not find statistically meaningful differences across regions once controlling for other characteristics and the endogeneity of family structure. Other variables were included in the specification to test their importance for heightfor-age z-scores but they do not yield statistically significant results and were left out of the final specification. These include living in an urban area, whether the child has a private insurance plan, sewage disposal in the household, mail delivery service, dangerous location in the sense of being close to a dump, sewer, polluted river or a hill subject to sliding, garbage service, street-lighting and household's perception of the quality of the health service. Note that the inclusion of none of these variables (or groups of them) made no difference to the main results. --- Robustness checks One possible drawback of the estimation strategy presented above is the fact that for a certain number of children in the sample the explanatory variable "girl" in the main equation and "firstborn girl" in the auxiliary equation refer to the same child. In order to confirm our results, we have run the same specification but excluding firstborn children (thus from second order onwards). The results were very similar to those presented in Table 2: lone motherhood is associated with lower height-for-age z-scores with a coefficient of -1.89 (rather than -2.10) and statistically significant at 1%. Similarly, "firstborn girl" is associated with lone motherhood with a level of significance of 3% and a coefficient of between 0.169 (rather than 0.166). These results confirm that our findings are not dependent on the child's order of birth, and neither is the instrumental variable strategy. 23 --- Conclusions This paper has studied the causal relationship between family structure and children's health conditions in Brazil. In particular, we assessed whether lone motherhood has any influence on the height-for-age (z-score) of children under the age of 6. Using data from the Pesquisa de Orçamentos Familiares collected between 2008 and 2009, we find that children being raised by a lone mother have a height-for-age z-score that is 0.31 points lower than that of children of similar characteristics that cohabit with both progenitors. The results are robust to different model specifications and are the outcome of an instrumental variable econometric strategy that has been used for the first time in the context of child development analysis. More precisely, we use male preference for firstborn sons (as opposed to firstborn daughters) to instrument the probability of a woman becoming a single mother. Robustness checks also indicated that the results are not dependent on children's birth order. The mechanisms that help to understand the positive relationship between stunting and lone motherhood in Brazil, while controlling for other socio-economic and demographic factors, are difficult to disentangle. The previous literature has indicated that lone mothers probably suffer higher levels of stress given the need to deal with the dual role of sole carer and primary breadwinner. 24 Stress may affect women's capacity to care for children and therefore child development may be jeopardised. Lone mothers also lack monitoring by a cohabiting partner that could, for example, dissuade her from healthharmful and risk-taking attitudes with regard to the child. Finally, women that raise their children on their own may have a smaller extended family and also fewer social relations (due to the amount of time and energy that needs to be devoted to childcare) and, as a result, may find it harder to seek or obtain help (in all domains). Our findings indicate that lone motherhood should be a major concern for health policy design in Brazil. As in other parts of the world, each year, more and more children are being raised by a lone mother. Moreover, our results are probably highly conservative as we have intentionally not considered teenage mothers in order not to confound biological immaturity with lone motherhood (Finlay et al., 2011). Health policy designers in Brazil should not only focus on the (shrinking) inequalities by region or race but should also shift their attention to the (increasing) inequalities by family structure. --- Acknowledgments Sara Ayllón gratefully acknowledges financial support from Spanish projects ECO2010-21668-C03-02, ECO2013-46516-C4-1-R and XREPP (Direcció General de Recerca) and Natalia Batista from FAPESP (2011/11253-1) and CNPq (Project-400876/2011-6). We wish to acknowledge the Institute of Geography and Statistics (Brazil) for providing the Census data that made this research possible and the Minnesota Population Center (Integrated Public Use Microdata Series, IPUMS) for making it available to us.

This paper studies the relationship between lone motherhood and children's height-for-age z-scores in Brazil. In order to isolate the causal effect between family structure and children's condition, we estimate a treatment-effects model that uses male preference for firstborn sons (as opposed to firstborn daughters) to instrument the probability of a woman becoming a single mother. We find that children being raised by a lone mother have a height-for-age z-score that is 0.31 points lower than that of children of similar characteristics that cohabit with both progenitors. We argue that the increasing trend of lone motherhood in Brazil should be treated as a major concern in health policy design.

Introduction Discrimination against people with disabilities in the health care system for many people is stereotypically associated with inhumane conditions in psychiatric hospitals. Not so long ago, such a situation was common in many countries of the world, and Lithuania is no exception. In recent decades, there has been a debate in health care practice for people with disabilities that there is already a shift from a medical model to a social model, and new models are developed, such as the human rights model, which can be linked to the United Nations Convention on the Rights of Persons with Disabilities. On the other hand, in many countries, including Lithuania, the analysis of the situation of people with disabilities in the health care system in terms of discrimination is not carried out systematically, and it can hardly be said that this topic is a priority. In order to systematize the research conducted in Lithuania on the analyzed topic, I performed the analysis of scientific works in the scientific bases available to me, such as Academic Search Complete (EBSCO); Education Source (EBSCO); ERIC (EBSCO); Health Source-Consumer Edition (EBSCO); Health Source: Nursing/Academic Edition (EBSCO); SAGE Journals Online; ScienceDirect; SocINDEX with Full Text (EBSCO); Springer LINK and Google Scholar. Since my research is focused on the situation in Lithuania, I first chose keywords in Lithuanian, narrowing the field of the research and searching for scientific articles reflecting discrimination against people with disabilities in the Lithuanian health care system. Later, I repeated the search using the same keywords, but already in English, I searched for articles in English that are related to discrimination against people with disabilities in the health care system in Lithuania. I have focused on research papers written over the last ten years (2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019). I set myself the following tasks: to find out to what extent the situation I am going to delve into is researched? What are the quantitative indicators of scientific works? What is the manifestation of discrimination against people with disabilities in the context of the health care system? I also sought to predict the novelty and relevance of the article in both aspects of Lithuanian science and practice. I have not found a single scientific monograph in the last decade, I have found eight doctoral dissertations related to my field of research (in a broad sense). Only one of the dissertations-the doctoral thesis by Ru<unk>k<unk> -in its philosophical approach is closest to the interpretation of my research data and the perception of the formation of findings. In her research, the author revealed the peculiarities of constructing the dignity of persons with disabilities through consciousness-raising strategies (Ru<unk>k<unk>, 2014). The analysis of scientific articles has highlighted two topics in a broad sense that are related to discrimination against people with disabilities in the health care system. Issues of capacity and related legal regulation are analyzed in the articles by Juodkait<unk> (2014) presents the model of supported decision-making as a tool and form of socialization of people with psychosocial disabilities, analyses the aspects of its applicability in Lithuania. P<unk>rait<unk>-Andrikien<unk> (2012) analyses the problematic aspects of the institute of incapacity established in Lithuanian legal acts. Zaturskis and Kiaunyt<unk> (2014) investigate how the incapacity of a person with a mental disability is constructed and what dilemmas the social worker involved in the process faces. From the aspect of human rights, the articles of Ru<unk>kus presenting the United Nations Convention on the Rights of Persons with Disabilities as a phenomenon influencing the social concept of the world, including Lithuania, are significant: "The United Nations Convention on the Rights of Persons with Disabilities proclaims a fundamentally new approach, obliging countries to develop such legislation that persons with disabilities receive such support that does not stimulate old or new forms of discrimination, but creates particular conditions for the participation of persons with disabilities in education, health, culture, the labour market and other sectors and organizations of society, to make it a working norm and a particular aspiration" (Ru<unk>kus, 2014). Ru<unk>kus actualizes the concept of inclusive equality (Ru<unk>kus, 2018). Overcoming otherness as a resource, including changing the situation from the aspect of human rights, Ru<unk>kus presents the possibilities of the community (Ru<unk>kus, 2016). In his article, P<unk>ras analyses how human rights are observed in medical practice (P<unk>ras, 2017). Many of the aforementioned researcher's articles and other scientific works (together with co-authors) are devoted to the rights of people with mental disabilities or intellectual disabilities and their family members to a dignified life, including health care (<unk>umskien<unk> and P<unk>ras, 2014;P<unk>ras and<unk>umskien<unk>, 2012, 2015). In other works by P<unk>ras (with co-authors), the rights of people with intellectual or mental disabilities are analyzed in international contexts in relation to historical, cultural, economic and other environments, revealing their impact and analyzing the opportunities for change (Solantaus and P<unk>ras, 2012;Khandelwal et al. 2010). The state of the public's right to health in Lithuania is assessed as insufficiently ensured in the article by <unk>elkis (2007). The works of <unk>umskiene <unk> and her co-authors proving and explaining the facts of multidimensional discrimination against women with disabilities in the health system is directly related to the field of my research (<unk>umskien<unk> et al., 2014, 2015). The issues of legal regulation in a disability situation are discussed by Krik<unk>i<unk>nas (2015) and Gud<unk>inskien<unk> (2010). <unk>pokien<unk> (2010) emphasizes the importance of solidarity in medicine. Viluckien<unk> (2013) delves into the change in the concept of disability in medical sociology. The links between social policy and the health of people with mental disabilities are analyzed by Mikutavi<unk>iene <unk> and Gu<unk>inskien<unk> (2012). The link between discrimination and models of assistance provided is analyzed in several scientific works (Sauserien<unk> et al., 2019;Staponkut<unk> and Ra<unk>kauskien<unk>, 2019;Raipa and <unk>epurait<unk>, 2017;Mak<unk>tutyt<unk> and Naujanien<unk>, 2008). --- Materials and Methods The study of scientific works conducted allows us to assume that there is little research on discrimination against people with disabilities in Lithuania in the aspect of the health care system. In this context, the questions naturally arose: what is the situation of people with disabilities in the health care system in Lithuania? Are they discriminated against? If discrimination against people with disabilities persists, what is its manifestation? These and other similar questions reflect the scientific problem of the article. To answer these questions, I analyzed the data of the research Experiences, needs, and challenges of people with disabilities, their relatives, and professionals providing assistance to people with disabilities in the Lithuanian health care system. During the research, applying life history methodology, 8 interviews were taken from each of 30 people with disabilities (with different types of disabilities), from 30 of their relatives, moreover, 5 interviews from each of 50 professionals (doctors, nurses, physiotherapists, social workers, etc.) providing support to people with disabilities in the health care system all over Lithuania. I define the ontological perspective of research as the perception formed by postpositivism that one truth and one reality cannot be achieved. From the viewpoint of the epistemological perspective, I define interactive ethnography as the approach, namely, on the basis of which research data were collected (Spradley, 1980;Spradley and McCurdy, 1972). First of all, I associate the methodological perspective of the research not with the purified method, but with the disclosure of the logic of the research: the collection of research data was organized by abandoning the pre-construction, and the research participant was "followed"; great attention was paid to research ethics both by introducing the research participants with the research and ensuring their anonymity, and by respecting the research participant as a personality, his or her well-being and feelings, and later the selection and interpretation of the research data. The data analysis procedure and process complement the methodological perspective. Thematic analysis as a method of data processing and interpretation was chosen for its flexibility, the possibility for the researchers to think in their own way, nondogmatically exposing the findings and leaving room for the expression of the reader's perception and critical attitude (cf., Braun andClarke, 2006, 2012). In this article, in order to answer the questions raised, the data are analyzed only from the aspect of discrimination (based on my subjective perception, 82 episodes were selected for analysis from all the research material related to the expression of discrimination in the health care system). --- Results --- Disability Discrimination The analysis of the episodes of the narratives allowed to distinguish three objects of the subtopic: Prejudgement about the person's abilities; Other rules; Services to a particular person are not provided. The object of the subtopic Prejudgement about the person's possibilities is characterized by the multidimensional expression. However, on the other hand, despite different situations, circumstances, and other factors, the preconceived opinion, usually of one or another person-a doctor, another professional-about the physical, mental, professional, or other possibilities of a person with a disability dominates. For example, in Lithuania, in many sanatoriums and spas pools are adapted for people with disabilities, but it happens that due to a prejudgement about the person's abilities, they are not allowed there. There are various arguments: (...) the very fact of not allowing a person is motivated that the person does not have an accompanying person to supervise him or her, for security reasons, that not everything is adapted here, but nothing more. Although the administration of the sanatorium itself informs and confirms during the investigation that it has everything and everything there is adapted: a lift to the pool, shower rooms for people with mobility disabilities. The applicant herself has indicated that she has visited this sanatorium before, and, in that pool, maybe not everything is perfect, but it was enough to meet the needs (...) (S6). The object of the subtopic Other rules is related to the creation of different rules in the same sanatoriums or spa centers. Sanatorium managers decide not to allow a particular person to use their services. In the analyzed cases, it was found that not only Other rules for people with mobility disabilities are created, but a rule for a particular person is created. The semantics of the cases also reveal how much effort is needed to ensure that the person and the professionals assisting the person prove that the exclusive decision not to admit the person to the pool is discriminatory. Findings: The expression of the subtopic Prohibition of discrimination on the grounds of disability is related to Prejudgement about the person's abilities, "Other" rules, Not provided services to a particular person. Having examined the expression of the subtopic, I can state that the relevance of the subtopic Prohibition of discrimination on the grounds of disability and the necessity to change the situation in the Lithuanian health care system does not raise any doubts. --- Disregard of the Rights, Will and Wishes of a Person with a Disability After the complete inductive analysis of the expression of objects, the subtopic Disregard of the rights, will, and wishes of a person with a disability was divided into three semantic objects: The discussed treatment plan is not followed; The basic needs of the person are not met; Due attention is not paid in an emergency situation. A mother, who lives with her daughter with a mental disability, tells that when her daughter's health deteriorated, she had to receive hospital treatment, where the discussed treatment plan was not followed. The family lives in a town that did not have a hospital. Therefore, it was necessary to receive hospital treatment in the city hospital, which is 60 kms away. The mother discussed the plan of tests and treatment with the doctors, but it was not followed. When she called them, she would find out that nothing was done, when she went there, it was the same again. And again, the mother had to look for doctors, ask to pay attention to her daughter and her illness. The mother felt that she and her child were being discriminated against. The narrative context allows us to conclude that the mother tends to justify and understand the doctors, in her opinion, that they are good but very busy. On the other hand, telling about her experience in an even bigger city, the mother states that it is completely different there (...) we called that doctor from the city X, he says I don't want to traumatize that child, you see, there are wards without handles, I will ask for you to be admitted to that easier unit. Well, so we were admitted, they increased that dose, well and now we have not been to the hospital with these medicines for 7 years, she got married and gave birth to a baby. So, I have met very great people (Aar7). The expression of the mother's well-being, when the doctor does not follow the discussed treatment plan, does not arrive at the agreed time, ignores the mother's requests and observations, allows to assign the analyzed object to the subtopic Disregard of the rights, will and wishes of a person with a disability and treat as discriminatory. The expression of Disregard of the rights, will, and wishes of a person with a disability is reflected by the object of the subtopic. The basic needs of the person are not met. As can be seen from the episode selected for analysis, an elderly person with a disability and diabetes is admitted to the hospital's admissions department, where he spends more than eight hours. During that time, no one took care of the person and have him receive a meal, although he offered to pay. There are various circumstances: a weekend, tired workers on the one hand, but on the other hand-an old, sick person with a disability and diabetes. Not meeting basic needs is also encountered in caring for a relative because what they prescribe is obviously not enough, but she sometimes brings a packet of diapers from that Red Cross Society, there may not be every month, but sometimes it's every month, and we need to buy them less, because in practice we need diapers three pieces a day, at night it's necessary, and during the day it depends (Aar6). The expression of Disregard of the rights, will, and wishes of a person with a disability is reflected by the object of the subtopic Due attention is not paid in an emergency situation. A young woman with multiple sclerosis says she felt bad and called a friend. The woman does not remember the situation, and she relies on a friend's story. A friend took the woman to the admissions department, where the woman's doctor was on duty, who was surprised by why she had come here and understood the reason for her arrival as a desire to stay at the hospital. The doctor showed no desire to delve into the woman's well-being. The friend was surprised, but asked for some injection of medication, at least to sit, and when she recovers, they will go home. When the friend was asking the doctor, the woman started having seizures. The woman then received all the necessary help. The woman says that such a reluctance to delve into the person's state of health is common, as is the saying that "it is not that bad with you, why are you rushing to that hospital. " The same woman remembers another episode related to her critical health condition, when the tests were very bad, the options of treatment with medications were exhausted and she had to return home from the doctor in complete uncertainty: --- And you know, you come home -you know neither what medicine is nor what prognosis is, and if they had spoken to you humanly at least, and you don't know here they talked to you or not to you, they did not look into your eyes, they look at the papers and simply talk to you like this A2. Findings: The expression of the semantic objects of the subtopic Disregard of the rights, will, and wishes of a person with a disability is related to the objects of the subtopic-The discussed treatment plan is not followed; The basic needs of the person are not met; Due attention is not paid in an emergency situation, which proves discrimination against people with disabilities in the health care system. --- Elimination of the Discrimination Against People with Disabilities in Health Care The semantics of the title of the subtopic Elimination of discrimination against people with disabilities in the health care system could cover the whole topic Discrimination. In this case, the possibilities of elimination are delved into. After the complete inductive analysis of the expression of objects, the subtopic Elimination of the discrimination against people with disabilities in health care was divided into four semantic objects: "Rehabilitation treatment is not prescribed"; "You get medication and don't look for other problems for yourselves any more"; "A walking diagnosis, not a person"; "Stuffed with loads of medicine. " The titles of the three semantic objects are short quotes from the people's narratives. The abstraction was rejected because these quotes reflect the semantics of the object in a much more visual way than a generalizing statement. The object Rehabilitation treatment is not prescribed of the expression of the subtopic is found in the contexts of various conversations. It can be stated that rehabilitation treatment is relevant in many topics, subtopics, and contexts of conversations in general. Rehabilitation treatment, the dominant semantics of the narratives, is challenging to access. In one woman's narrative, we see that a woman with a mobility disability was ignored by a family doctor when she wanted rehabilitation procedures or treatment in a sanatorium. The family doctor did not prescribe it, and her reasoning for not prescribing was very subjective. The woman found a way out-she began to address the head of the outpatient clinic directly. She then received treatment. The subjective and discriminatory approach to the rehabilitation process is revealed in an episode of a professional physiotherapist's narrative: If it is a young person of working age, then professionals should focus all their efforts on them, invest as much as possible in them so that they can benefit society, pay taxes, work, not be, as I say dependent, and feel helpless. Physical rehabilitation alone is not enough, and they still need to be, like all other people, to integrate into work, to attend some events. So, I would suggest that young people be given special attention and not only work but also the time should be invested in them and rehabilitation should start immediately and be prescribed on a regular basis. Maybe older people also need rehabilitation, I'm not saying anything about it, but maybe it should beturned a little differently (S4). Although it is not explicitly stated that the rehabilitation of older people is unnecessary, various discriminatory clauses can be deduced from the context: "Maybe," "it should be turned a little differently. " On the other hand, such episodes of narratives, where rehabilitation is given unexpectedly to the person himself or herself, at the initiative of the doctor, are rare but still encountered: And there was a doctor. She came to me, and she is such a nice doctor, insanely nice, for some reason she came to me and started massaging me. She put her hands to my back and started massaging. Just for no reason. And says, Lord, how constrained you are, you need massages (A1). An accidental meeting with a doctor creates preconditions for a person's rehabilitation treatment, and by exploring the context of the narrative, we learn that the woman forgets back pain for several years. Another object of the expression of the subtopic, which is related to discrimination and which should be eliminated in the health care system, is medical professionals' indifference, the performance of formal duties: "You get medication and don't look for other problems for yourselves anymore." The woman who survived the accident does not remember anything. However, her parents still feel hurt when she, with multiple sclerosis and lost memory, was taken to a doctor for consultation. According to the parents, they were very worried about their daughter and sought help, but the doctor did not communicate with them, prescribed medication, and said: "Why are you going here, you get medication and don't look for other problems for you?" (A2). I would relate the semantics of the object of the subtopic "A walking diagnosis, not a person" to the dissociation of medical professionals and the patients' pursuit of empathy: <unk>... > she looked at me and she -well you won't get those medications here, then you will get in the wheelchair again and she kind of talks to herself, we can prescribe one experimental medicine here, but I don't know, maybe in a week, maybe in two you could die, and I'm sitting, chm, here and I don'--- t know, what or where, I realized only two things, if I don't get medication, it will be bad, I can agree on a new medication, but I can die (A2). From this episode of the narrative, some may see a violation of ethics, and others may perceive the situation as the doctor's efforts or the patient's hopeless health. However, the context of the whole narrative leads to the conclusion that the patient, as an individual, is discriminated against. The statements of the narrative such as "She was sitting, talking to herself," "We can prescribe one experimental medicine here, but I do not know, maybe in a week, maybe in two you could die," allow us to state that the doctor does not care about the person sitting in front of her as a human being with her feelings and experiences. It is highly unlikely that the doctor would say such words to her close person. Another object revealing the expression of the subtopic Elimination of discrimination against people with disabilities in health care is "Stuffed with loads of medicine. " A professional who works in a nursing home, says people with Alzheimer's are, in her opinion, unduly suppressed by medicine to keep them quiet, so that no more staff are needed to care for them. The professional says that the amount of medication administered is such that people become involuntary, apathetic, like "dolls. " After researching the narrative episode, the data obtained show that because of medicine, people become immobile, apathetic, like "dolls. " In a relative's narrative, there is a similar expression of the data: Well sure, when she was taken to the hospital, they would give her such medicine, what I didn't like, it made her very sleepy. When I came there, I could hardly talk to her, it seemed she was sleeping. They would say that it's such treatment (...) Yes, they said, it has to be so, but well [in the city X] it wasn't so Aar 7. The mother was anxious about why her daughter was "almost asleep," she would ask the doctors and hear an unjustified answer that "it is such treatment. " However, a long history of treating her daughter allows her mother to compare "such treatment" with treatment in a big city, where her daughter not only was not suppressed by medicine, but a psychologist was working with her, she also received another alternative treatment, she was taken out for a walk, etc. Analyzing the subtopic Elimination of discrimination against people with disabilities in health care, it was difficult to find an example of the expression of the elimination of discrimination. The narratives, in which the revealed situations prove the necessity of elimination, dominated. I managed to find one warm and sincere story of a young professional that illustrates that it is possible to see a human being in a person with any diagnosis and communicate with him or her as with an equal: (...) I was very attached to such a little old woman with Alzheimer's. She was called Laura, so it's even a pity to remember somehow. Really we communicated very well, and I was attached to her, and now it's even a pity to remember, well that I don't work and simply it's interesting how she's doing (smiles), actually, really, I myself, I would just find free time and would just go, would go to her, to talk to her. The first time even when I went to her, I was scared, and I didn't even understand, she tells me they brought me here, they brought me here, she says, they brought me here from home, and I didn't understand what's happened to her, why she was saying that, and she forgot herself why she came here. So, in fact, she also has Alzheimer's herself, but by herself, everything by herself. It's great to communicate with her, and you can talk about everything with her at that moment. Maybe she won't remember something, maybe she won't remember that she had a meal now, but she will talk to you like a human being (S9) The young worker felt the warmth from a woman with Alzheimer's, as evidenced by the semantics of this episode: "but she will talk to you like a human being. " Not the professional will talk to the woman but the woman with the professional. The context of the research suggests that the professional was exposed to severe working conditions, a "predatory" environment, and the communication with the woman with Alzheimer's allowed her to feel like a valuable specialist, to see the meaning of her work. Findings: After examining the expression of the object, the highlighted properties of the object allow us to assume that people with disabilities in the health care system are primarily faced with insufficient and limited rehabilitation treatment (Rehabilitation treatment is not prescribed), "formal" assistance when medicines are prescribed without seeing a person (You get medication and don't look for other problems for yourselves any more), when medical professionals do not want to delve into the person's psychological well-being or psychosocial problems (A walking diagnosis, not a person), when no alternative treatment is given (Stuffed with loads of medicine). First of all, I would relate the elimination of discrimination against people with disabilities in health care to these findings of the research. --- Legal Capacity is Violated Having analyzed the expression of the subtopic Legal capacity is violated, I distinguished two elements: The recognized legal incapacity results in poor quality medical care; The forcible inclusion in the process of establishing legal capacity. These elements not only describe the object of the subtopic but also reveal the impact on discrimination. The object of the subtopic The recognized legal incapacity results in poor quality medical care is illustrated by the narrative when a doctor while filling in the documents, noticed a record in the medical history about a person's disability and incapacity, and decided that the person should be transported to a psychiatric hospital: (...) a person with an intellectual or mental disability has been declared legally incapacitated and had a caregiver, his relative. This means that this person with a disability had a health problem, very sharp pains in the abdominal cavity, internal organs. The relative went to the emergency department of one of the cities of our country together with the patient in an ambulance, the doctors seemed to start filling in the documents and saw that the disability had been diagnosed in the medical history, incapacity due to a mental disability, and they immediately told that this person needed to be taken to a psychiatric hospital, because of an exacerbation of his illness, because he is shouting in the hospital. The caregiver tried to argue that he has pains, not an exacerbation of the mental illness, nothing to do with the illness. But the doctors were unyielding, they put him into an ambulance and sent him to a psychiatric hospital, probably the patient was probably given sedatives to make him calm. According to the caregiver's testimony, the patient and his pains were not given much attention, just treat mental illnesses but not relieve existing pains. A few days later, the hospital applied to the court for involuntary treatment for the court to issue a permit. The court granted this request from the hospital that due to an exacerbation of the disease the person's treatment was necessary, and when he was discharged from the psychiatric hospital, in the words of the caregiver, when they went to the city hospital, the patient was diagnosed with a rib fracture. Of course, the caregiver could not answer when those ribs of the patient were broken before or after going to a psychiatric hospital, which, in fact, could have been the cause of the pain with which he complained. So, in this case, we recommended that they apply to the ministry because of the patient's violated rights, for it to carry out an investigation in that case (...) (S6). Distinguishing the elements of the narrative and the description of the data suggest that the person, possibly due to his legal incapacity and diagnosed disability, did not receive quality medical care. However, he was sufficiently actively and persistently represented by a court-appointed caregiver. The person was admitted to a psychiatric hospital due to pain, "and when he was discharged from the psychiatric hospital, in the words of the caregiver, when they went to the city hospital, the patient was diagnosed with a rib fracture." The caregiver appealed to a state institution, which also got actively involved in representing the person's rights, trying to make people draw conclusions from this situation and make decisions that do not discriminate against persons with legal incapacity. The state institution "appealed to the Ministry of Health to consider whether it would not be better to have psychiatric wards in general hospitals instead of separate psychiatric hospitals. " However, the elements of the narrative, such as "the psychiatric hospital strongly opposed and argued that if the necessary importance of complex treatment arose, the hospital would bring doctors to the hospital, or the hospital itself would take care of taking the patients to the treatment institution, and medical care would be provided" (although the finding of the research is evident-no assistance was provided in a particular case), allows us to assume that the system is difficult to reform. More than that, the institutional interests are above the interests of the individual. Another object of the subtopic-The forcible inclusion in the process of estab-lishing legal capacity-is related to the object. The recognized legal incapacity results in poor quality medical care. A person with difficulty walking who has a physical disability says that due to a conflict in the family, he was involved in the process of determining incapacity due to various circumstances. According to him, the daughter wrote the application, the court was on the next day, and after the court, he was immediately taken to a psychiatric hospital. The person spent two weeks in a psychiatric hospital, they examined him there, observed him, he was kept guarded, in his words, it was more terrible in the hospital than in prison. After examining the person's health, the person was invited to a commission, where he was heard, the commission was interested in the situation in the family. The person was not declared incapacitated, and he was discharged from the hospital to home. Although he had a disability, had difficulty walking, was not brought to the psychiatric hospital voluntarily, he had to return home by himself. According to the person, "sitting on a bench" at the bus station, he felt bad"the heart apparently couldn't stand it." An ambulance took him out of the bus station, and the person was lying in the hospital. This episode is also not directly related to discrimination in the health care system. On the contrary, the health care system acquitted the person, did not recognize him as incapacitated. However, the humiliating process of determining incapacity itself, indifference when discharging from hospital, discriminates against a person. Findings: The expression of the objects The recognized legal incapacity results in poor quality medical care; The forcible inclusion in the process of establishing the legal capacity of the subtopic revealed during the research proves that the person's right to legal capacity equally with other persons in all spheres of life in the health care system is violated and it is discriminatory. --- Prohibition of Torture and Cruel and Degrading Treatment Having conducted the analysis of the expression of the subtopic Prohibition of torture and cruel and degrading treatment, I distinguished three objects: "Kicked and called a penguin"; Doctor's indifference is accepted as humiliation; Ignoring as humiliation. The title of the first object is a mother's words, which I could abstract with the concepts of bullying or degrading behavior. However, as I have already mentioned, it is important for me that the title of the object reflects the semantics. By that, I aim to make the reader realize that the situation requires change. The title of the object-Kicked and called a penguin-has a much stronger message within it than, for example, degrading behavior. Other titles of the objects of the subtopic-Doctor's indifference is accepted as humiliation; Ignoring as humiliation-they could also be not distinguished and integrated into the subtopic. However, I see different meanings in them. Ignoring is a deliberately constructed behavior, while the causes and circumstances of indifference may be different. The episode of the Kicked's narrative of the object, called a penguin of the subtopic, is one of the most revealing cruel and humiliating behaviors that gives, if not physical, then deep spiritual suffering to both the mother and her child. From my subjective point of view, eliminating the narratives that reflect the history of people with disabilities in the health care system (narratives about the events that happened twenty or thirty years ago), it is one of the most revealing episodes how a child and a mother, who are in the situation of disability, are tortured nowadays: Well there was probably a medical professional there, we went to the room, already for the disability group, I'm sorry... (...) maybe I would have dressed her somehow differently, but since already in such a month, I bought a blue winter hat, well, it's such white blue, such a white fur inside, the shoes also suit the hat, the shoes like this -the fur is here, my daughter sat down like that and I sat down here (shows how she is sitting down), a medical professional, a woman, is sitting, she took that card, threw it there, and I tell her it will be hard to untie those shoes, the daughter does not understand what is going on here, the doctor says untie those shoes (in a loud tone), already in such a tone, I just leaned over to untie, she came up, you don't untie (loudly), well I think ok I won't untie, I sat down, she came up, I don't lie at all, because I don't have the reason to lie, came up and (...) kicked her feet (cries) I see the man is sitting there, was sitting, he didn't even raise his head, it was probably a medical professional there too, they were all there afraid of her, they were sitting and no one was reacting, they don't see, they don't even want to see, stand up, she is sitting, the penguin is sitting here, and I understood that she didn't like (...) clothing, that I dressed her, the penguin came and is sitting here, go, she didn't go anywhere, as she was sitting and did not go, she bowed her head... And it was scary for me that I couldn't protect her (cries). However, after that I went out, I gathered all my strength, I called (...),I say I'm still in your outpatient clinic now, I say I'll call the TV now, I say her surname is so and so, in writing, I say you don't think I'm going out now, I say it was very hard for me. However, I say I have to gather all my strength if I don't defend my child. She's not a medical professional,

In recent decades, there has been a debate in health care practice for people with disabilities that there is already a shift from a medical model to a social model, and new models are developed, such as the human rights model, which can be linked to the United Nations Convention on the Rights of Persons with Disabilities. On the other hand, in many countries, including Lithuania, the analysis of the situation of people with disabilities in the health care system in terms of discrimination is not carried out systematically, and it can hardly be said that this topic is a priority. The scientific study has revealed that this is the case. In this context, the questions naturally arose: what is the situation of people with disabilities in the health care system in Lithuania? Are they discriminated against? If discrimination against people with disabilities persists, what is its manifestation? These and other similar questions reflect the scientific problem of the article. Answering these questions requires obtaining the data of the research, needs, and challenges of people with disabilities, their relatives, and professionals assisting people with disabilities in the Lithuanian health care system were analyzed, which were processed referring to the principles of thematic analysis. The findings of the research prove the multidimensional expression of discrimination against people with disabilities in Lithuania's healthcare system.

ries) I see the man is sitting there, was sitting, he didn't even raise his head, it was probably a medical professional there too, they were all there afraid of her, they were sitting and no one was reacting, they don't see, they don't even want to see, stand up, she is sitting, the penguin is sitting here, and I understood that she didn't like (...) clothing, that I dressed her, the penguin came and is sitting here, go, she didn't go anywhere, as she was sitting and did not go, she bowed her head... And it was scary for me that I couldn't protect her (cries). However, after that I went out, I gathered all my strength, I called (...),I say I'm still in your outpatient clinic now, I say I'll call the TV now, I say her surname is so and so, in writing, I say you don't think I'm going out now, I say it was very hard for me. However, I say I have to gather all my strength if I don't defend my child. She's not a medical professional, an uncultured woman, will not kick my child in my presence, so I say, I am getting terrified of what is happening to those people with disabilities who do not have parents at home who are closed in this house, so they are also kicked like this when my child is kicked in my presence in the mother's presence (Aar17). This case could be considered accidental, but the mother's statements 1 allows us to assume that this is a systemic situation. Such cruelty of professionals traumatizes a person, leaves long-term grievances and consequences. On the other hand, it differs from the narratives that reflect the history of health care in people's ability to fight against such discrimination: "And it was scary for me that I couldn't protect her (cries), but after that, I went out, I gathered all my strength, I called (...)", "if I don't defend my child. " The analysis of the narrative of the object Doctor's indifference is accepted as humiliation shows that the doctor's treatment of the patient has discriminatory features, humiliates the patient as a personality. Such an expression of medical professionals' indifference, when people with disabilities and their relatives feel humiliated, is often found in narratives. People's stories that doctors don't delve into the situation: "a cold? This cold is because of old age, no one here will cure you" Aar 2; "you can use any drops that you want, nothing will help you anymore" Aar 21-are a reality these days. Ignoring as a phenomenon is somewhat less common in narratives, but its mani festation is obvious: one accepts it as cruel and degrading behavior that causes a lot of psychological suffering. A woman says that when she came to visit her father, who has a mobility disability, she found him distressed, agitated, talking in whispers, because the ward doctor, a neurologist, had "punished" them. He "discharged" the man who said that the treatment did not help anyway home the same day and "punished" the whole ward, saying that he would not come to them for three days. 1 "... the man is sitting there, was sitting, he didn't even raise his head, it was probably a medical professional there too, they were all there afraid of her," "they were sitting and no one was reacting, they don't see, they don't even want to see," "I am getting terrified of what is happening to those people with disabilities who do not have parents at home who are closed in this house, so they are also kicked like this when my child is kicked in my presence in the mother's presence. ". The woman states: "my dad said agitated that he hadn't slept all night and kept repeating-so they are not going to treat me now? It was so difficult for me to get into the hospital, and now everything is in vain" Aar 23. As can be seen from the other circumstances of the narrative, the patient received treatment, but both father and daughter felt humiliated because they had little to do with the conflict but were "taught" that the doctor's decisions are non-negotiable. During the research, the distinguished objects Kicked and called a penguin; Doctor's indifference is accepted as humiliation; Ignoring as the humiliation of the subtopic Torture and cruel and degrading treatment and the distinguished features related to the objects-physical and psychological torture of a person with long-term consequences; indifference as a form of patient humiliation, ignoring causing psychological suffering, etc.-show that there is a lack of systemic solutions in the health care system. --- Conclusion In the aspect of discrimination, it has been established that in the Lithuanian health care system, the facts have been found that people with disabilities are discriminated against because of their disability. People with hearing impairments do not even have a theoretical opportunity to take a driving test because the family doctor does not send them to a specialist doctor for a check-up. Persons with a certain mobility disability, even though they had a certificate required for sanatorium treatment, were additionally referred to a paid consultation of a sanatorium doctor, who made a decision whether a person can attend the pool or not. It can be stated that exceptional rules have been created for people with mobility disabilities. The fact of discrimination against one person also became clear: the managers of the sanatorium decided not to allow the use of their services to a particular client with a mobility disability. The rights, will, and wishes of a person with a disability are disregarded: the discussed treatment plan is not followed (the relative must repeatedly ask the doctor to perform the tests or prescribe treatment). The basic needs of the person are not met (a person with diabetes is kept without food for eight hours in the admissions department, a woman must leave three euros at the reception to send her the results of the tests). Due attention is not paid in an emergency situation (a woman with multiple sclerosis brought to the admissions department, where the doctor treating her was on duty, did not receive the necessary help until the seizures started, etc.). There is no expression of the facts of the elimination of discrimination against people with disabilities in the health care system. The manifestation of discrimination is evident in the situation of rehabilitation treatment (rehabilitation treatment is often only available through a complaint or a bribe). In case of a difficult health condition (you get medication and don't look for other problems for yourselves any more). There are frequent facts about the overuse of medications, from the experiences of both professionals and relatives (the professional says that the amount of medication administered to people with Alzheimer's is such that they become involuntary, apathetic, like "dolls"). The expression of legal capacity equally with other persons in all spheres of life in the health care system is also negative: there are facts discovered that the recognized legal incapacity results in poor quality medical care, and the forcible inclusion of a person with a disability in the process of establishing legal capacity. The provision of the Convention on the prohibition of torture and cruel and degrading treatment is violated: a professional kicks a child and calls her a penguin, people with disabilities accept the doctor's indifference and ignorance as humiliation.

In recent decades, there has been a debate in health care practice for people with disabilities that there is already a shift from a medical model to a social model, and new models are developed, such as the human rights model, which can be linked to the United Nations Convention on the Rights of Persons with Disabilities. On the other hand, in many countries, including Lithuania, the analysis of the situation of people with disabilities in the health care system in terms of discrimination is not carried out systematically, and it can hardly be said that this topic is a priority. The scientific study has revealed that this is the case. In this context, the questions naturally arose: what is the situation of people with disabilities in the health care system in Lithuania? Are they discriminated against? If discrimination against people with disabilities persists, what is its manifestation? These and other similar questions reflect the scientific problem of the article. Answering these questions requires obtaining the data of the research, needs, and challenges of people with disabilities, their relatives, and professionals assisting people with disabilities in the Lithuanian health care system were analyzed, which were processed referring to the principles of thematic analysis. The findings of the research prove the multidimensional expression of discrimination against people with disabilities in Lithuania's healthcare system.

Introduction COVID-19 is an infectious disease caused by SARS-CoV-2, which mainly affects the functioning of the pulmonary system [1]. Current evidence shows that the COVID-19 pandemic has a much higher mortality rate in older adults due to morbidities and bad lifestyle (poor diet and physical inactivity) associated with aging [2]. Factors associated with increased risk of mortality in COVID-19 include comorbidities related to aging, such as obesity, insulin resistance, and cardiovascular disorders, and individuals, especially older adults, are at risk of having lower functional capacity and physical activity levels [3][4][5], which makes them more vulnerable to the infection [2,4]. During periods of social isolation and physical distancing for a pandemic, coping strategies (physical activity and adequate diet) and safety measures (use of face masks) that promote well-being and improve or maintain the general state of health should be performed and encouraged among the general population to mitigate the negative impacts of the disease [6]. The COVID-19 pandemic has had an unprecedented impact on the global health, economy, and functioning of societies [7]. Latin American countries with a high level of social and economic inequality have experienced worse effects of the pandemic. For example, S<unk>o Paulo, Brazil has a high population density and great disparity in demographic and epidemiological profiles, social and economic levels, and accessibility to health services and protection and safety measures, such as the use of face masks [8]. Therefore, understanding the sociodemographic variables and adherence to mask use is essential to auxiliary health decisions by public and health authorities to minimize the effects and negative consequences of the COVID-19 pandemic on public health [9]. The assessment of sociodemographic variables determines the impact of population diversity on the effects of the pandemic [10] and how choices regarding safety, security measures, and adherence could affect the consequences and outcomes in the field of public health. It is known that a population's profile and social characteristics can impact safety measures, hygiene, social distance, outcomes, and possible changes in timing of pandemics [11]. Due to the risk and characteristics of the professional practice and health literacy, it is quite plausible that health professionals, because of their frequent contact with the public, are more sensitive regarding adherence to safety measures [12]. Moreover, the physical and social distancing, use of face masks, and eye protection devices in public and health care facilities are needed for the public and health professionals to control COVID-19 transmission [13]. However, in low-income countries like Brazil, the lack of literacy and access to health care, the spread of fake news among the general population, and the lack of proper management by the government can make a difference in the results and outcomes of such complex health scenarios [14]. Unfortunately, this is what we observed in Brazil during the COVID-19 pandemic. Brazil has been one of the countries with the worst management of the public health crisis; it is on the brink of a progressive social and economic collapse. Thus, studies that aim to check the population's sociodemographic profile and the choices related to security and protective measures during a pandemic are essential to make more precise decisions based on technical and scientific knowledge. An online-based cross-sectional study involving 12 Bangladeshi residents 64 years of age recruited via social media investigated the influence of factors related to perception, knowledge, attitudes, and practices regarding COVID-19 and found that the factors that impact perception and choices were female sex, older age, higher education, higher family income, and urban area residence [15]. A cross-sectional survey conducted by telephone or mobile phone with older individuals living in the state of Minas Gerais, Brazil showed that older individuals were knowledgeable and had good health literacy regarding COVID-19, but those that did not implement all the preventive measures were older adult male individuals living by themselves with a low educational level, and they are more vulnerable to COVID-19 [16]. Importantly, individuals 60 years and older are more vulnerable to COVID-19, and the use of face masks is a protective, safety, and health care measure to decrease the risk and spread of infection [13]. In addition, older people have a higher peak viral load and, especially those with comorbidities, have higher mortality rates related to COVID-19 than young people. This would be associated with chronic inflammation present in older people who are frail, which could allow a "more effective" action from SARS-CoV-2 leading to serious infection-related complications [17]. Currently, epidemiologists emphasize that the use of face masks covering the mouth and nose effectively stops airborne infections. In general, health and government officials followed the World Health Organization recommendations and, in some cases, forced the population to wear face masks in public places. However, in some countries like Brazil, there is a low rate of health literacy among government officials at all levels. Research shows that using the right type of face mask, according to location and profession, protects and reduces the infection risk [18]. Our aim is to present the sociodemographic and economic profile and health features (about COVID-19) and compare the individual determinants of face mask use during the COVID-19 outbreak among younger and older Brazilian people. --- Participants The sample was selected using a nonrandom method and comprised of 2673 participants (mean age 40.0, SD 13.8 years). These participants were divided into two age groups: <unk>59 years (n=2378, 89%) and <unk>60 years (n=295, 11%). --- Procedures Participants were invited to answer the questionnaire voluntarily through posts made on social media (Facebook and Instagram) and WhatsApp using a standard text that publicized the study and drew attention to the importance of understanding the behavior of the population in relation to COVID-19, which could provide subsidies to implement awareness actions, reducing the spread of the disease. A link to the informed consent form was provided to each participant. Upon consent and agreement to voluntary participation, the participants were directed to the mandatory study questions. The questionnaire was developed by the researchers; corrected and adjusted by a panel of health experts, including a professional statistician; made available on the online platform Google Forms; and disseminated through social networks. The online questionnaire [19] was composed of 14 closed-ended questions about the following variables: age, sex, origin, marital status, religion, family income, education, presence of signs or symptoms or confirmed diagnosis of COVID-19, and occupation as a health professional (yes or no). In addition, multiple-choice questions about COVID-19 included the following: knowledge about the forms of transmission of COVID-19; risk groups, signs and symptoms, and what to do if they were present; preventive measures (hand hygiene, use of masks, and cleaning of surfaces) to be taken in case of traveling; and information on popular beliefs regarding the prevention, transmission, and treatment of COVID-19. --- Statistical Analysis For the descriptive analysis of categorical variables, frequency and percentage were calculated. For continuous variables, mean, SD, median, minimum, and maximum were calculated. To compare the variables of interest (associated with mask use), chi-square and likelihood ratio test (only for comparisons regarding the level of education) were used. A significance level of 5% (P value<unk>.05) was used. The data were analyzed using SPSS, version 19 (IBM Corp). --- Results Our sample consisted of the adult Brazilian population from different states of Brazil: Acre (n=1), Alagoas (n=3), Amapá (n=3), Amazonas (n=1), Bahia (n=23), Ceará (n=36), Distrito Federal (n=22), Esp<unk>rito Santo (n=32), Goiás (n=31), Maranh<unk>o (n=23), Mato Grosso (n=31), Mato Grosso do Sul (n=13), Minas Gerais (n=109), Pará (n=13), Para<unk>ba (n=12), Paraná (n=52), Pernambuco (n=2), Piau<unk> (n=2), Rio de Janeiro (n=73), Rio Grande do Norte (n=8), Rio Grande do Sul (n=24), Rondônia (n=1), Roraima (n=5), Santa Catarina (n=30), S<unk>o Paulo (n=2117; in the state of S<unk>o Paulo, the use of facial masks became mandatory on May 7, 2020), Sergipe (n=2), and Tocantins (n=4). The majority of participants were from S<unk>o Paulo. Table 1 shows that most of the 2673 individuals in the study were aged <unk>59 years (n=2378, 88.9%), were female (n=2039, 76.3%), were from the city of S<unk>o Paulo (n=2331, 87.2%), were married (n=1261, 47.2%), were Catholic (n=1241, 46.4%), had a monthly family income of 4 to 7 minimum wages in R$ (n=813, 30.4%), and had completed or were currently doing postgraduate studies (n=1181, 44.2%). In addition, 61.8% (n=1652) were not health workers, 84.4% (n=2256) did not show symptoms of COVID-19, and 97.4% (n=2604) had no confirmed diagnosis of the disease. The studied age groups (<unk>59 years and <unk>60 years) were not homogeneous regarding the following variables: sex, Brazil region, marital status, religion, total family income, professional type, and health characteristics and status (Table 1). Table 2 compares the profiles of participants with regard to the use of masks between the groups in terms of sex (male vs female), education level, occupation as a health worker (yes vs no), and presence of signs and symptoms or a confirmed diagnosis of COVID-19 (yes vs no). On the use of masks, there were significant differences in sex (female vs male; P<unk>.001), level of education (P<unk>.001), and occupation as a health professional (P=.001). Females, health professionals, and those with a higher level of education adhered to the use of masks more than others. Vancini et al JMIR AGING --- XSL • FO --- RenderX --- Discussion --- Principal Findings The main aims of this study were to describe the sociodemographic variables, determine the profiles of individuals compliant to the use of face masks, and compare them between younger and older people. The majority of the 2378 participants in the group aged <unk>59 years were women (n=1833, 77.1%), were living in the southeast region (n=2060, 86.6%), and had postgraduate degrees (n=1062, 44.7%). In the case of the 295 individuals aged <unk>60 years, the majority were women (n=206, 69.8%), were living in the southeast region (n=271, 91.9%), and had completed or were still completing higher education (n=121, 41%). In addition, the majority of participants in both groups have been using face masks; this was significantly influenced by sex, level of education, and whether the participant was a health professional or not. This study has two major findings. Nearly 30% to 40% of the participants were health professionals, and 80% to 90% were from S<unk>o Paulo, that is, people who have good health literacy and educational level and those who are living in regions with the highest socioeconomic level in Brazil. Bambra et al [20] reported that social, economic, demographic differences and inequalities, and lack of access to health care have implications in any pandemic recorded in history, including COVID-19. Dowd et al [9] pointed out that understanding the profile of sociodemographic variables are important for all governments to rapidly make policies to mitigate the negative effects of the COVID-19 pandemic. Through sociodemographic studies, it was possible to verify that the most serious cases and deaths were prevalent among older adults and those with comorbidities. This is important information for health care systems worldwide. Hence, tracing the sociodemographic profile of different populations worldwide to outline short-, medium-, and long-term positive coping strategies (eg, focused on improving physical and mental health) to help mitigate the COVID-19 pandemic will help decrease inequalities in access to social and health services for future generations. It is interesting to note that hospitalizations and mortality are higher in men than in women and that men are more inclined to smoke and thus have the potential for poorer respiratory outcomes in COVID-19 infection [21]. Regarding the use of face masks, in general, the majority of the participants in this study, both the general population and health professionals, reported adherence to this measure during the course of the COVID-19 pandemic. The factors that significantly influenced this relevant control measure were sex, level of education, and whether the participant is a health professional or not. We highlight three clinical trials, but only one of them is directly related to the use of facial masks as a central measure to control the spread of COVID-19 infection. Bundgaard et al [22] conducted a nonblind, randomized, controlled trial to investigate whether the use of facial masks could reduce the risk of SARS-CoV-2 infection. They included adults (aged >18 years, n=6000) without previously confirmed COVID-19 or symptoms suggestive of COVID-19 who spent more than 3 hours a day outside the home with exposure to other people. The authors concluded that the use of a face mask could be a protective factor for the user against SARS-CoV-2 infection. However, more evidence is needed through robust clinical trials to provide consistent scientific evidence for recommendations from health authorities worldwide and in the future. Liang et al [23] through a meta-analysis concluded that the use of masks is an auxiliary method and measure of health and prevention in relation to the outbreak of COVID-19 and highlighted that these protective health measures are impacted by the level of knowledge and health literacy, [24] and different beliefs, moral values, and even conditions of access to health. --- Final Considerations In this study, women (P<unk>.001), health workers (P=.001), and people with a higher level of education (P<unk>.001) had greater adherence in relation to the use of masks. A potential correlation was found between gender, where there was a higher incidence of disease in men, and there has been a globally observed shorter life expectancy in men as compared to women [25]. Determining sociodemographic profiles and identifying the factors that favored the use of face masks, especially in S<unk>o Paulo, does not reflect the actual scenario in Brazil, which is a country with many social inequalities, but provides subsidies to study other regions from the same point of view, which can assist in facing the current scenario and future health crises. --- Study Limitations and Practical Applications This study has limitations. Using social media to collect the data may have influenced the study sample, as many participants are health workers and living in the state of S<unk>o Paulo, the most economically developed region in Brazil. Nevertheless, we were able to gather an expressive sample. In view of the results of our study, we believe that the implementation of health care policies aimed at certain age groups, such as older adults, and populations, for example, men and people who are not health professionals, can increase the compliance to disease prevention measures, for example, the use of face masks, since these populations are heterogeneous from the health care point of view. Other limitations were the absence of some items in our questionnaire regarding family size (number of people living in the same house), the type of mask used (which can be difficult information to access for those people who are not health professionals), evaluation of the proportion of infected men and women, and a larger sample of people 60 years or older. One of the difficulties of our study was to obtain a larger sample of older participants. Our expectation was to have a more equalized sample size between younger and older groups, which was not possible. It is necessary to understand why older adults tend to answer questionnaires less than younger people despite the massive dissemination of the instrument to this audience. Finally, we did not include questions regarding the smoking habits and alcohol consumption (and other health habits) of younger and older people. These are factors that can impact the general health status and outcome of a COVID-19 infection in cases of abuse and excessive or constant use. Despite this, these are areas of study that need to be further explored and may be the focus of future studies. Finally, education actions, carried out by health workers, for health promotion and disease prevention can be stimulated and carried out increasing the health literacy of the population, which will provide individualized and effective actions. --- Authors' Contributions RLV, LCN, and CRVC conceptualized the study. RLV, LCN, CABL, MSA, RGS, PTN, BK, LHVP, MCBTL, REAB, and CRVC designed the methodology. The formal analysis was done by RLV, LCN, and CRVC, the investigation was done by RLV, LCN, CABL, MSA, RGS, PTN, BK, LHVP, MCBTL, REAB, and CRVC. The data was curated by RLV, LCN, and CRVC. The original draft was prepared by RLV, LCN, CABL, MSA, RGS, PTN, BK, LHVP, MCBTL, REAB, and CRVC. RLV, LCN, CABL, MSA, RGS, PTN, BK, LHVP, MCBTL, REAB, and CRVC reviewed and edited the paper. RLV, LCN, CABL, MSA, RGS, PTN, BK, LHVP, MCBTL, REAB, and CRVC contributed toward visualization. CRVC supervised the study. RLV, LCN, and CRVC contributed toward project administration. All authors have read and agreed to the published version of the manuscript. --- Conflicts of Interest None declared.

Background: Sociodemographic variables may impact decision making regarding safety measures. The use and selection of adequate face masks is a safety and health measure that could help minimize the spread of COVID-19 infection. Objective: This study aims to examine sociodemographic variables and factors relating to COVID-19 that could impact decision making or the choice to use or not use face masks in the prevention and care of a possible COVID-19 infection among a large sample of younger and older Brazilian people. Methods: An online survey composed of 14 closed-ended questions about sociodemographic variables and COVID-19 was used. A total of 2673 participants consisted of Brazilian people (aged ≥18 years) from different states of Brazil and were grouped according to age (≤59 years and ≥60 years). To compare the variables of interest (associated with wearing a face mask or not), chi-square and likelihood ratio tests were used (with P<.05 being significant). Results: Most of the participants in both groups were women from the southeast region who had postgraduate degrees. Approximately 61% (1452/2378) of individuals aged ≤59 years and 67.8% (200/295) of those aged ≥60 years were not health professionals. In the group aged ≤59 years, 83.4% (1983/2378) did not show COVID-19 signs and symptoms, and 97.3% (2314/2378) were not diagnosed with COVID-19. In the older adult group, 92.5% (273/295) did not show signs and symptoms of COVID-19, and 98.3% (290/295) were not diagnosed with the disease. The majority of the participants in both groups reported using face masks, and their decision to use face masks was influenced by the level of education and their occupation as a health professional. Conclusions: Younger and older adults have worn face masks during the COVID-19 outbreak. It is difficult to measure how much of a positive impact this attitude, habit, and behavior could have on the degree of infection and spread of the disease. However, it can be a positive indicator of adherence to the population's security and safety measures during the pandemic.

Introduction: While a growing corpus of literature regarding the stress suffered by caretakers for people living with dementia (PLWD) already exists, very little data is available regarding this subject among Romanian caretakers. Objectives: This cross-sectional study aims to compensate for this by assessing a small (N=72) sample of caretakers through the use of self-reporting questionnaires for subjective feelings of stress and burden. Methods: Responders filled and online survey containing miscellaneous socio-demographic questions and the Kingston Caregiver Stress Scale (KCSS) along with the Caregiver Health Assessment Self Questionnaire (CHASQ). Results were collected and analysed in SPSS for subsequent correlations. Results: The majority (77%) of caretakers are women and 86% of responders are offering their care at home, emphasizing pervasive gender roles and lack of availability or accessibility of social services for the PLWD in Romanian society. Three thirds of caregivers were children of PLDW. More than half of responders (51%) had KCSS scores that suggested severe stress while less than 9% related only mild stress. Most responders (52%) related social aspects of their lives as most affected by their caregiver status. Conclusions: While in line with most other findings and limited in scope and means by its methodology, this study offers a quick snapshot on the subjective levels of stress affecting caretakers of Romanian PLWD and can lead towards further points of inquiry on the matter in the Romanian population. --- Disclosure of Interest: None Declared --- EPV0527 Exploring the paradigm of depressive disorders through an evolutionary and biopsychosocial lens T. Ochi1 *, A. J. Loonen 1, G. G. Simutkin2, N. A. Bokhan 2, A. N. Kornetov3 and S. A. Ivanova 2 Introduction: Depression can be considered to be a common psychological response to adversity or loss from which an individual may recover quickly based on a natural resilience mechanism. In major depressive disorder, however, we see that biopsychosocial factors exist that can prevent this natural resilience mechanism from taking effect. Objectives: To investigate neurotransmitter pathways linked with antidepressant response, genetic epidemiological studies and a literature assessment of biopsychosocial factors were conducted. Methods: Newly admitted patients with a depressive episode according to the criteria of ICD-10 (F32 or F33) who had not been on antidepressant medication for at least 6 months were recruited. More than half the patients have never been treated with antidepressant medication during their entire life. The patients' depression was of at least moderate severity as measured by the Hamilton's Depression Rating Scale (HAMD-17). To determine the effect of adrenergic pathway genes to antidepressant response, the outcome was measured by the difference in HAMD-17 score between entry and two weeks of treatment after two and four weeks of treatment and entry and four weeks of treatment. Multiple linear regression was conducted to identify the independent factor associated with <unk>HAMD-17 between the three time periods, including age, sex, depression diagnosis, type of antidepressant taken and selected SNPs. Literature assesement utilised a snowball technique, building on prior literature reviews conducted. The selection of included literature was determined by the authors. Results: The Tomosk cohort was mainly women, with less than 20% of patient being male. The cohort was dynamic thus the number of participants involved in each investigation varied. Most patients took SSRIs, specifically sertraline, paroxetine, escitalopram, fluoxetine and fluvoxamine. Comparing the medication taken, <unk>HAMD-17 was significantly more improved in participants taking tricyclic antidepressants at 0 -2 weeks and 0 -4 weeks. From our literature assesment, we determined that targeted therapy can undermine the influence of biopsychosocial factors and allow natural resilience to bring depression to an end. Many mental activities is not exclusively individual, but depends on the sociocultural context as people are part of a community. Conclusions: Depressive disorders can be understood as a rather habitual dysregulation of human behavior which, unlike normal behavior, is not limited by natural resilience in time and severity. Our investigations looked at polymorphisms impacting serotonergic, dopaminergic and adrenergic neurotransmissions and enzymes.

21 cases of bipolar disorder, 21 cases of schizophrenia, two cases of chronic hallucinatory psychosis and 3 cases of delusional psychosis. Forty-three patients were fit to continue working, 133 patients were fit with restrictions and twenty-six were unfitted to work. A professional reclassification was recommended for 37 patients in positions with a lower mental load. One employee suffering from advanced schizophrenia was offered early retirement on grounds of disability. Permanent unfitness was pronounced in 11.6% of cases. Conclusions: The impact of mental disorders on cognitive abilities can be so significant as to result in temporary or permanent unfitness for work. However, the decision of medical fitness for work for the same psychiatric pathology may vary from one individual to another and from one workstation to another.

INTRODUCTION Refugees face many difficulties in their lives, and settling in a new and markedly different environment can be an added difficulty for many of them (Cislo et al., 2010;Correa-Velez et al., 2010;Dow, 2011;Ngum Chi Watts, 2012;Ngum Chi Watts et al., 2013;Beadle, 2014). These difficulties may lead to poor 'psychosocial adjustment' and emotional problems (Cislo et al., 2010(Cislo et al., : 1174) ) in refugees, who often embody significantly higher mental health problems than other populations in general (Norredam et al., 2009;van Wyk et al., 2012). As elsewhere, refugees in Australia have lower levels of personal well-being than other migrant groups (Australian Survey Research Group, 2011). This is particularly so for newly arrived refugees, and more so for women, who are often culturally displaced, socially isolated (Iglesias et al., 2003) and have ambivalent feelings about their future (Kaiser et al., 1998;Ngum Chi Watts, 2012). This acculturative stress is likely to result in depression among refugees (Barnes and Aguilar, 2007). For any individual, having to relocate to another social setting necessitates extensive adjustment, which often leads to changes in health status as well as disruptions to family connection and social network (Correa-Velez et al., 2010;Dow, 2011;Ngum Chi Watts, 2012;Ngum Chi Watts et al., 2013). This is more marked among refugees who have experienced violence and civil conflict in their homeland (Palmer and Ward, 2007;Pavlish et al., 2010). For many refugees, resettlement can be very daunting. It has been suggested that the resettlement process that refugees go through can have more negative impact on health and well-being than their pre-migration situations (Correa-Velez et al., 2010;Kurban, 2014). doi: 10.1093/heapro/dav015 Nevertheless, there are factors which have helped to protect refugees during their settlement processes, in particular, social support from peers and their own ability to cope (Correa-Velez et al., 2010). According to Mulvaney-Day et al. (2007: 479), social support provided by 'unrelated, close friends' has shown a positive influence on the physical and mental health of refugees. Social support can help to alleviate some of the difficulties associated with resettlement in a new environment (Barnes and Aguilar, 2007;Tempany 2009;Kurban, 2014). We contend that one aspect of social support for refugees is being part of a peer support group. In this paper, we discuss the experiences of refugee women who participated in the peer support programme for newly arrived refugee women in Melbourne, Australia. Our project adopted a two-pronged approach to establishing peer support networks among refugee women from similar communities. Peer support training enabled the participants to meet, discuss issues and consequently establish communicative relationships within the peer group. Additionally, the women were given access to a free mobile phone. Research has shown that mobile phone access can act as a health promotion tool (Fukuoka et al., 2012;Pop-Eleches et al., 2011;Rotheram-Borus et al., 2012). In this study, participants were provided with a free mobile phone and free unlimited calls within the peer support group numbers, and to limited set of local and overseas numbers, for a 12-month period, to augment the peer group relationships, as well as relationships with a small number of people and institutions external to the peer group. Peer support group as social support and health enhancing strategy: theoretical framework In this article, peer support is perceived as a subset of social support in which the relationships are formed between individuals who are similar to each other. Peer support has received much attention within the mental health area (Mead et al., 2001;Solomon, 2004;Schutt and Rogers, 2009). It has been defined as'social emotional support, frequently coupled with instrumental support, that is mutually offered or provided by persons having a mental health condition to others sharing a similar mental health condition to bring about a desired social or personal change' (Solomon, 2004: 393). This concept is clearly relevant to our project, which attempt to use peer support group to enhance the health and well-being of refugee women. In the case of the refugee situation, emotional, physical and tangible support which is offered by 'peers', who are also refugees, can lead to desired personal and social changes within their communities. Peer support embodies 'active ingredients' which enhance positive health and well-being among group members (Solomon, 2004;Randall and Salem, 2005). Peer support groups which provide a channel for individuals to periodically meet to address commonly shared concerns and problems have resulted in social support among group members, which has, in turn, led to the improvement of quality of life of those involved (Elafros et al., 2013). Within peer support groups, empathy, sharing, support and assistance are often offered (Solomon, 2004). As such, feelings of social isolation (such as loneliness, rejection and frustration) can be overcome (Schutt and Rogers, 2009). Schutt and Rogers (2009: 699) put it clearly that peer support 'provides resources for effective functioning and a foundation for coping with stress and loss'. Additionally, a peer support group has been seen as the principal ingredient of the empowerment process (Schutt and Rogers, 2009). Peer support programmes not only increase social support, they can also promote empowerment among group members (Van Tosh and delVecchio, 2000;Dumont and Jones, 2002). Peer support makes the most of the ability of peers to contribute to the situations and needs of others in the group as well as their potential for influential relationships with others (Whittemore et al., 2000;Marino et al., 2007). In our study, we based our research within the peer support framework discussed earlier. The peer support group training sessions and the provision of a free mobile phone offer a means through which meaningful empowerment processes could eventuate (Schutt and Rogers, 2009). Here, we emphasise the empowerment that become materialised at the individual level, and we refer to this as 'personal empowerment' (Chamberlin, 1997). According to Chamberlin (1997), this personal empowerment is 'a multi-dimensional concept' which embodies the feeling of being part of a group and promotes positive self and the conquering of personal difficulties. Within the refugee context, peer support could empower individuals to find ways to overcome difficulties in their new homeland. Additionally, we contend that participation in peer support group can be perceived as health-promoting behaviour. Within the health behaviour framework (Kafaar et al., 2007), it is assumed that by participating in peer support group, people will receive benefits of some kind. For example, participants may perceive that being a group member would assist them with difficulties in life. Additionally, it will entitle them to some support that will help them fight against isolation and difficulties in their everyday life. As such, participation in peer support group training can be seen as a health-promoting behaviour with the expectation that support from others may follow. --- Peer support group activities: our project The peer support group activities ran for 12 months. Different groups have different start times, but the whole programme started in 2010 and ended in 2012. Participants attended weekly peer support training sessions for the first 6 weeks and five bi-monthly sessions. Group composition and timings were guided by participant preference, resulting in 9 groups with 9-15 members. The women practised'swapping time' where, for 3-5 min, they took turns in the roles of talker and listener. The themes for each session were selected using a strength-based, assets model designed to direct the women's attention to the positives in their lives (Smith, 2006). These themes included the following: something good, something new; goals and aspirations; educational successes; personal pride and other topics that were defined by circumstances of the time. The group sessions ended with a whole-group discussion during which each woman shared a thought, feeling or anecdote with the rest of the group. The importance of confidentiality was stressed to the participants from the start of the programme, and this helped to establish trust as an expected group norm. The women were presented with certificates of participation at the end of the fifth and the last session. In the third training session, each woman was given a mobile phone with the following unlimited free-call numbers on speed dial: • Intragroup numbers: peer support group members from the same community; • Landline numbers: home landline and four participantchosen Australian landline, or overseas numbers from selected countries and • Service numbers: telephone interpreter service (TIS), four participant-chosen service provider numbers and two members of the research team who facilitated the peer support groups (L. K. and D. W.). A special agreement was established with the phone service provider that enabled the free calls to be provided cheaply. The phone calls made by the women were recorded automatically in a call log that captured the time, duration and destination of the calls (this aspect is discussed elsewhere). Only outgoing calls could be logged as it was not possible to log incoming calls. The intragroup numbers linked people within their heritage culture. As the Australian landline and overseas numbers were selected by the participant, they were predominantly numbers of close friends or relatives of the participants and therefore classified as numbers associated with the participants' heritage culture. The third set of numbers provided the participants with links to the host culture. These were the TIS (which provided free access to all government and selected private service providers); four selected service providers including schools, clinics and hospitals and the two researcher facilitators. It should be noted that there were some women who did not attend all the training sessions, and some who along the way stopped using their phones. However, no one actually gave the phone back and wanted to be taken out of the programme. In our qualitative component (see below), we did include women who made very few calls compared with their colleagues. --- Methodology This paper is based on the qualitative component of our project that examines the roles of peer support and mobile phone-enhanced communication in the settlement experience of refugee women living in Melbourne, Australia. A full project has been reported elsewhere (Walker et al., 2014). Initially, potential participants were invited by the Afghan, Burmese and Sudanese community leaders to an information session where the study was explained, questions answered, and participant information sheets and informed consent forms, in both English and the community languages, distributed. A snowball sampling technique was also used, where the first group of participants invited people they had relationships with to join the programme (Liamputtong, 2013). This recruitment process helped to elicit moral approval and practical assistance from heritage culture gatekeepers, husbands or adult children, who had the capacity to influence the women's participation. In our full study, 111 women were recruited; 44 from the South Sudanese, 31 from the Afghan and 36 from the Burmese communities. The mean length of stay in Australia are 2.88, 4, 4.19 and 6.81 years for the Burmese 1 (B1: mostly Buddhist), Burmese 2 (B2: Muslim), Afghan and Sudanese communities, respectively. Within the consent form were questions that asked participants for yes/no responses to questions requesting participation consent to an interview. Interviewees were selected from those responding 'yes' to an interview. Thus, the number of participants who took part in the study component on which this paper is based was not determined by saturation. All of these participants also agreed to being audio-taped. Where possible, women selected for interview were approached directly to invite participation. Where language was a barrier, participation was invited through the relevant interpreter. At the end of the programme, 29 participants were interviewed. Invitations to participate in an interview were based on the women's mean calls per week and mean call duration (see Table 1). Each cultural group was proportionally represented. Interviews were conducted by the second and third authors, took place in participants' homes, lasted 60-90 min and were recorded after participant consent. Apart from three participants who were proficient in English, all interviews were assisted by a professional interpreter. Questions explored the women's programme experiences, the changes in their lives and relationships and the significance of their call patterns. The data were analysed using thematic analysis (Braun and Clarke, 2006). This method of data analysis aims to identify, analyse and report patterns or themes within qualitative data. Initially, we performed open coding where codes were first developed and named. Then, axial coding was applied which was used to develop the final themes within the data. This was done by reorganising the codes that we had developed, from the data during open coding, in new ways by making connections between categories and subcategories. This resulted in themes, which were used to explain the lived experiences of the participants. The emerging themes are presented in the Findings section. Three transcripts were initially coded by two authors (L. K. and R. W.) who are qualitative researchers, and differences in coding discussed and resolved. Subsequently, for all other interview transcripts, uncertainty about assigning codes to specific pieces of text was resolved jointly by the two researchers. Ethics approval for the project was granted by the Faculty Human Ethics Committee, La Trobe University. In presenting the narratives of the women, we adopted the use of fictitious names in order to preserve their confidentiality. For ease of reading, we also minimally edited the verbatim quotes to make them more grammatically correct. --- Findings To most of the women in our study, participating in peer training sessions and having access to a mobile phone made a huge difference to their lives. There are several major themes that emerged from the study: creation of social networks, enhancement of well-being and provision of empowering experiences. --- Creation of social networks Social networks were created through the programme that was developed for our study. The peer support training sessions and the access to a mobile phone allowed the women more connections with others as well as strengthen their own personal/social networks. --- Cultivating new social network For most women, the programme provided an opportunity for them to meet other women in their community. Most often, however, social networks between the women were increased due to the effect of group sessions. Many women suggested that having only a mobile phone would not create the network and that it was only through group sessions that such networks developed. However, other women remarked on the benefit of both having access to a mobile phone and participating in peer group session trainings. Meeting others in a group setting and having their mobile numbers and a means to make connection enabled them to connect with others. If it wasn′t for this telephone I wouldn′t know because that person she doesn′t even know my other mobile number (muffled) that I made at the group. So if it wasn′t this group I wouldn′t have met the person. (Rita, Sudanese) Since the women had more opportunities to connect with others in the community, their lives were changed. For me, I can say there is a change in my life because I met other people that I don′t know before... I don′t talk to before [but] now they are part of our community and I get to know them better. (Nyawech, Sudanese) Creating strong links within the networks The peer support programme and access to a free mobile phone also created stronger relationships among group members. We particularly noted this relationship, within the Sudanese community, between the older women and the young women who had no parents in Australia. Often, refugee children and young people have lost their parents through war and escape attempts. In these stronger relationships, the older women acted as a mother for these young women. It is because of this programme... we sort of become close... [We have become] close to these young woman already. And they are [treated as] our daughters. Some of them, they don′t have their mom here. So, we play their role now and we practice it a lot because of this. (Nyibol, Sudanese) Social isolation is common among refugees, and some women claimed that they did not have any 'friends' prior to the programme, which helped to create a closer connection between the women in the community. For those who might have seen or known each other beforehand, the programme provided an opportunity for them to form a closer relationship. Thus, links between individuals as well as community became strengthened. Having access to a mobile phone and being connected to others in the community allowed the women to strengthen ties with members of their cultural community and participate more fully in it. This is an essential aspect of resettlement for many refugees, including the women in our study. Access to a mobile phone enabled the women to connect with family members who were left behind in their home country. This is crucial for refugees who feel a strong need to be in contact with their family members who live far away from them. For many women, the free mobile phone from the programme arrived at 'the right time'. --- Enhancement of well-being Repeatedly, newly arrived refugees and migrants endured many burdens, particularly emotional burdens, and yet they had few that they could rely on. However, our programme helped to increase the well-being among the women in the study. It not only offered a sense of happiness but also lessened social isolation among the participants. --- Increasing sense of happiness Participating in the peer support group programme and having access to a mobile phone augmented a sense of happiness among the women. Some women even suggested that the day they commenced the programme was 'a beautiful day' for them. The women also talked about feeling happy to be able to meet others in the peer support training sessions. This sense of happiness took away the worries that most women had in their life, to the extent that some women declared that they have become a 'free' person. Access to a mobile phone allowed the women to be connected with their family members at times when they had to be outside their home for an appointment or a class. This helped to lessen their anxiety about those who are left at home, particularly their young children. Importantly, it became apparent that the phones facilitated mutual emotional support among the women. When I call my friends, I share all my feelings with them and I take all of my stories, my concerns and my worries out of my chest. So it makes me feel much better. (Jila, Afghan) The women talked about the complexity of their lives as refugees and remarked on the value of the phone as a tool to harness the peer resources in response to their emotional needs. --- Reduction of social isolation As the programme allowed the women to connect to others, this diminished their sense of isolation. Refugee women who were mothers in particular tend to feel more isolated in their new homeland. For the women in our study, although they had children in their lives, things were not the same as they were back in their homeland. Children tended to have a separate life due to school or work and seldom had time for their mothers. This led to feelings of isolation among these women. However, having access to a mobile phone allowed the women to call others and talk instead of not having any meaningful activity to do. This also led to feelings of happiness among the women. Now having this number... having this mobile... I call my friends you know... I call my children even in America [and] I′m here. If it wasn′t this telephone I would be just watching television, you know. I don′t even understand what they are saying, just the picture. But now this telephone has kept us laugh. We call each other and we talk and you laugh... We make joke on the phone and we laugh, and you know the more you laugh the happier you are. It has brought us back some memories... some of the things that we used to do back home. (Nyibol, Sudanese) --- Increasing social support Due to the increased social interaction between individuals through the programme, social support ( physical, emotional and tangible) between group members was created. Repeatedly, the women spoke about the emotional support that they received from others in the group. The women also received tangible support from group members through knowing each other and through the use of mobile phones. Importantly, the mobile phone and access to peer group members on their phone on speed dial took on life-saving significance for some women. Once I was at TAFE and doing English classes, I suddenly didn′t feel well. I got stomach-ache and the teacher had to call ambulance. I couldn′t call my husband, but because of this phone, I called one of my friends. I asked her to let my husband know that I was not feeling well and I was taken to the hospital. So at that time, I found out how important this telephone was. Otherwise he wouldn′t know. (Farhana, Afghan) Peer support embodies both receiving and giving support to others. Around practical support, the women became aware of not only their own but other women's needs and availed themselves to support others in their network. --- Provision of empowering experiences Our programme provided several empowering experiences to the women in the study. Many women had not had any opportunity to own technology, such as a mobile phone or computer, in their own country. Having access to new technology such as a mobile phone was an empowering experience for these women. The women felt proud of themselves for having knowledge about, and skills to use, a mobile phone. Additionally, what the women learnt from the peer support training programme empowered them to acquire further skills or learn more about other issues which would become valuable for their lives in a new living environment. The programme assisted the women with the acquisition of English language and provided more opportunities to practice English. The women believed that the connection that they had created through the peer training sessions and the free-call mobile phone gave them an opportunity to be an 'informed' individual who would have better knowledge about things around them. They became more confident about travelling to places outside their home or community, which led to feelings of empowerment and self-capability among the women. We got this phone and we contact each other, and then we go everywhere. We know so many places. So that has improved it [life]. We know so many places and we can go everywhere now. (Myint Thin, Burmese) Access to mobile phones also made things easier for the women. Mobile phones enabled the women to settle into Australia with better ease. For example, it increased their ease of obtaining essential ingredients for cooking. The mobile phone also allowed the participants to connect with healthcare providers more efficiently. For women who were mothers, the mobile phone allowed them to deal with emergencies that might arise regarding the health and well-being of their children who were at schools. I have been in trouble many times, you know, with my children. Sometimes there is an accident, and they call me to let me know that it happened and that I needed to come or they were going to send the child to the hospital. One of the children got sick in school, so they called me and I couldn′t call them back because I didn′t have the credit. So I went to school and when I went to pick up the kids, all these incidents already passed. They told me what happened, and I felt that... where was I when I was needed? But now with this one [mobile phone], everything is there immediately. If anything happens, 'come now', I will be able to because I have the means to call them back. (Suzan, Sudanese) --- DISCUSSION In this article, we have focused our attention on the unique aspects of our programme that helped to enhance the health and well-being and ease the settlement process of many recently resettled refugee women. It has been suggested that participating in peer support groups provides beneficial effects to group members (Roth and Crane-Ross, 2002;Solomon, 2004;Ochocka et al., 2006;Rogers et al., 2007;Schutt and Rogers, 2009). The findings of our project support this notion. However, our project also reveals that it was the combination of participation in a peer support group programme and access to a free-call mobile phone that provided the best effect on the well-being of our participants, who were isolated and faced multiple complexities in life refugees (Schutt and Rogers, 2009). Roth and Crane-Ross (2002) and Schutt and Rogers (2009) have suggested that there may be some special features that enforce the positive effects of peer support group. We content that the special feature of free mobile phone access contributes to this positivity. The mobile phone is not only a 'unifying medium for information exchange' (Kyem and LeMaire, 2006: 6), but also 'a social amenity' (Goodman, 2005: 34) and a means for increased economic opportunities for individuals (Sife et al., 2010). In a study of mobile phone use by immigrants from Guinea-Bissau in Lisbon, Portugal, Johnson (2013) observed that mobile phones are widely used to facilitate relationships within the heritage culture in Lisbon. Importantly, it has been evidenced that the mobile phone can function as a health promotion tool (Fukuoka et al., 2012;Pop-Eleches et al., 2011;Rotheram-Borus et al., 2012). This has been witnessed in our study. For example, reconnection is an important part of recovering from trauma and difficulties (Goodman, 2005). For the women in our study, having access to a free-call mobile phone allowed them to'reconnect' with others and family members as well as their traditional ways of life (Goodman, 2005). This helped the women to feel less worried and isolated. Although some women had their own mobile phone prior to participating in our study, our data showed that the freecall element of our mobile phone was important for them. Due to their low income, they frequently ran out of credit in their own mobile phone. Mobile phone calls are expensive, and as most of them are on a prepaid plan, they simply could not afford to make the kind of calls they had made in our programme. They referred to the phone we provided as the'magic phone' because it had unlimited credit. Although some participants said that they were disturbed by unwanted calls at inconvenient times, the benefits of having access to a free mobile phone outweighed this drawback. In our study, peer support is viewed as a subset of social support in which relationships are formed between individuals who are similar to each other. The initial training was undertaken in peer groups, but the provision and receipt of social support extended into the broader community. In our study, peer support training enabled the participants to establish communicative relationships among participants from the same communities, whilst the mobile phones augmented the peer group relationships, and relationships with a small number of people and institutions external to the peer group. Our study builds on the role of peer support in refugee resettlement by adding a reliable communication channel that enables social network development, which in turn influences the acculturation journey of refugee women (see also Walker et al., 2014). In the following sections, we discuss several salient issues emerging from our study. Ngum Chi Watts, 2012;Benza and Liamputtong, 2014). Most migrant and refugee women have to deal with multiple stresses associated with relocation and social adjustment when settling into a new homeland (Meadows et al., 2001;Pavlish et al., 2010;Kurban, 2014). For refugees who have to deal with multiple difficulties, isolation can be a 'compounding factor' which make their life situations worse (Hinton and Earnest, 2010: 224). As a result of participation in peer support trainings, as Wallerstein (2002: 74) suggests,'social isolation may be diminished', and this led to the improvement of health and well-being among the women in our study (Schutt and Rogers, 2009). In an online support group research conducted by van Uden-Kraan et al. (2009), the participants strongly experienced what the authors termed as 'enhanced social well-being'. Participation in a support group resulted in increased social contacts as well as decreased loneliness. Our results similarly showed this 'enhanced social well-being', as participation in peer support groups helped to reduce isolation and loneliness among the women. Additionally, the social support helped the women to feel that they were not dealing with life's challenges alone (Polakoff and Gregory, 2002;Hinton and Earnest, 2010). We contend that the support that the women received from their peer support group is crucial to their health and well-being and allowed them to deal with their vulnerabilities in a new homeland (Hinton and Earnest, 2010). Additionally, peer support enhances empowerment among individuals in the group (Dumont and Jones, 2002;van Uden-Kraan et al., 2009). Through learning and sharing during the peer support training and communicating on their mobile phones, the women in our study cultivated a sense of their own abilities and had an opportunity to reinforce connections with others. This helped to transform their lived experiences from 'being socially isolated individuals' to being part of a larger community (Schutt and Rogers, 2009: 706;Kitchen et al., 2012). This, we believe, is the 'personal empowerment' (Chamberlin, 1997) process for the women in our study. Although peer support emphasises 'individual strengths', it simultaneously moves 'towards autonomy' as well as 'community building' (Mead et al., 2001;Dumont and Jones, 2002). Thus, peer support can be empowering for both individuals and their communities. Wallerstein (2002) suggests that participation in a community, and a sense of community belonging, has consistently been seen as a predictor of health and well-being. Wang and Hu (2013) similarly contend that a sense of community and social support received from others in the community can have a protective health effect on individuals. This is apparent in our study. Having a sense of community connection not only reduced the participants' sense of isolation but also helped them to settle in their new homeland with greater ease. Research has shown that, for most refugees and immigrants, a sense of belonging to one's ethnic community is crucial for the health and well-being among these vulnerable people (Correa-Velez et al., 2010;Moscardino et al., 2010). Empowerment, Wallerstein (2002: 73) suggests, is a'social protective factor' which can also be seen as a 'health enhancing strategy'. This is clearly seen from our findings. Many women suggested that the connections and knowledge they had cultivated from the programme made them feel 'brave' and'safe' enough to get out of their community and to do things that they previously had no opportunity or courage to do. This has created the feeling of empowerment and self-capability among the women. The connections that were cultivated through the programme allowed the women to perform tasks which are more health promoting, for example having a 'chat', and obtaining advice from others. In conclusion, our programme provided evidence that appropriate peer support strategies can be incorporated into programmes designed to assist refugees with health and well-being enhancement, as well as acculturation and resettlement needs. We argue that mobile phone technology is ubiquitous and the issues are about making access possible for specific population groups (and we did this by providing free phones and calls) and identifying the uses that are most important to members of particular population groups (Glazebrook, 2004). Our programme has shown that, by tapping on community resources to ameliorate personal or resettlement issues, the burden on service providers could be reduced. The findings of this study also offer a model for future research and health promotion programmes regarding people from other refugee backgrounds, within Australia or elsewhere. --- Peer support and health enhancement We have shown in this paper that participation in peer support group is a health-promoting behaviour. As Kafaar et al. (2007) theorize, by participating in peer support group, individuals will receive some kinds of benefits, such as assistance for dealing with difficulties in life and combating against isolation. Peer support, according to Mead et al. (2001: 135), is a system of gaining and bestowing assistance. It is operated within the 'principles of respect' and'shared responsibility' among group members. Peer support is also about having empathetic appreciation of the situations of others through shared experiences. When individuals in the group sense that they have shared experiences with others, a connection is created. Peer support bestows 'a sense of connection, belonging, and community' which frequently falls short among marginalised individuals (Schutt and Rogers, 2009: 699), and this clearly is the situation of refugees, particularly those who are newly arrived, including the women in our study. Clearly, these are health-promoting behaviours resulting from having access to peer support groups. Peer support is a form of social support, which functions both at the individual as well as community levels (Richmond and Ross, 2008;Thoits, 2011). As social support theory suggests, support is reciprocal (Barnes and Aguilar, 2007), the women in our study gave help to others as well as received it when needed. This was particularly so among older women who provided support to young women with no parents living in Melbourne. This support was essential for young people who have experienced loss and grief and for successful settling into a new life (Goodman, 2005;Barnes and Aguilar, 2007). Social support provided by the older women enhanced a sense of belonging and security (Richmond and Ross, 2008) among the younger women. Several authors have theorised that giving and receiving social support can be health-promoting behaviours (Solomon, 2004;Randall and Salem, 2005;Hinton and Earnest, 2010;Umberson et al., 2010;Thoits, 2011). The support that one receives from social ties can act as a buffer against health difficulties (Berkman et al., 2000;Richmond and Ross, 2008). Barnes and Aguilar (2007: 226) argue that being part of a community offers 'an important sense of belongingness and social identity'. It also promotes an opportunity for the creation of social bonding, resulting in increased social support and improvement of emotional well-being among individuals. This was evident from our findings. Additionally, the women in our study emphasized the practical support they received and provided to other peers in their social group (Finfgeld-Connett, 2005;Barnes and Aguilar, 2007). Peer support was developed into a complex system that benefitted not only the women, but also the community. The women became aware of not only their own but other women's needs and availed themselves to support their friends. --- Peer support and social well-being Refugees and immigrants tend to face social isolation in their new homeland (Hinton and Earnest, 2010;Pavlish et al., 2010), and this is particularly marked for recently arrived individuals (Pavlish et al., 2010). In our study, social isolation, which was experienced by all, was particularly pertinent for women who are mothers (Liamputtong, 2006;

In this article, we discuss qualitative findings basing on the experiences of refugee women living in Melbourne, Australia, who participated in a peer support training programme and received a free mobile phone. We pay attention to social support as a health enhancing strategy and empowerment that occurred among the participants. Participation in peer support groups and access to a mobile phone were beneficial for the women. Peer support functioned as social support among group members. The programme allowed the women to be connected to their families and the wider communities and assisted them to access health care and other settlement aspects with greater ease. It also increased personal empowerment among the women. Our programme shows that by tapping on community resources to ameliorate personal or resettlement issues, the burden on service providers can be reduced. Our findings also offer a model for future research and programmes regarding refugee people elsewhere.

s and immigrants tend to face social isolation in their new homeland (Hinton and Earnest, 2010;Pavlish et al., 2010), and this is particularly marked for recently arrived individuals (Pavlish et al., 2010). In our study, social isolation, which was experienced by all, was particularly pertinent for women who are mothers (Liamputtong, 2006;

In this article, we discuss qualitative findings basing on the experiences of refugee women living in Melbourne, Australia, who participated in a peer support training programme and received a free mobile phone. We pay attention to social support as a health enhancing strategy and empowerment that occurred among the participants. Participation in peer support groups and access to a mobile phone were beneficial for the women. Peer support functioned as social support among group members. The programme allowed the women to be connected to their families and the wider communities and assisted them to access health care and other settlement aspects with greater ease. It also increased personal empowerment among the women. Our programme shows that by tapping on community resources to ameliorate personal or resettlement issues, the burden on service providers can be reduced. Our findings also offer a model for future research and programmes regarding refugee people elsewhere.

Introduction Social exclusion is a dynamic, procedural, multidimensional, and relational social phenomenon, which makes it possible to understand poverty and its consequences on the moral dependence of families without work [1]. Among these characteristics, multidimensionality makes social exclusion a phenomenon compatible with the operational framework of composite indicators. This framework offers a set of methods that make it possible to simplify the representation of complex social phenomena and assist decision makers in the elaboration of public policies [2,3]. However, no method of constructing composite social indicators is exempt from shortcomings. The normalization, weighting, and aggregation of the sub-indicators particular to each method impact the composite indicator scores [4][5][6]. These different scores result in uncertainties in the position of the observations in the ranking and the strength of the link between the composite indicator and the conceptually most significant variables of the multidimensional social phenomenon [2]. Therefore, it is impossible to determine in advance which method to use to construct a stable composite social indicator that captures the concept of the multidimensional phenomenon. Furthermore, a method that offers a satisfactory solution to represent the social exclusion of a city may not present the same performance in another city, as social exclusion is a social phenomenon dependent on space [7]. This research aims to map social exclusion through a decision framework that allows for the identification of the methods that construct a stable composite indicator that captures the concept of the multidimensional phenomenon. For this, the stability and capacity of six methods used to represent the social exclusion of eight cities were analyzed. The results of this analysis contribute to the literature in six different ways. First, it offers a decision framework for choosing a method to construct a composite social indicator. Second, it shows to what extent geographic space matters in defining the method used to construct a composite social indicator. Third, it identifies the best-performing method regarding stability and linkage with the conceptually most significant variables of the multidimensional phenomenon. Fourth, it reveals which methods perform poorly and should be avoided. Fifth, it indicates which mathematical properties favor the representation of composite social phenomena. Sixth, the research contributes to the debate of social phenomena from a geographical perspective and public policies since the results have great potential for appropriation by public policy managers. --- Literature Review 2.1. Multidimensional Social Exclusion Poverty and social exclusion are disadvantages resulting from income inequality, unemployment, material deprivation, and access to social and political activities [8]. Social exclusion, in particular, overlaps with the poverty concept and implies the total or partial removal of individuals from current social systems, compromising social participation [9] and well-being [10]. Social scientists understand social exclusion as a comprehensive concept of a multidimensional nature, including income, housing, transportation, citizenship [11], and other indicators. On the one hand, the scope and multidimensionality of social exclusion allow for its representation from different perspectives. For example, social exclusion can be represented with an emphasis on the perspectives of health [12], transport [13,14], children [15,16], and later life [17]. On the other hand, the scope and multidimensionality of social exclusion make it challenging to develop a universal theoretical framework that allows for comparisons since the dimensions and indicators used in social exclusion measures are very different, as shown below. Dimensions: transportation [13]; housing [10]; socio-demographics and transport [18]; economic, social, and political dimensions [11]; economic, social, political, and cultural dimensions [9]; and demographic, socio-economic, and environmental dimensions [12]. Indicators: income distribution, monetary poverty, health, labor, housing conditions, and material deprivation [8]; socio-economics, education, connectedness, housing, and health services [16]; poverty, education, unemployment, social security, and the family situation [12]; and physical conditions, public transport services, education opportunity, employment opportunity, medical care opportunity, food opportunity, and commercial opportunity [13]. In addition to the lack of a universal theoretical framework to represent social exclusion, the operationalization of the social exclusion concept has long been associated with several problems [11]. In particular, these problems reflect the flaws and limitations of the composite indicator construction methods [2]. There are several methods for building composite indicators [19], with the choice of the method being a subjective decision, which is reflected in a variety of methodological approaches. For example, it is possible to cite composite indicators of social exclusion constructed through Simple Additive Weighting methods [15], Principal Component Analyses [12,13,20], Benefit-of-the-Doubt approaches [14], Machine-Learning approaches [17], and multicriteria methods (e.g., the Preference Ranking Organization Method for Enrichment Evaluation [8] and the Technique for Order Preference by Similarity to Ideal Solution [21]). There is a consensus in the literature about the failures and limitations of the methods of constructing composite indicators. Despite this, the quality of the multidimensional representation of social exclusion has been superficially explored. In particular, works concerned with the quality of composite indicators of social exclusion focus exclusively on the external validity of the construct [17,21]. Therefore, these works ignore or disregard the importance of constructing a stable composite indicator in which variations in the way of normalizing, weighting, and aggregating the sub-indicators do not generate significant fluctuations in the scores [5]. This research explores this gap and seeks to answer the following question: which methods construct a stable composite indicator that captures the concept of multidimensional social exclusion? --- Methods for Constructing Composite Indicators from a Geographic Perspective Phenomena such as poverty, social exclusion, social vulnerability, well-being, and inequality have two characteristics in common: dependence on geographic space [7,[22][23][24][25] and a multidimensional nature [10,[26][27][28][29][30]. The search for the literature of interest to this research was based on these two characteristics and was carried out with the following criteria: articles published in the Web of Science, in the Geography category, with the term "composite indicator" in the abstract, and published in the last five years (2018-2022). Fourteen research papers met these criteria, and the method used to construct the composite indicator was identified in ten. The most frequently used method was the Simple Additive Weighting (SAW) method. SAW has two main advantages: the simplicity of operation and flexibility in choosing the weighting scheme for sub-indicators. For example, it is possible to operationalize SAW with equal weights [31][32][33] or with participatory weights [34,35]. Another widespread method with the advantage of the data-driven weighting of sub-indicators is the Principal Component Analysis [36]. Methods such as the Stochastic Multi-Attribute Acceptability Analysis [37] and the Geographic Weighted Principal Component Analysis [38] are less frequent but, together with the Benefit-of-the-Doubt [39], have the advantage of considering spatial heterogeneity. Finally, Ordered Weighted Averaging is a sophisticated method that allows for the consideration of spatial heterogeneity, the non-compensation between sub-indicators of poor and above-average performance, and the emphasis of the positive or negative aspects of the multidimensional phenomenon [40]. Even though this list of methods is representative, it disregards one of the most popular methods in the composite indicator literature [19]: the Technique for Order Preferences by Similarity to Ideal Solutions (TOPSIS). Taking these aspects into account, this paper evaluates the performance of six methods: SAW with equal weights (EWs) or SAW-EW, SAW with participatory weights (PWs) or SAW-PW, Principal Component Analysis (PCA), Benefit-of-the-Doubt (BoD), Ordered Weighted Averaging (OWA), and TOPSIS. SAW-EW consists of aggregating normalized sub-indicators (e.g., by the max-min and z-score functions) with equal weights. Attributing equal weights is especially advantageous when causal relationships are unknown or when experts disagree on the relative importance of sub-indicators in the multidimensional phenomenon concept [2]. SAW-PW considers that the sub-indicators have different levels of relative importance in the concept of the multidimensional phenomenon. This method considers experts' opinions in the weight definition, which is especially advantageous when the experts know about the phenomenon and the geographic units [41]. OWA also considers decision makers' participation in constructing the composite indicator. The method aggregates the normalized sub-indicators ordered by performance and weighted with a value of 0 or 1. The OWA corresponds to SAW-EW when all subindicators are weighted with a value of 1. In turn, weighting the five highest-performing sub-indicators with a value of zero corresponds to an emphasis on the negative aspects of social exclusion and non-compensation between the sub-indicators of poor and aboveaverage performance [42]. This weighting is also advantageous because it considers spatial heterogeneity. The weighting of sub-indicators with a value of 0 or 1 is performed based on the sub-indicators' performance, causing the aggregate sub-indicators (those with a weight of 1) to change from one spatial unit to another. PCA involves the data-driven weighting of sub-indicators, constructing a composite indicator that retains most of the variance of the original data. Additionally, the weights do not vary across geographic units and are free from subjectivities and judgment biases [43]. These characteristics make PCA an advantageous method when comparability is a critical attribute of the analysis and when specialists do not have knowledge about all the spatial units involved. BoD also involves the data-driven weighting of the sub-indicators. However, the weights are defined based on the performance of the sub-indicator in each spatial unit. Thus, BoD constructs a composite indicator that considers spatial heterogeneity, as the sub-indicators' weights vary from one spatial unit to another. This weighting scheme highlights each spatial unit's positive aspects and is considered advantageous for avoiding disputes about the weighting scheme adopted in constructing a composite indicator [44]. TOPSIS consists of implementing a function that normalizes the sub-indicators based on their distance to the best and worst scores, the so-called positive and negative ideal solutions. The method uses the compensatory aggregation approach and offers flexibility in adopting the weighting scheme [21,45]. This flexibility is advantageous because it allows for the weighting of sub-indicators using the equal weights, data-driven, and participatory schemes. This set of methods covers the most relevant mathematical properties in constructing composite indicators. The SAW-EW and TOPSIS weight sub-indicators with equal weights. The latter uses a normalization function that considers the distance of scores for a positive and negative ideal solution. The SAW-PW and the OWA weight the sub-indicators based on expert opinion, with the second considering spatial heterogeneity and non-compensatory aggregation. The PCA and the BoD weight the sub-indicators statistically. The former retains as much of the original information in the composite indicator. The latter emphasizes the positive aspects of each spatial unit by assigning greater weights to the higher performance indicators. The question is as follows: which of these mathematical properties constructs a more stable composite indicator that captures the concept of social exclusion? --- Materials and Methods The development of this research is associated with a project named "Mapping and analyzing territorial inequalities in medium-sized cities in the interior of Paraná, Brazil." This project aims to understand the processes of social exclusion, poverty, and inequalities in the face of the growing appreciation of the territorial dimension in analyzing public policies, especially social policies [46]. --- Study Area: Medium-Sized Cities of the State of Paraná, Brazil Cities were selected due to their importance in territorial development and because they present very different realities that need to be analyzed from their internal dynamics [46]. Figure 1 shows the location of eight mid-sized cities in the State of Paraná, Brazil, used as a reference in this study. --- Study Area: Medium-Sized Cities of the State of Paraná, Brazil Cities were selected due to their importance in territorial development and because they present very different realities that need to be analyzed from their internal dynamics [46]. Figure 1 shows the location of eight mid-sized cities in the State of Paraná, Brazil, used as a reference in this study. According to the last Brazilian census recorded in 2010, the mid-sized cities analyzed in this research have more than 100 thousand and less than 1 million inhabitants [47]. Census tracts are the geographical reference unit for constructing the composite indicator of social exclusion. Census tracts are the smallest units for aggregating demographic census data and comprise between 200 and 250 households [47]. The number of census tracts varies with population size across the eight mid-sized cities: Apucarana, 113; Rattlesnake, 418; Foz do Iguaçu, 320; Guarapuava, 182; Londrina, 770; Maringá, 483; Ponta Grossa, 398; and Toledo, 109. --- Theoretical Framework: Multidimensional Social Exclusion Sub-Indicators The theoretical framework used in this research is based on the methodology developed by the Center for Studies and Mapping of Social Exclusion for Public Policies [48]. This framework has the advantages of using a consolidated methodology, the availability of sub-indicator data, and information obtained from specialists on the relative importance of sub-indicators in the social exclusion concept. Five dimensions of social exclusion are addressed in this framework: Economic dimension: influences the other dimensions, consisting of indicators with a greater availability of data, ease of access, and levels of stratification. Educational dimension: the main element of mobility in social conditions today, given the relationship between levels of education and income. Demographic dimension: socially excluded people have a lower life expectancy than average due to higher infant mortality and fertility rates. Environmental dimension: more privileged populations seek to occupy more wooded areas to avoid the thermal discomfort resulting from the densification of buildings in cities. Household dimension: connects all previous dimensions to urban space and reflects them in the housing and neighborhood conditions. Figure 2 presents the five dimensions and the fifteen sub-indicators of the theoretical framework of social exclusion used in constructing the composite indicators, as well as the direction of the relationship of each sub-indicator with social exclusion. According to the last Brazilian census recorded in 2010, the mid-sized cities analyzed in this research have more than 100 thousand and less than 1 million inhabitants [47]. Census tracts are the geographical reference unit for constructing the composite indicator of social exclusion. Census tracts are the smallest units for aggregating demographic census data and comprise between 200 and 250 households [47]. The number of census tracts varies with population size across the eight mid-sized cities: Apucarana, 113; Rattlesnake, 418; Foz do Iguaçu, 320; Guarapuava, 182; Londrina, 770; Maringá, 483; Ponta Grossa, 398; and Toledo, 109. --- Theoretical Framework: Multidimensional Social Exclusion Sub-Indicators The theoretical framework used in this research is based on the methodology developed by the Center for Studies and Mapping of Social Exclusion for Public Policies [48]. This framework has the advantages of using a consolidated methodology, the availability of sub-indicator data, and information obtained from specialists on the relative importance of sub-indicators in the social exclusion concept. Five dimensions of social exclusion are addressed in this framework: Economic dimension: influences the other dimensions, consisting of indicators with a greater availability of data, ease of access, and levels of stratification. Educational dimension: the main element of mobility in social conditions today, given the relationship between levels of education and income. Demographic dimension: socially excluded people have a lower life expectancy than average due to higher infant mortality and fertility rates. Environmental dimension: more privileged populations seek to occupy more wooded areas to avoid the thermal discomfort resulting from the densification of buildings in cities. Household dimension: connects all previous dimensions to urban space and reflects them in the housing and neighborhood conditions. --- Operational Framework: Construction and Performance Analysis of Composite Indicato The theoretical framework presented in Section 3.2 was operationalized using t methods detailed in Section 2: SAW with equal weights (EWs) or SAW-EW, SAW participatory weights (PWs) or SAW-PW, Principal Component Analysis (PCA), Be of-the-Doubt (BoD), Ordered Weighted Averaging (OWA), and TOPSIS. Then, two criteria were applied to evaluate the performance of the composite in tors: linkage with external variables and stability. The link with external variables allows for the verification of the relationship composite indicator with conceptually significant variables in the concept of the mu mensional phenomenon [2]. Studies on social phenomena such as social exclusion u stand that income is the conceptually most significant variable [1]. Therefore, a soci clusion composite indicator captures the concept of the multidimensional phenom when its scores are similar to those of the income variable. This similarity is usually fied by the correlation coefficient between the composite indicator and the external v ble [4]. In particular, the Spearman correlation coefficient indicates how much the co site indicator captures the multidimensional phenomenon, even in the presence of ou or for data without normal distribution [49]. The strength of the link between the co site indicator and the income variable, indicated by the Spearman correlation coeffi is based on the rule of thumb by [50] as follows: R <unk> 0.3 = insignificant, 0.3 <unk> R <unk> 0.5 = w 0.5 <unk> R <unk> 0.7 = moderate, 0.7 <unk> R <unk> 0.9 = strong, and R > 0.9 = very strong. Another way to verify the similarity between the composite indicator scores an come is by calculating the Mahalanobis distance. The Mahalanobis distance is a biv outlier detection approach that allows for identifying the geographic areas with soci clusion scores incompatible with the external variable [35]. This research uses the pr tion of bivariate outliers obtained through the Mahalanobis distance as a second me of the composite indicator's capacity to capture social exclusion correctly. The second performance analysis is associated with constructing a composite in tor with a stable structure [2,4]. It requires verifying the levels of uncertainty produc changes in normalizing, weighting, and aggregating the sub-indicators [5]. In th search, the uncertainty analysis is adapted to verify the stability of the composite ind --- Operational Framework: Construction and Performance Analysis of Composite Indicators The theoretical framework presented in Section 3.2 was operationalized using the six methods detailed in Section 2: SAW with equal weights (EWs) or SAW-EW, SAW with participatory weights (PWs) or SAW-PW, Principal Component Analysis (PCA), Benefit-ofthe-Doubt (BoD), Ordered Weighted Averaging (OWA), and TOPSIS. Then, two criteria were applied to evaluate the performance of the composite indicators: linkage with external variables and stability. The link with external variables allows for the verification of the relationship of the composite indicator with conceptually significant variables in the concept of the multidimensional phenomenon [2]. Studies on social phenomena such as social exclusion understand that income is the conceptually most significant variable [1]. Therefore, a social exclusion composite indicator captures the concept of the multidimensional phenomenon when its scores are similar to those of the income variable. This similarity is usually verified by the correlation coefficient between the composite indicator and the external variable [4]. In particular, the Spearman correlation coefficient indicates how much the composite indicator captures the multidimensional phenomenon, even in the presence of outliers or for data without normal distribution [49]. The strength of the link between the composite indicator and the income variable, indicated by the Spearman correlation coefficient, is based on the rule of thumb by [50] as follows: R <unk> 0.3 = insignificant, 0.3 <unk> R <unk> 0.5 = weak, 0.5 <unk> R <unk> 0.7 = moderate, 0.7 <unk> R <unk> 0.9 = strong, and R > 0.9 = very strong. Another way to verify the similarity between the composite indicator scores and income is by calculating the Mahalanobis distance. The Mahalanobis distance is a bivariate outlier detection approach that allows for identifying the geographic areas with social exclusion scores incompatible with the external variable [35]. This research uses the proportion of bivariate outliers obtained through the Mahalanobis distance as a second measure of the composite indicator's capacity to capture social exclusion correctly. The second performance analysis is associated with constructing a composite indicator with a stable structure [2,4]. It requires verifying the levels of uncertainty produced by changes in normalizing, weighting, and aggregating the sub-indicators [5]. In this research, the uncertainty analysis is adapted to verify the stability of the composite indicator construction method. In other words, the research verifies how much the results obtained by one method vary concerning the results obtained by the other methods. In particular, two uncertainty analyses were performed. The first uncertainty analysis shows the proportion of the general variation in the census tracts' position in the social exclusion ranking. The second uncertainty analysis shows the variation in the social exclusion scores. A summary of the research's operational framework is illustrated in Figure 3. construction method. In other words, the research verifies how much the results obtained by one method vary concerning the results obtained by the other methods. In particular, two uncertainty analyses were performed. The first uncertainty analysis shows the proportion of the general variation in the census tracts' position in the social exclusion ranking. The second uncertainty analysis shows the variation in the social exclusion scores. A summary of the research's operational framework is illustrated in Figure 3. In short, the development of the research boils down to five steps. First, data are collected on the fifteen sub-indicators of social exclusion for each of the eight selected cities. Second, six composite indicators of social exclusion are constructed for each city using the selected methods. Third, the correlations between the composite indicator and income and the proportion of outliers are verified as a measure of external validity. Fourth, variations in the scores and ranks are verified as a measure of the stability of the composite indicators. Fifth, the methods that build stable composite indicators and that capture the concept of multidimensional social exclusion are identified. --- Results and Analysis Table 1 makes it possible to compare the performances of the composite indicators constructed by the six methods in capturing the conceptually most significant variable of social exclusion: income. In short, seventy-three percent of the composite indicators are moderately or strongly correlated with the income variable. In short, the development of the research boils down to five steps. First, data are collected on the fifteen sub-indicators of social exclusion for each of the eight selected cities. Second, six composite indicators of social exclusion are constructed for each city using the selected methods. Third, the correlations between the composite indicator and income and the proportion of outliers are verified as a measure of external validity. Fourth, variations in the scores and ranks are verified as a measure of the stability of the composite indicators. Fifth, the methods that build stable composite indicators and that capture the concept of multidimensional social exclusion are identified. --- Results and Analysis Table 1 makes it possible to compare the performances of the composite indicators constructed by the six methods in capturing the conceptually most significant variable of social exclusion: income. In short, seventy-three percent of the composite indicators are moderately or strongly correlated with the income variable. BoD is the method that presented the largest proportion of weak correlations with the income variable. In four cities, CI-BoD was weakly correlated with the income variable. Moderate, strong, or very strong correlations were observed in all cities for the composite indicators constructed by the SAW-PW and PCA methods. Seven cities showed moderate, strong, or very strong correlations between the composite indicators constructed by TOPSIS and the income variable. Six cities achieved moderate, strong, or very strong correlations between the income variable and the composite indicators constructed by the SAW-EW and SAW-OWA methods. The results in Table 2 show that none of the methods has more than 10% of social exclusion scores incompatible with income. The difference in the percentage of bivariate outliers among the six analyzed methods is only 1%. This low difference indicates that no method stands out positively or negatively regarding the number of census tracts with income scores incompatible with the composite social exclusion indicator scores. The scores of the composite indicators constructed by the OWA and BoD methods are the most compatible with the census tracts' income. Both methods present an average of 6.26% of outliers. The PCA composite indicator scores show the highest percentage of outliers with income, an average of 6.79%. The general average of bivariate outliers is 6%, indicating that the percentage of census tracts with social exclusion scores incompatible with income is low. These low percentages of outliers suggest that the social exclusion scores of census tracts are highly compatible with income, regardless of the method used. The low percentage of census tracts with social exclusion scores incompatible with income does not overlap with the low correlation between the composite indicators constructed by the BoD method with income. Therefore, the link between the income variable exclusion and the composite indicator suggests that only BoD may not be an adequate method to represent the social exclusion concept. The uncertainty analysis reinforces the suggestion that BoD should be avoided. Table 3 reveals an average change of 24% in the census tracts' position in the social exclusion ranking when the BoD method is applied to construct the composite indicator. This percentage is, on average, 18% for the composite indicators constructed by PCA and TOPSIS. The composite indicators constructed by SAW-EW, SAW-PW, and OWA are more stable, with less than a 15% change in the position of the census tract in the ranking of social exclusion. The uncertainty associated with the different ways of normalizing, weighting, and aggregating the sub-indicators of each method is lower in the composite indicators constructed by the SAW-EW method. The composite indicators constructed by the PCA and TOPSIS methods are 1.3 times more unstable than those constructed by SAW-EW, SAW-PW, and SAW-OWA. The BoD method constructs the most unstable composite indicator among the methods studied. The position of the census tracts in the ranking of social exclusion obtained using the BoD method can vary by 24% up or down concerning the average position obtained using the other methods. The uncertainty analysis associated with the variation in the scores presented in Table 4 reinforces these results. It indicates that the primary sources of uncertainty are associated with data-driven weighting and normalization using the distance function. On average, the social exclusion composite indicator scores change by 0.42 when the BoD method is applied to construct the composite indicator. The PCA and TOSPIS methods also show significant instability. The social exclusion scores change by more than 0.20 on the composite indicators constructed by PCA and TOPSIS. These results indicate that the weights obtained from the data and by distance normalization generate more instability in the composite indicator than the non-compensatory aggregation, the weights obtained from expert opinion, and the equal weights. An analysis of Tables 1-4 makes it possible to identify which methods construct the composite indicators with the best performance in terms of stability and connection with the conceptually most significant variable in the concept of social exclusion. In Guarapuava, the non-compensatory aggregation of the sub-indicators, the emphasis on sub-indicators of poorer performance, and the consideration of spatial heterogeneity contribute to a better representation of social exclusion. The social exclusion composite indicator constructed by OWA strongly correlates with income and presents only 4.4% of outliers. The average change in the position of the census tracts in the social exclusion ranking is 12% up or down, and the average change in the social exclusion scores is, on average, 0.17. A visualization of these results is presented in Figure 4. outliers. The average change in the position of the census tracts in the social exclusion ranking is 12% up or down, and the average change in the social exclusion scores is, on average, 0.17. A visualization of these results is presented in Figure 4. Weighting the sub-indicators with equal weights and aggregating them by the average results provide a better representation of social exclusion in Cascavel, Foz do Iguaçu, and Maringá. The SAW-EW method constructs the most stable composite indicators of social exclusion in these cities. The variation in the position of the census tracts in the Weighting the sub-indicators with equal weights and aggregating them by the average results provide a better representation of social exclusion in Cascavel, Foz do Iguaçu, and Maringá. The SAW-EW method constructs the most stable composite indicators of social exclusion in these cities. The variation in the position of the census tracts in the ranking of social exclusion is 1.32 times lower than the average of the other methods. The scores vary 1.36 times less than the average of the two other methods. The composite indicators of the social exclusion of Cascavel, Foz do Iguaçu, and Maringá present the lowest percentage of bivariate outliers among the methods analyzed. The correlations of the composite indicator with income exceed 0.50 in all cities. A summary of the results is displayed in Figures 567. Weighting the sub-indicators with equal weights and aggregating them by the av age results provide a better representation of social exclusion in Cascavel, Foz do Igua and Maringá. The SAW-EW method constructs the most stable composite indicators social exclusion in these cities. The variation in the position of the census tracts in t ranking of social exclusion is 1.32 times lower than the average of the other methods. T scores vary 1.36 times less than the average of the two other methods. The composite dicators of the social exclusion of Cascavel, Foz do Iguaçu, and Maringá present the low percentage of bivariate outliers among the methods analyzed. The correlations of the co posite indicator with income exceed 0.50 in all cities. A summary of the results is display in Figures 567. The SAW-EW method allows for the construction of stable composite indicators that capture the concept of social exclusion in six of the eight cities. The method fails to capture the concept of social exclusion in the cities of Londrina and Ponta Grossa. These results suggest that assigning equal weights to sub-indicators does not deteriorate the composite indicator's capacity to capture the concept of the multidimensional phenomenon. Furthermore, the results indicate that a method of simple execution and understanding by public managers offers a good representation of multidimensional social phenomena. The SAW-EW method allows for the construction of stable composite indicators that capture the concept of social exclusion in six of the eight cities. The method fails to capture the concept of social exclusion in the cities of Londrina and Ponta Grossa. These results suggest that assigning equal weights to sub-indicators does not deteriorate the composite indicator's capacity to capture the concept of the multidimensional phenomenon. Furthermore, the results indicate that a method of simple execution and understanding by public managers offers a good representation of multidimensional social phenomena. SAW-PW is the method that constructs the most stable composite indicators that best capture the concept of social exclusion in the cities of Apucarana, Londrina, Ponta Grossa, and Toledo. The weights obtained from expert opinions favor the representation of social exclusion in these four cities. However, the performance of the composite indicator constructed by the SAW-PW method is significantly superior in Apucarana and Toledo when compared to that in Londrina and Ponta Grossa, as shown in Figures 891011 SAW-PW is the method that constructs the most stable composite indicators that best capture the concept of social exclusion in the cities of Apucarana, Londrina, Ponta Grossa, and Toledo. The weights obtained from expert opinions favor the representation of social exclusion in these four cities. However, the performance of the composite indicator constructed by the SAW-PW method is significantly superior in Apucarana and Toledo when compared to that in Londrina and Ponta Grossa, as shown in Figures 891011. The correlation of the composite indicator with income is 1.32 and 1.30 times lower in Londrina and Ponta Grossa than the average for Apucarana and Toledo. The variation in the position of the census tract in the social exclusion ranking is 2.25 and 1.33 times higher in Londrina and Ponta Grossa than the average for Apucarana and Toledo. Even so, the SAW-PW method better represents social exclusion in Londrina and Ponta Grossa than the other methods. Ponta Grossa presents the worst performance in the linking of the composite indicator with the conceptually most significant variable of social exclusion. The average correlation between the composite indicators and the income variable is 0.50. The composite indicators constructed by SAW-EW and OWA show an insignificant correlation with the income variable. The correlation of the composite indicator with income is 1.32 and 1.30 times lower in Londrina and Ponta Grossa than the average for Apucarana and Toledo. The variation in the position of the census tract in the social exclusion ranking is 2.25 and 1.33 times higher in Londrina and Ponta Grossa than the average for Apucarana and Toledo. Even The correlation with income and the variation in the scores of the eight composite indicators constructed for Londrina are worse than the results for the other cities. The variation in the position of the census tracts in the ranking of social exclusion is worse in Londrina than the average of the other cities when using five of the six methods. Only the composite indicators constructed by SAW-PW, PCA, and TOPSIS moderately or strongly capture the concept of social exclusion in Londrina and Ponta Grossa. However, the SAW-PW method is a more stable composite indicator than the PCA and TOPSIS methods in the two cities. In Londrina, the position of the census tracts in the ranking varies 1.50 times less in the composite indicator constructed by the SAW-PW method than in that constructed by the PCA or TOPSIS methods. The social exclusion scores vary 1.68 times less in the composite indicator constructed by the SAW-PW method than in that constructed by the PCA or TOPSIS methods. In Ponta Grossa, the composite indicator constructed by the SAW-PW method is 1.31 and 1.64, more stable than that constructed by PCA and TOPSIS concerning the ranking position and score variations. These results indicate that space matters in defining the method used to construct the composite indicator. SAW-EW and SAW-PW perform the best in representing social exclusion in 88% of cities. However, the performance of these methods varies between cities, and the SAW-EW method fails to represent the multidimensional phenomenon in two cities. --- Discussion of the Results This research addresses a topic of great interest among researchers in the composite indicators field: the influence of geographic space on the measurement of multidimensional social phenomena [7]. The research results reveal that multidimensionality and spatial dependence on social phenomena such as social exclusion prevent the determination of a fully reliable method for their measurement. For example, a method that provides a satisfactory solution for representing social exclusion in one city may not perform as well in another. These results enrich the current literature on the impact of space and the construction methods of composite indicators on the representation of the multidimensional phenomenon. On the one hand, the research results confirm that space matters in the representation of social exclusion [22,23]. On the other hand, the research results add to the literature that the representation of social exclusion is also directly influenced by the construction method of the composite indicator. In this respect, the research offers a valuable contribution to identifying which

This research proposes a decision framework that allows for the identification of the most suitable methods to construct stable composite indicators that capture the concept of multidimensional social phenomena. This decision framework is applied to discover which method among six best represents the social exclusion of eight medium-sized Brazilian cities. The results indicate that space is important in the definition and performance of the method, and ease methods to apply present the best performance. However, one of them fails to capture the concept of the multidimensional phenomenon in two cities. The research makes six important contributions to the literature. First, it offers a decision framework for choosing the best-fit method to construct a composite social indicator. Second, it shows to what extent geographic space matters in defining the best-fit method. Third, it identifies the best-fit method regarding stability and linkage with the conceptually most significant indicator of social exclusion. Fourth, it reveals the methods to be avoided, given their poor performance. Fifth, it indicates the mathematical properties that best represent composite social phenomena. Sixth, it illuminates the debate on social exclusion from a geographical and public policy perspective.

indicator. SAW-EW and SAW-PW perform the best in representing social exclusion in 88% of cities. However, the performance of these methods varies between cities, and the SAW-EW method fails to represent the multidimensional phenomenon in two cities. --- Discussion of the Results This research addresses a topic of great interest among researchers in the composite indicators field: the influence of geographic space on the measurement of multidimensional social phenomena [7]. The research results reveal that multidimensionality and spatial dependence on social phenomena such as social exclusion prevent the determination of a fully reliable method for their measurement. For example, a method that provides a satisfactory solution for representing social exclusion in one city may not perform as well in another. These results enrich the current literature on the impact of space and the construction methods of composite indicators on the representation of the multidimensional phenomenon. On the one hand, the research results confirm that space matters in the representation of social exclusion [22,23]. On the other hand, the research results add to the literature that the representation of social exclusion is also directly influenced by the construction method of the composite indicator. In this respect, the research offers a valuable contribution to identifying which method offers the best representation of the multidimensional phenomenon, as current studies [17,21] focus exclusively on externally validating the composite indicator of social exclusion. The results also show that the composite indicators' stability and capacity used to capture the concept of the multidimensional phenomenon vary according to the method and space. At this point, it is possible to connect two understandings sedimented in the literature and to conclude that the flaws and limitations of composite indicator construction methods are space-dependent. This connection reinforces the importance of a decision framework that allows for the identification of the most suitable methods to construct stable composite indicators that capture the concept of multidimensional social phenomena. The application of the decision framework shows that widely used methods in the construction of composite indicators of social exclusion, such as PCA [12,13,20] and BoD [14,39], perform poorly and should be avoided. Composite indicators constructed using subjective weighting offer better representations of social exclusion than those constructed using data-driven weighting. This result contributes to the discussion about the problem of the incompatibility of weights obtained endogenously with the relative importance of the sub-indicators in the concept of the phenomenon [36,43]. --- Conclusions Analyzing the composite indicators constructed by the six methods for each of the eight cities provides evidence to reach eight conclusions. First, it confirms the current argument in the literature that there is no perfect method to construct a composite indicator [2,51]. Second, popular methods, such as BoD, that consider spatial heterogeneity through the individualized weighting of the sub-indicators of the best performance of each spatial unit show poor results and should be used with caution. Third, sophisticated methods, such as OWA, that combine non-compensatory aggregation, spatial heterogeneity, and the emphasis of the positive or negative aspects of the phenomenon do not guarantee better results. Fourth, methods that are simple to implement and easy to understand by public managers, such as SAW-EW and SAW-PW, offer satisfactory results in most cases. Fifth, data-driven weighting through the BoD and PCA methods is a critical source of uncertainty for composite indicators, reinforcing the argument that the weights of the sub-indicators obtained through this weighting scheme are not necessarily compatible with the concept of the multidimensional phenomenon [36,43]. Sixth, weighting the subindicators based on expert opinion improves the performance of composite indicators, which capture the concept of the multidimensional phenomenon in 100% of cases. Seventh, the weighting of sub-indicators with equal weights using SAW and TOPSIS constructs composite indicators that capture the concept of social exclusion in 81% of cases, indicating that space also matters in considering therelative importance of the sub-indicator in the multidimensional phenomenon. Eighth, normalization by distance improves the capacity of composite indicators of social exclusion to capture income. However, it increases the percentage of bivariate outliers and the instability of composite indicators. From these conclusions, it is possible to point out the following research contributions: First, researchers can identify methods that build stable and reliable composite indicators, in a context in which space matters, through a four-criteria decision framework. Two, the performance of the composite indicator in terms of stability and ability to capture the concept of social exclusion varies from city to city, supporting the argument that geographic space matters in representing multidimensional social phenomena. Third, considering the opinion of experts on the relative importance of sub-indicators makes it possible to construct more stable composite indicators that always capture the concept of the multidimensional phenomenon. Fourth, composite indicators constructed using data-driven weighting methods show unsatisfactory results. In particular, the PCA method constructs composite indicators that are not very stable, while BoD constructs composite indicators that do not capture the concept of the multidimensional phenomenon in 75% of cities. Fifth, the mathematical properties that most favor the representation of composite social phenomena are participatory and equal weights weighting, non-compensatory aggregation, and normalization using the max-min and distance functions. Sixth, the geographic perspective is a critical property for the debate on social phenomena, so the framework developed in this research has great potential for appropriation by public managers in the planning and development of public policies. In short, geographic space matters in the method's definition, making it impossible to indicate a priori which method to use to construct a composite indicator. Some methods generate more consistent results than others, indicating the need to compare the performance of at least two methods with different weighting properties. Considering that the research results are based on two validations, exploring new ways to validate the composite indicators is desirable. It is suggested to expand the number of validations and consider composite indicators of social exclusion constructed from satellite images and Google Street View images. Another limitation to be considered in future research is comparing scores from different cities. The social exclusion scores obtained in this research are not comparable between cities insofar as the maximum and minimum values used in normalization are specific to each city. Additionally, it may be useful in future work to evaluate the framework's responsiveness to other theoretical frameworks, for example, constructs that consider threshold levels for the sub-indicators (see [17]). The results of this research have important policy implications related to the fight against social exclusion and poverty. As space matters and influences the performance of the methods to construct stable composite indicators, urban planners and managers must experiment with these methods to search for the best-fitting alternative. Moreover, it is also advisable to confront statistical outcomes with local urban characteristics, including occupation history, physical conditions, land use patterns, and social and economic structures, to elaborate customized policies grounded in reality. --- Data Availability Statement: The data used in the analyzes are available at: Martinuci, O.S., Machado, A.M.C., Libório, M.P. (2021). Data for: Time-in-space analysis of multidimensional phenomena, Mendeley Data, V4, doi:10.17632/m3y4jncvch.4. --- Conflicts of Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

This research proposes a decision framework that allows for the identification of the most suitable methods to construct stable composite indicators that capture the concept of multidimensional social phenomena. This decision framework is applied to discover which method among six best represents the social exclusion of eight medium-sized Brazilian cities. The results indicate that space is important in the definition and performance of the method, and ease methods to apply present the best performance. However, one of them fails to capture the concept of the multidimensional phenomenon in two cities. The research makes six important contributions to the literature. First, it offers a decision framework for choosing the best-fit method to construct a composite social indicator. Second, it shows to what extent geographic space matters in defining the best-fit method. Third, it identifies the best-fit method regarding stability and linkage with the conceptually most significant indicator of social exclusion. Fourth, it reveals the methods to be avoided, given their poor performance. Fifth, it indicates the mathematical properties that best represent composite social phenomena. Sixth, it illuminates the debate on social exclusion from a geographical and public policy perspective.

Background Alcohol use among college students is problematic globally, but little is known about the extent to which various measures, such as campus alcohol policy and education, deter excessive student drinking. In the context of South Korea, transition to college is often associated with an escalation in binge drinking; one investigation reported that approximately 71.2% of students consume at least four to five standard drinks per drinking session [1]. In the United States, although binge drinking rates have decreased over time, 30-40% of adults consume four to five standard drinks per drinking session [2], while in Europe, around 60% of men and 41% of women between the ages of 18 to 23 binge drink regularly [3]. Considering that there are numerous negative consequences of college binge drinking including violence, date rape, accidents, and academic problems [4], more research on prevention efforts is necessary. Rates of student alcohol use have been shown to vary between schools; even when individual-level characteristics such as gender, race, and ethnicity [5] have been adjusted for. There are also multiple area-level characteristics such as peer drinking norms [6], wealth and entertainment of the neighborhood surrounding the campus [7], and alcohol outlet density [8,9] that previous studies have associated with student drinking. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has identified the following environmentalfocused strategies for decreasing college binge drinking: 1) retaining the minimum legal drinking age (MLDA) of 21, 2) enforcing the MLDA, 3) increasing taxes on alcohol, 4) retaining a ban on Sunday alcohol sales, and 5) enacting bans on happy hours and other price promotions. Although such policies are enacted at the state or local level, when colleges partner with other organizations or coalitions to implement or retain such policies, reductions in risky alcohol use and related problems among students are possible [10]. Previous studies in the international literature have also shown that certain policy interventions influence student alcohol consumption. Whilst policies vary among institutions, emerging evidence indicates that policy-makers should target both individual and environmental strategies to reduce excessive alcohol consumption and binge drinking among students. Typical environmental policies include campus alcohol bans, bans for minors, no alcohol use at college events, prohibition of beer kegs and alcohol displays on campus [11], and limitations on maximum number of drinks purchasable per student [12]. In one study, students attending schools with a ban on alcohol use were up to 30% less likely to engage in binge drinking [13]. Attending colleges that restrict high volume sales or target underage drinking has been associated with lower rates of alcohol-involved driving while substance-free residence halls have been associated with reduced alcohol-related problems [14]. Regulating excessive alcohol use, through distance and access-based interventions that reduce the average distance between a college and outlet or the number of outlets in a county have also been effective in decreasing excessive alcohol consumption [15]. Banning alcohol advertisements and kegs on campus, and enforcing deterrence policies more strictly have been associated with decreased alcohol consumption [16]. Recent studies have also found that while campaigns to drink responsibly are ineffective for heavy drinkers, strategic campaigns that promote responsible drinking may be effective among mild and moderate drinkers [17]. However, in 2008, Nelson and colleagues found that 23% of colleges in the United States were not employing any recommended strategies to reduce alcohol-related harm, while 45% were only employing a single recommended strategy such as 1) interventions challenging alcohol expectancies, 2) restrictions on alcohol retail outlet density, 3) enforcement of laws to prevent alcohol-impaired driving, and/or 4) responsible beverage service policies in social and commercial settings [18]. Overall, limited research has been done to assess the association between self-reported campus alcohol policy and education experience on alcohol consumption among college students. On the individual level, alcohol education programs, especially those directed towards individuals that typically use alcohol at higher rates (e.g. members of Greek organizations and participants of athletic events) have shown to be effective in some studies [19]. Ultimately, according to a study of 734 college administrators, most institutions in the United States continue to offer some type of alcohol education program, despite their limited success, in combination with restrictive environmental policies that reduce student access to alcohol (e.g. limits on alcohol deliveries, and/or alcohol advertisements on campus) [11]. Although alcohol policies have been enacted to prevent and reduce harmful drinking of college students, limited research has been done to assess the association between type of campus alcohol policy and student alcohol consumption from a multilevel model approach. Therefore, the present study focuses on examining the association between perceived college alcohol policy and student drinking, while controlling for both individuallevel and college-level characteristics. --- Methods --- Study sample and data In the 2017 national statistics published by the Korean Educational Development Institute on college students, we found that 1,951,940 students (4-year: 1,506,745; liberal arts: 445,195) are enrolled in 356 colleges (4-year: 195, liberal arts: 161) in South Korea. Thus, we stratified a proportionately representative sample of undergraduate students from 54 4-year colleges and 28 liberal arts colleges (Table 1). Students in these colleges were further stratified according to sex, year level, major, GPA, pocket money, smoking status, stress level, depressive thoughts, suicidal thoughts, and number of clubs/organizations. In total, 5000 students completed the survey instrument. The response rate was 68.7%, with the total number of approached participants being 7278. A financial incentive of 10,000 Korean Won (equivalent to around 9 U.S. Dollars) was given to each participant upon completion of the 14-page survey instrument. Of these students, we excluded 10 students who had missing data for their major and GPA, and 211 students who had missing data for questions related to the AUDIT-C, for a final study sample of 4592 college students. More information regarding the survey have been published in previous studies [20,21]. Data was collected via face-to-face surveys with students. Questions were mainly about student drinking behavior, health, sociodemographic characteristics, and thoughts on campus-alcohol policy. Whenever possible, the instrument included alcohol-related questions that had been previously used in other international, national or large-scale epidemiological studies including the Harvard College Alcohol Study [14], the Korea National Health and Nutrition Examination Survey (KNHANES) [22], and the Korea Youth Risk Behavior Web-Based Survey (KYRBS) [23]. College-level information such as number of students, faculty, and staff were found on the Korean Educational Development Institute website, which provides basic information about all registered colleges in the country. A standard drink was defined as the amount of alcohol contained in one glass of alcohol drink (approximately 8 g of pure alcohol), equivalent to:1 shot of soju, 1 glass of bottled beer, 2/3 of a canned beer, 1/2 glass of draft beer, 1/2 bowl of makgeolli (rice wine), 1/2 glass of wine, 1 glass of whiskey, 1 shot of cheongju (refined rice wine), 1 shot of herbal liquor, 1 shot of fruit wine, or a 3/5 glass of mixed liquor (soju+beer), in accordance with the standards of the Korea Centers for Disease Control & Prevention. Our survey instrument followed the guidelines of the Institutional Review Board of Yonsei University's College of Medicine (Number: Y-2017-0084). All procedures were performed in accordance with the ethical standards of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the survey in written form. Data collectors were trained about the survey's ethical standards regarding privacy, anonymity, and confidentiality by our research team and collaborators from Gallup Korea. Each question of the questionnaire was required to be administered privately to students in a face-to-face manner at a quiet, enclosed space on campus such as a café or lecture room. The survey contained no identifying values that could link the information to the participant; making it completely impossible for researchers to identify specific participants. --- Measures --- Outcome variable Alcohol intake, measured through the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), was selected as the outcome variable. The AUDIT-C is an abbreviated 3-item measure consisting of the first three questions from the full-length AUDIT questionnaire (Table 2). The AUDIT-C assesses alcohol consumption over the past year, and can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence). Items are scaled (scale: 0-4) and summed to create a total score (scale: 0-12). Higher AUDIT-C scores indicate greater alcohol consumption; generally, the higher the AUDIT score, the more likely the patient's drinking is affecting his or her safety. Among Korean men, a score of 4 or more is considered positive, optimal for identifying hazardous drinking or active alcohol use disorders, whilst a score of 3 or more is considered positive among Korean women [24]. --- Perceived type of campus alcohol policy Perceived type of campus alcohol policy was measured via individual answers to the question, "What is your university's campus alcohol policy?" Response options were as follows: "Unaware of campus alcohol policy," "bans all drinking on campus," "bans minors (under 19) from drinking on campus," "occasionally allows drinking on campus at certain locations/during events," "allows drinking in outdoor spaces," and "allows drinking in all areas." Students could only select one answer, based on their knowledge of their school's campus alcohol policy. Multiple choice options were unavailable. Alcohol education experience (lecture/mail/campaign) Alcohol education experience was measured via individual answers to the question, "In the past 12 months, how many times have you encountered or taken part in the following alcohol prevention activities at you university?" Response options were as follows: "attended alcohol prevention programs, lectures, or training," "received a mail or brochure on alcohol prevention," "saw posters or promotion materials on alcohol prevention," and "participated in a moderation campaign on campus." Individuals were able to select their response on the following frequency scale: "never," "once," "twice," "3 times," "4 or more times." The sum of these responses was re-categorized into a new variable: 'alcohol education experience' and individuals were classified into the following categories: "none," "1-2 times," "3-4 times," "more than 5 times." --- Statistical analysis In order to examine the study participants' general characteristics, chi-square tests were performed to compare differences between groups. To examine the association between perceived type of campus alcohol policy and alcohol education experience with alcohol consumption, multilevel linear regression analysis was employed. Both area-level characteristics with respect to each college campus (college type, number of students, number of faculty members, number of workers/administrators, region) and individual-level characteristics (sex, year level, major, GPA, pocket money, smoking status, stress level, depressive thoughts, suicidal thoughts, number of clubs/ organizations) were controlled for in the mixed model. The beta values used in this model indicate the nonstandardized regression coefficient, which signifies how much the mean of the dependent variable (AUDIT-C) changes given a one-unit shift in the independent variable (perceived type of campus alcohol policy / frequency of alcohol education experience). Kendall's tau-b correlation coefficient was used to measure the relationship between our variables of interest (perceived policy type, alcohol education experience frequency) and AUDIT-C. The simultaneous relationship between type of campus alcohol policy and alcohol education experience frequency on AUDIT-C was determined through subgroup analyses, by running the linear regression analysis on the sample, when stratified by sex. The calculated p-values in this study were considered significant if lower than 0.05. All analyses were performed using SAS software, version 9.4 (SAS Institute, Cary, North Carolina, USA). --- Results Table 3 shows the general characteristics of the study sample. Three thousand five hundred ninety-six students reported to being "unaware of campus alcohol policy," followed by 704 students reporting to college "bans all drinking on campus," 85 students reporting to college "bans minors from drinking on campus, 201 students reporting to college "occasionally allows drinking on campus at certain locations/during events, 148 students reporting to college "allows drinking in outdoor spaces," and 69 students reporting to college "allows drinking in all areas." Students who perceived that their campuses allow drinking in outdoor spaces (7.189 <unk> 3.009) or all areas (7.232 <unk> 3.392) had the highest AUDIT-C scores. Kendall's correlations showed that AUDIT-C was positively correlated with both perceived policy type (Kendall's tau-b = 0.24, p <unk>.0001) and education experience (Kendall's tau-b = 0.02, p = 0.04). Kendall's correlations also showed that AUDIT-C was positively correlated with both perceived policy type and education experience. Considering that small correlation coefficients can be highly significant in large sample sizes and a Kendall correlation is equal to 2/<unk> times the inverse sine of the Pearson correlation [25], these correlation coefficient values may represent significant associations. Table 4 shows the results of the multilevel regression analysis performed to investigate the association between various factors and AUDIT-C score among our study sample. Compared to students "unaware of campus alcohol policy," students whose campuses "allow drinking in outdoor spaces" (<unk> = 0.755, p = 0.290) or "allow drinking in all areas" (<unk> = 0.820, p = 0.044) on campus had higher AUDIT-C scores, even when area-level characteristics including college type, number of students, number of faculty members, number of workers/administrators, and college region were controlled for. Alcohol education experience was not a predictor of reduced alcohol consumption. Females (<unk> = -0.269 p = 0.021) scored lower on the AUDIT-C than males as did seniors (<unk> = -0.614, p = 0.003 = 0) relative to freshmen. Students in the lowest GPA bracket (<unk>3.0) scored higher on the AUDIT-C than students in the highest GPA bracket (<unk>4.0). Past smokers (<unk> = 1.543, p <unk>.0001) and students who reported to currently smoking (<unk> = 1.456 p <unk>.0001) had higher AUDIT-C scores compared to those reporting to not smoking, as did students participating in two or more clubs/organizations (<unk> = 0.337, p = 0.055) relative to no clubs/organizations. For males, allowing alcohol consumption in outdoor spaces (<unk> = 1.1690, p = 0.0009) or in all areas (<unk> = 1.0777, p = 0.0479) resulted in more alcohol consumption (Fig. 1). For females, allowing alcohol consumption in all areas (<unk> = 0.9834, p = 0.0486) resulted in more alcohol consumption. Receiving alcohol education 1-2 times, or 3-4 times were not associated with higher AUDIT-C, which was in alignment with the existing body of literature. --- Discussion Our results suggest an association between self-reported campus alcohol policy and student alcohol consumption. Relative to students unaware of campus alcohol policy, students who believe that their college allows drinking in outdoor spaces or all areas may consume higher amounts of alcohol than their peers. Such findings are in alignment with previous studies that have found that students drink more on school grounds when they perceive lax policy enforcement by college officials [26]. Interestingly, alcohol education experience, pertaining to alcohol prevention programs through lectures, mail, brochures, posters, promotion materials, or moderation campaigns, was not a significant predictor of decreased alcohol consumption among students in our investigation, and only affected female students who had received alcohol education more than five times in their college years. Alcohol education programs have had mixed results when it comes to college interventions: online and/ or offline alcohol education courses for college students have been both successful [27] and unsuccessful [16,28,29] in mitigating alcohol-related high-risk behaviors among student populations. What is clear is that while educational experiences may have no effect among all college students, among students who violate campus alcohol policies and/or engage in high-risk drinking behaviors, alcohol education or counseling is an effective measure in preventing alcohol misuse [30]. Furthermore, as emphasized by Kelly-Weeder and colleagues, integrating educational interventions with environmental approaches can increase program effectiveness [17]. Our findings also show specific socio-demographic groups that should be particularly targeted when establishing campus alcohol policies: males, freshmen, students with low GPA, students receiving high amounts of pocket money, current and past smokers, and students in two or more clubs/organizations. Findings from major college alcohol investigations including the Harvard College Alcohol Study have already noted these vulnerable populations; as seen in the 1993, 1997, 1999, and 2001 Harvard College Alcohol Study, males, students under the age of 21, students with academic problems related to alcohol such as missing class and/or getting behind in school work [13], and smokers have all been associated with consuming more amounts of alcohol than other subpopulations [4]. Likewise, previous studies have found that students who are more active in school activities such as clubs/organizations [31] or university athletics drink more, and find alcohol problematic on campus [15]. A difference between previous studies and our study is that in the context of year level, students in South Korea have the highest AUDIT-C scores in their freshman year, whereas students in international studies mostly consume high amounts of alcohol during their sophomore and junior years [3,13,32,33]. This phenomenon may be particular to South Korea; students in South Korea have been noted to consume the most amount of alcohol in their freshman year (often, unwillingly) at various orientation, and/or freshmen events where juniors and seniors pressure incoming students to drink [1]. Similar trends were also found among some Asian countries like China [32] and Taiwan [34], where alcohol use was greatest among 1st year students. However, in most European countries like France [33], Belgium, Colombia, Ireland, and Poland [3,4] age and/or year of study were not associated with binge drinking and associated drinking behaviors. Our study has a number of limitations. First, our study is cross-sectional in design and therefore, it is difficult to make causal inferences about the effect of campus alcohol policy type or education experience on alcohol consumption. The data is based on self-reported answers, and the question about campus alcohol policy may be ambiguous as only single choice answers were possible. Furthermore, the group size is too small to meaningfully interpret trends, especially because being 'unaware' of campus alcohol policy does not mean full prohibition or liberalization. Future investigations should attempt to overcome these limitations through the survey instrument and design. Second, there are not enough previous studies with regard to a nationally representative sample of Koreans when it comes to measuring type of campus alcohol policy/education experience and its effect on drinking behavior of college students. It is difficult to see whether the values we calculated are similar to that of the statistics found in previous studies, especially for the college students' age group. Similarly, all alcohol education experiences ranging from lectures, to campaigns were given equal weights in our analysis because our survey instrument measured these experiences together. However, certain activities may have a greater impact on drinking behavior than others. Future studies should take this factor into account and attempt to give weights to these experiences or measure them separately as individual effects. Furthermore, various sampling biases may have emerged from our surveying methods; because college students in South Korea drink large amounts of alcohol relative to adults, different patterns are likely to emerge in adult populations. Likewise, a small number of Christian colleges that were originally in our sample declined our request for participation because of their teetotalism principles and thus, had to be replaced with non-Christian colleges. Because of the face-to-face method that we employed for accuracy of obtaining responses to complicated questions, there may have been response biases, relative to social desirability. The majority of questions in our survey instrument required students to think about their drinking behaviors in the last 12 months or so, which likely resulted in recall bias. Finally, although we included numerous lifestyle covariates as potential confounders, the limited nature and number of questions in our instrument, as well as information publicly available regarding each college campus, made it difficult for other confounding variables, relative to health, socio-demographics, geneenvironment, environment, and lifestyle, to be measured and controlled for. Despite these limitations, our study also has several strengths. Few studies have measured the effect of environmental and educational campus alcohol policies on drinking behavior for a nationally representative sample of college students in South Korea, especially with a multi-level statistical model which controls for macro-related characteristics. Our findings not only show which sub-groups are at higher risk of consuming dangerous amounts of alcohol, but show that alcohol education experience is effective only when done frequently, and in combination with environmental deterrence policies among certain subgroups (females). --- Conclusion In conclusion, this study emphasizes the importance of prohibiting alcohol consumption in open, public college spaces, if only to prevent high-risk students from perceiving that college alcohol policies are lax. While alcohol policies and educational programs may be limited in impacting the drinking behaviors of all college students, it is undeniable that college alcohol policy is associated with student drinking behavior. It is especially important for schools to have non-judgmental and supportive mechanisms that help students with alcohol-related Fig. 1 Subgroup analysis of the association between perceived alcohol policy and education experience by sex problems and/or AUDs (Alcohol Use Disorders) [35]. According to Blanco and colleagues, roughly 20% of college students meet the criteria for an AUD [6]. Thus, college educators and administrators should be aware that relative to students unaware of their school's campus alcohol policy, students who believe that their college allows drinking in outdoor spaces or all areas may consume higher amounts of alcohol than their peers. --- Availability of data and materials Data will be made available upon request. --- Authors' contributions SSO and YJJ made substantial contributions to analysis and interpretation of the data. SSO was involved in drafting the manuscript and revising it critically for important intellectual content. SIJ was in charge of revising the manuscript and giving final approval of the version to be published. EC Park conceived, designed, and directed this study. All authors participated sufficiently in the work and take public responsibility for appropriate portions of the content. All authors read and approved the final manuscript. --- Ethics approval and consent to participate Our survey instrument followed the guidelines of the Institutional Review Board of Yonsei University's College of Medicine (Yonsei IRB No. Y-2017-0084), registered on January 3rd, 2017. The trial registry can be accessed at https://irb.yonsei.ac.kr/ upon request. All procedures were performed in accordance with the ethical standards of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the survey in written form. --- Consent for publication All authors give consent for publication. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Campus alcohol policy has been associated with student alcohol consumption in numerous studies. However, more information is required to assess the extent to which school policy affects student drinking behavior; especially when both individual-level sociodemographic characteristics of students and area-level characteristics of college campuses are controlled for. Thus, this paper explores the association between campus alcohol policy and student alcohol consumption among a nationally representative sample of college students in South Korea, while controlling for both individual and area-level characteristics.We surveyed and analyzed the data of 4592 students from 82 colleges. Multilevel (hierarchical) linear modeling was used to identify the association between campus alcohol policy and alcohol consumption levels, measured via the AUDIT-C (Alcohol Use Disorders Identification Test -Consumption). Controlled individual-level characteristics included sex, year level, major, GPA (grade point average), pocket money, smoking status, stress level, depressive thoughts, suicidal thoughts, and number of clubs/organizations. Controlled area-level characteristics included college type, number of students, number of faculty members, number of workers/administrators, and region. Results: Compared to students unaware of their school's campus alcohol policy, students who self-reported that their campuses allow drinking in outdoor spaces (β = 0.755 p = 0.010) or in all areas (β = 0.820, p = 0.044) had higher AUDIT-C scores. Students attending schools with a large number of students, males, freshmen, students with low GPA, students with high amounts of pocket money, and smokers also had higher alcohol consumption scores relative to their peers. Alcohol education experience in the form of lectures, mail, and/or campaigns were not associated with student alcohol consumption levels. Conclusion: Our results suggest an association between self-reported campus alcohol policy and student alcohol consumption. College educators and administrators must be aware that relative to students unaware of their school's campus alcohol policy, students at colleges that allow drinking in outdoor spaces or all areas consume higher amounts of alcohol than their peers; even when area-level factors are controlled for.

Introduction LAWRENCE 1 -Listen up yeah, this is Simon. He's got a project he wants to talk to you lot about. UNKNOWN -Who? (Lots of background talking). LAWRENCE -Simon, the guy I told you about. (Shouts). Listen up! SIMON -Um, thanks for coming in. Basically I'm a student doing social work at university and I want to do some research with a group of you on what it's like for a young man growing up in St Pauls today. When I say I want to do it with you, I mean I'm looking for maybe half a dozen, maybe all of you, to become researchers with me, I don't just want to interview you or whatever. You'd actually be researching your own lives, if that makes sense. UNKNOWN -Oh okay, how much? (Laughing). SIMON -Hold up... I'll train and pay you a one-off amount but you need to sign up for twelve weeks of group sessions where we'll just hang and talk about issues you raise, then we'll do whatever you want with what we learn. We can make a music video, do photography or a film... whatever you want. Whatever that is will be yours, not mine. I just want to record the group sessions we do each week for my research and work with you to make something that's useful for the community and for you guys. It would be like three hours a week for twelve weeks, that's the basic commitment I'm looking for. After that you get paid and if we haven't finished you can carry on if you want, or leave... no pressure, no questions. You can leave anytime you like, but if you go earlier than the twelve weeks then obviously you won't get the full amount. JERMAINE -Si, I have a question, so how much we gettin' paid for this? (Laughter). SIMON -£100. But look, over twelve weeks at three to five hours a week that's only like £4 an hour... but it's all I've got in the budget... you also get skills in research or whatever interests you, so if you want to make a film or do music I'll arrange for you to get trained up in that too if I can, so, like, you can get a lot out of this if you put in... I hope that by doing this together we might come to see things differently; I don't know, anything's possible I guess. JACOB -Look yeah, you don't need these lot. Let's just me and you work on it Si, and you just pay me the others share. (Laughter). 1 All names have been changed (except Simon's). MARCEL -It's a good opportunity, you lot don't do nothing anyways so you should sign up, you might learn something. You need to be motivated though, that is, have a motive to action. In this paper we offer a critical reflexive analysis of a Participatory Action Research (PAR) project undertaken with seven young men aged 15-24 in the inner-city neighbourhood of St Pauls, Bristol, a provincial English city of around half a million people. Animated by benign intent and a genuine attempt to build a collaborative enquiry, we will surface some of the different ways ideological control was nonetheless exerted inter-and intra-personally. Specifically, we will explore how PAR, as a particular participatory social research approach, exerts control over meaning in practice, and in the process administers and recycles feelings of failure and marginalisation among participants, including the 'professional' researcher. So that this description might deliver some real-world utility beyond postmodern descriptions of power, position and identity, we conclude by considering what actionable knowledge our analysis contains for the practice of participatory social research. The project in question was my (Simon's)2 doctoral fieldwork and took place over the eighteenmonth period immediately prior to August 2011, when rioting young people took to the streets of several English metropolitan cores, including St Pauls, a small and diverse neighbourhood of around three and a half thousand people located immediately adjacent the city's central shopping mall and retail concourses. St Pauls was and remains one of the most youthful and ethnically diverse neighbourhoods in the city, and also one of the most disadvantaged across a range of indices (for example, child poverty, over-crowding, unemployment, life expectancy), ranking at the time of the fieldwork 284 out of 32,482'super output areas'3 in England (North Bristol Primary Care Trust, 2004, Bristol City Council, 2010). I decided to work through a Participatory Action Research (PAR) method and ethic with young men living in the area, with the intention of producing a highly situated (auto)ethnographic account of urban marginality and the increasingly consumerist identities of youth, masculinity, social class and race in the inner city. I wanted to understand the worldview of a demographic of young people statistically overrepresented as adults in the acute mental health and criminal justice systems (see Fernando, 2017, for more on this). And in contrast to the service cultures of the education, social care and health systems I had experienced in my professional life, which examined the issue of differential access and outcomes for Black boys and men (if at all) through a biomedical and observational lens, I wanted to subject the issue to a poststructural analysis drawn from a participatory and political epistemology (Sedgwick, 1982, Cresswell andSpandler 2009). Put another way, I wanted to engage with the social, economic and political context of my co-participants and offer a challenge to the prevailing and enduring locus of mental health as residing inside the individual. My hypothesis was that such an approach was morally imperative under circumstances of social exclusion because it returned the value of the research process to my co-participants. And I also supposed both that the ethical issues of beneficence and justice inherent to fieldwork would be best realised in this way, and that such a research process would deliver an emancipatory outcome of some kind for my coparticipants. John O'Neill once wrote that 'the privatisation of meaning... is a principal source of social control in a liberal society'(1972: xi). My intention for this research was that its processes re-socialise the meaning my co-participants gave to their lives and'structures of feeling' (Williams, 1977). Where so often these young identities and lives are problematised and pathologised by the state, and commodified by the market (which does a sophisticated job of selling particular identities and lifestyles back to the young people and street culture from whom it has appropriated them), I was keen that the voices of my co-participants should destabilise the assumed purpose and role of public services (for example the assumption that health professionals deliver care that is benign), their real life encounters exposing the different ways in which power is administered and experienced, intraand interpersonally. Briefly, the most important theoretical influences on my research and practice at this point were multi-disciplinary and critically engaged. Phenomenology provided my philosophical instincts with a language that simultaneously rejected the mind/body dualism of Cartesian science (which dominates the professional and policy landscape of mental health) and legitimised experience as evidence. The disciplines of 'liberation psychology' (Mart<unk>n-Baró, 1994, Watkins andShulman, 2008) and critical pedagogy built on this foundation, offering me an epistemological frame that I embraced for its politics and provocation as much as its method. (Freire, 1971, Fals-Borda and Rahman, 1991, Rahman, 1993, Cahill, 2004, 2006, Cammarota and Fine, 2008). Postmodern critical theory was generally important, but the reflexive ethnography advocated and practiced by Behar (1996), Bourgois, (2002) and Belmonte (2005), was especially influential in encouraging me to consider and make visible my own positionality. In the same postmodern current, critical childhood studies and theories of children and young people's participation (Percy-Smith, 2005, Thomas, 2007, Cordero Arce, 2012) were also contributing influences, not least becauseat the timethe voices and perspectives of young Black working class men were almost entirely absent from this literature. To find them I looked to a body of sociology concerned for issues of social exclusion, race and class in the British inner city (Gilroy, 1987, Back, 1996, Hall, Winlow and Ancrum, 2008) and, in particular, to an ethnographic monograph of St Pauls written a generation earlier, Endless Pressure (Pryce, 1979). The data presented in this paper come from the transcripts of our taped Friday night group discussions in a small local community flat in St Pauls between June and December 2010, a much longer period than the twelve weeks I originally set aside and anticipated. In fact, because of the way the recruitment and research had unfolded, I was still a weekly visitor to the neighbourhood throughout the spring and summer of the following year. My eventual withdrawal was prompted by the rioting that gripped several English metropolitan areas, including St Pauls, in August 2011, which mobilised elements of its youth to overrun and smash parts of the nearby retail mall). The additional period was largely spent trying to encourage the completion of a short film my coparticipants had wanted to make, but because our relationships deepened over these months it also contributed to a more nuanced understanding of their lives on my part. The young men I recruited to the project were offered training, skills and accreditation in film making, as well as an individual stipend of £100 for their (anticipated) twelve weeks participation in the project. Our critical reflexive analysis in this paper centres on a heated exchange in the group that brought to a head my decision some months earlier to offer this one-off stipend. We have chosen this extract over others that might also have provided fertile territory for the same themes, because it is an opportunity to lay bare an inconvenient truth about participatory research: that too much of what is personally uncomfortable and challenging to our identities as researchers is often tidied out of the final presentation, when in reality, as Olesen & Nordentoft observe, 'we can only learn from what we are doing as researchers and facilitators if we dare to explore sensitive incidents and gain insight into what is at stake in dialogical reflexive processes'(2018, p.12). --- The'stipend' The extract that follows was informed and preceded during the week by a dramatic split in the group. I had booked a local production company to visit us at the community flat to help with the film making process, providing support and equipment, training and skills to the group as they scripted and shot their idea for a short documentary film. The group, comprising Ashley (aged 16), Jermaine (19), Tyreese (17), Ledley (15), Lawrence (24), Marcel (23) andTrigga (17 --- ASHLEY -You didn't show up at all this week, you did fuck all, what have you done for this project, tell me? JERMAINE -I been here every week... SIMON -C'mon mate, every week, really? I was here every week, I was about the only one who was here every week. --- JERMAINE -Most weeks then. TYREESE -You don't say nothing though even when you was here, fucking sleeping through most of it! (Laughter). --- SIMON -Look, yeah, I never ever wanted this to happen, where we got to this place. I thought offering you a few quid to participate would make things fairer. I'm committed to writing up what we've done and getting something out of this, a qualification and stuff. I wanted you all to get something out of it too, but it was difficult because half the time people didn't turn up, or fell asleep, or fucked about. So now what do we do? I was going to just pay everyone regardless tonight and ask if anyone wanted to carry on meeting and working together. But hardly anyone turned up last week to film, and I gotta tell you that pissed me off 'cos we spent nearly £2k for him to come down here and work with you on your film. --- ASHLEY -How much!? SIMON -Yeah his time and crew and equipment costs money, and he gave a lot of it away for free still. ASHLEY -Fuck, man, I didn't know that. Look, all I'm --- LEDLEY -Yes. 4 A fool. The exchange above, and the session around it, were highly charged and full of strong feelingsanger, embarrassment, confusion, fear, anxietythat moved in a complicated pattern that was sometimes adversarial and dominating, and sometimes highly participatory and self-organising. The embodied and expressed feelings involvedwhich are only partially captured by the textare an important site of information in any critical reflexive analysis since they speak to a group process and embodied experience that might otherwise get lost beneath the noise of multiple and competing voices (Heen, 2005). That the stipend (or perhaps more accurately my administration of it) should elicit such strong feelings might reasonably supply evidence of it being a poor ethical decision to include one. And yet some years later, and even through a critical reflexive lens, the outcome remains more complicated to judge than that. I had made my mind up some time before the fieldwork started to offer the stipend in return for participation in the project. I had wrestled with the ethical implications of this, and had no satisfactory answer to the objection that it might act as an inducement (although it was approved by the university ethics committee). In fact, as the period of engagement and recruitment wore on (six months in all) I confess I ended up hoping that it would induce participation. However, I also saw compelling ethical reasons for offering something material to participants when I was in position to do so because my studentship included a small budget to support fieldwork costs. I was looking for co-researchers (not research subjects) in a place of enduring and multiple material disadvantages, and I was asking for an investment of time and labour in a supposedly 'horizontal project', the fruits of which were likely to increase my own status and prospects through award of a PhD. It was, I thought, an appropriate acknowledgment of the lived concerns, priorities, and material reality of my co-participants. While the money was not initially intended as an inducement to participate, I nonetheless found myself increasingly wielding it as such as the weeks wore on; or at least, to induce participation in particular ways consistent with my understanding of participatory research and my identity as a researcher. Each week the group meetings were undermined and interrupted by my co-participants' absence, routinised lateness, and their ability to sleep through much of our time together. Just as frequent were the silences, apparent boredom, and incessant'messing about'. Rarely was any proposed fieldwork actioned between our meetings, and even the best sessions contained within them less than an hour (of the three hours for which we met) of reflective, generative, dialogue and planning. Through all this I was often left feeling frustrated and de-skilled, confronted by strong feelings of failure that my efforts were not 'good practice' and that the project was in some ways confirming stereotypes rather than challenging them. The stipend soon began to show subtly in my conversations with the group, in the form of a joke or a gentle reminder that was also undeniably a language of compliance and control through which I aimed to corral and mobilise. This came to a climax in the excerpt above. Despite the ongoing challenges of attendance, punctuality and participation, I was keen not to withhold payment for worry this might herald a complete breakdown in our accumulated trust, even though I badly wanted to in the case of Jermaine and Ledley, who were entirely absent at least half the time. By this stage I was simply happy to be rid of the money and hoped that enough interpersonal work had been done that the group would want to continue to meet and finish our enquiry together. As it turned out, Ashley and Tyreese were very keen to discuss the ethics of my decision. Because of this, the exchange delivered a rare dialogic moment in our time together. It was a conflict but it 'felt' horizontal and participatory as I was for a time submerged beneath feelings and agencystronger than my ownabout the value of the stipend beyond its monetary worth, and about the issue of collective accountability and fairness: "It's supposed to be a group thing, and two of us didn't do nothing." In the moment the feelings were raw, but only because they were honest, and this emotion achieved a genuinely catalysing and galvanising effect, clarifying purpose, commitment, and expectations ("It shouldn't be about money"). For my part, and contrary to my expectations, I actually got more respect from the group when I sounded "pissed off" at the money we had already wasted, than when I didn't just propose to give it away like "a mug". When it came, this respect was a relief, but only because it gave me permission to acknowledge the frustration I had experienced and administered in much more subtle ways over the preceding weeks. Because it is certainly true that while I was 'holding' the money I was also in fact nourishing a particular process of subjectification that meant my co-participants were required to conform to a position in the group that was more or less consistent with my beliefs about what a valid, successful participatory action research project contained, by way of outputs and outcomes (see also Healy, 2001). An unacknowledged academic research identity was present that remained, to my embarrassment, hidden in plain sight throughout. For it was not at all obvious to me that my commitment to realising emancipatory research of the kind described by my textbooks, and embodied by my own personal search for legitimacy, could ever become an ideological project seeking to control the process and privatise its meaning (Stronach & MacLure, 1997, Lilleaas, 2013). Self-evidently, I thought, I was trying to effect the very opposite of this outcome. The consequences of this unacknowledged identity, and my adherence to its structure of thought in practice, was an occasionally oppressive reliance on the kinds of technical skills and personal and intellectual faculties privileged by it (literacy, self-confidence, planning, timekeeping, sociability, motivation, teamwork, emotional intelligence and critical thinking). For my co-participants these qualities were either very badly wounded, perhaps, by earlier formal experiences of scholastic failure and exclusion, or suffocated by the effects of the local moral economy articulated by street culture, which was suspicious of and often hostile towards behaviours inconsistent with the local image and story of Black masculinity. Much of what I sought from my co-participants as the correct research behaviour (for example; studiousness, attention, effort, curiosity), was coded in street culture (and reinforced by my positionality) as 'White'. The move towards me risked exclusion from the group and accusationstypically delivered using humourof betrayal; or 'washout' as the group would know and call it. Under these conditions the stipend became a potent symbol not only of the research(er) identity that I was affecting, but also of the embodied and expressed dispositions, manners and symbols of my adulthood, my whiteness and my middle-class identity. At various times, these dispositions became positional techniques and effects of power that, unintentionally but too frequently, revealed and poked at the wounds of my co-participants. One example was my assumption, which became an insistence, that there should be a social action output; a 'thing' that we (I) could point to as evidence of the validity and success of our enquiry, and a demonstrable disruption of the "story of failure" the group had assigned to St Pauls. Another was my asking the group one evening to write down questions for the interviews they hoped to carry out, which had the effect of humiliating Jermaine, whose lack of functional literacy was exposed and exacerbated by the clumsiness of my noticing and the group's laughter at his exposurenotwithstanding their own limitations in the same area. Throughout our time together I would have considered my efforts to be grounded in an ongoing spirit and practice of critical reflexivity, so it is no easy thing to acknowledge that some internal assumptions escaped my interrogation and bled out into the research process. Eventually, time and distance from both the field and the text revealed a deeper level of insight than I was capable of in the moment and immediate aftermath. My opening analysis at the time located my 'failure of the methodological form' as speaking to a deficit in representation of young socially excluded men in the available literature on PAR, and a romantic idealisation of emancipatory research born in another time (Freire, 1971, Gutierrez, 1988, Mart<unk>n-Baró, 1994). Only more recently have I been able to connect with a deeper layer of assumptions I was still, even in my initial analysis, holding onto about the meaning and identity of academic research, and, by extension, myself as its student. --- Critical encounters JERMAINE -I think what we say anyway, they already have planned anyway, so it ain't gonna really matter. This is just a cover up. We care, but our thoughts don't really count. Critical-reflexive analysis here is concerned with the ways in which power is distributed and moves through a participatory research setting, in particular the embodied intra-and inter-personal aspects of this movement (Arieli et al. 2009, Berger, 2015, Levy, 2016). Critical reflexivity is really the only route to engaging effectively with the situated, contextual and contingent operation of power/knowledge, particularly that produced by a process of group enquiry and sense-making that claims to be highly participatory and emancipatory. This is because '[b]eing attentive to power/knowledge relations makes it possible to recognise reproductions of cultural norms and how such norms constantly mould our relations, interpretations, and categorisations' (Nordentoft & Olesen, 2018: 56). Put more simply, reflexivity in research processes is needed because existing power differences between participants may generate tendencies to re-enact the same social norms that we set out to challenge (Healy, 2001). Bourdieu's theories of doxa and habitus (1977) offer real descriptive and explanatory value in the reflexive effort at this point. Bourdieu views power as culturally capitalised and constantly recycled and re-legitimised through the dialectical interplay of agency and structure.'Habitus'the socialised norms and tendencies that guide our behaviour and thinkingis thus 'the way society becomes deposited in persons in the form of lasting dispositions, or trained capacities and structured propensities to think, feel and act in determinant ways' (Wacquant 2011, p. 316). Context and environment are key influences on habitus, and in this sense the 'container' for the enquiry -PARis a 'field' in which we, as participants, both wielded and experienced power in an ongoing dynamic. Bourdieu's related concept of doxa allows us to move towards a fuller description of the ways in which my identity as a'researcher' obscured'research' itself as a contested and ideologically privileged site (Lilleaas, 2013). For Bourdieu, doxa is 'an adherence to relations of order which, because they structure inseparably both the real world and the thought world, are accepted as self-evident'(1984: 471). The analysis of power expressed by these two concepts can help the collaborative researcher unpack the ways in which we can and do resist particular forms of power and domination in one field, and collude with them in another (Moncrieffe 2006). The particular discourse I was busy administering represented only one side of the dialectical struggle and one voice in the dialogic story. The other side was variously expressed and enacted by my co-participants as agents of a local street culture partially constructed from a re-purposed image and story about them told from above. There was no cultural capital to be earned by my coparticipants expressing feelings of vulnerability among their peers; in fact street culture rewarded interpersonal presentations that flowed in precisely the opposite direction; habitus-based inequalities that found normative expression in values like'swagga', an embodied disposition that aesthetically extended to both the particular brand and relative 'newness' of one's clothes, while asserting one's individuality, independence, self-reliance and, consequently, dignity. Our research space flickered into life for only three hours each week; it was simply too temporary and fragile to nourish a countercultural challenge to the reality produced outside it every day. Consequently, when they did get going, our group discussions were for many weeks filled with cautious generalisations and third-person voices, and our social action project (the documentary film) was stymied by a culture of self-reliance that meant individuals were keen to work alone (preferably on their own ideas), and were reluctant to lead, assume collective responsibilities, and even adopt a specific role within the group effort. Whilst PAR trades on its capacity to deploy multiple and diverse methodologies, many of them purposefully non-scholastic (for example, through use of the arts, oral history and community mapping), this feature alone does not overcome the kind of deficit in personal and collective confidence which profound inter-generational social and economic exclusion will eventually produce. For example, consider the inheritance of a racist discourse, internalised and embodied, that Black men don't do intellectual work. (For an exploration of this discourse and its consequences in a related context see Sewell, 1997). Local street culture, as its dialectical antithesis, had re-claimed this discourse as a site of personal resistance and dignity (synthesis); ascribing status and respect (the principal local cultural capital) to young men who moulded their selfhood to its racialised image of hyper-heterosexuality, physicality, self-reliance, and certain expressions of creativity like musicality and entrepreneurialism. Confidence and self-worth were made possible in and by this identity, but only on these narrow terms. This dialectical call and response, whereby 'through cultural practices of opposition, individuals shape the oppression that larger forces impose upon them' (Bourgois, 2002, p.17), might have been at the centre of our enquiry, but it was also in the room with us. Wacquant (2008) describes this dialectic as 'the objective divisions that pattern social space and the subjective visions that people acquire of their position and extant possibilities in it'(p. 197). For example, the extract below reveals how "staying out of trouble", "thinking ahead", "talking posh" or "doing stuff Black people don't do" is regulated by street culture through the out-group accusation and image of "wash out". In our penultimate session some weeks after the stipend had been discussed and distributed, Tyreese said to the group that he was going to miss meeting every Friday night: "It's good to just chill and talk, it don't ever happen normally. I like it." In the room in the moment, I missed it, but much later his statement on the meaning of our time together (that the value of the project was in the opportunity it provided to relax and reflect) finally penetrated the academic research doxa and came into view; a moment I caught only when I named the guilt I felt reading it backan embodied clue as to the divergence my own priorities had represented and delivered in the project. Confronted by Tyreese's words, I was finally able to recognise and consider that a participatory ethic in these circumstances of exclusion had demanded a radical re-positioning of research, and not, as I had tried to effect, a re-positioning of my co-participants (Reason, 2006). --- ASHLEY -This Consequently, perhaps one of the reasons we often seemed'stuck' in the reflective side of the PAR 'cycle' was because reflecting may have been the most meaningful purpose and outcome of the enquiry to the participants. In this, an alternative image and practice of social research emerges, bottom-up; one that assimilates storytelling, testimonial (Brabeck, 2003), and the remembering and naming of cultural experiences and knowledge (Belenky et al, 1997, Qui<unk>ones Rosado, 2007). In this re-positioned form of enquiry, a group of young men 'whose members have suffered from diminished senses of themselves by virtue of racism and classism', could use the temporary and fragile research space to nurture a shared understanding of themselves (Tuhiwai Smith, 1999, in Watkins andShulman, 2008, p. 276). According to Tandon (1988), this is an image of participatory enquiry with an ancient heritage, a history of ordinary people working together to understand their world, most often orally or through the arts rather than by formal research outputs. Because of this form,'such efforts have been largely unrecognized and delegitimized by those producing knowledge at the dominant centres of societies' (Watkins and Shulman, 2018, p. 270). --- Conclusion (LAWRENCE) "Sayin' people in St Pauls is good or bad isn't breaking it down enough. People can be good and bad. Listen yeah, say if my family ain't got no money to eat and I go out a rob some guy for money to feed my family; am I good or bad? Like, what's more important, feeding my family or not being seen as bad by you?" By way of a conclusion we wish to briefly consider some of the more actionable insights that fall from this experience and analysis. To do this we must begin with a necessary provocation in order to lift the paper out of a preoccupation with itself and a continued collusion with the very academic research doxa we've attempted to describe and de-centre. Because while we have been especially keen to embrace critical reflexivity, we are nonetheless concerned for the ways a self-conscious presentation risks denying and prioritising the suffering delivered into the lives of our young coparticipants. The anthropologist Philippe Bourgois describes this as: 'the profoundly elitist tendencies of many postmodernist approaches. Deconstructionist 'politics' usually confine themselves to hermetically sealed academic discourses on the 'poetics' of social interaction, or on cliches devoted to exploring the relationship between self and other. Although postmodern ethnographers often claim to be subversive, their contestation of authority focuses on hyperliterate critiques of form through evocative vocabularies, playful syntaxes, and polyphonous voices, rather than on engaging with tangible daily struggles. Postmodern debates titillate alienated, suburbanized intellectuals, they are completely out of touch with the urgent social crises of the inner city'(2002, p.14). I walked away from St Pauls each Friday night knowing that Jermaine was going home to care for his depressed mother; that Ashley's mother was exhausted from working double shifts and struggling to find the rent that month; that Lawrence was in mourning for a friend who had killed himself by hanging in the local park; and that Sol (who had initially been keen to join the group) was now in hiding for fear of his life after being accused of a stabbing. I also learned that Ashley gave the stipend to his mother to help her make the rent; that Tyreese gave his to a younger brother for a school science trip, and that Jermaine used his to take some driving lessons on his way to a hoped-for driving job. These tangible actions and what they tell us about the realities and priorities of the material world my co-participants negotiated daily are important considerations in any ethical judgment about my choices, the offer of the stipend, or indeed my co-participants. In their early ideas for the short film, my co-participants wanted to invite those outside their neighbourhood to consider a less binary judgment of their lives and the choices their environment delivered to them -"People can be good and bad". In this same spirit we think they also invite the would-be collaborative researcher to embrace both/and thinking. My co-participants lived lives filled with love, joy and growth as well as want, violence and suffering. They were at times frustrating and flawed; as was I. And each member could be morally sophisticated in their thinking and appraisal of me and the world around them; as could I. The offer of a stipend acted as an inducement to participate in the project. And, given the material difference it made to my coparticipants' options, it was the right thing to do. Finally, one can work in a critically reflexive way that de-centres 'truth' and still say something about a material world that is everyday and tangible in its injustices. A foundational piece of learning from this experience is that the collaborative social researcher cannot hope to engineer another reality where knowledge and power relations will be fixed and can be planned for. Nor should they be seduced by the neatly rendered research write-up, characteristic of an academic research identity, that confers sequential order and clear methodological form but that is not representative of actual experience. As collaborative researchers we must guard against the creation of 'coherence, singularity and closure' where there was none, and avoid creating 'a cosy camaraderie with the reader' in an 'ultimately conservative and uncritical' rendering of the status quo (Stronach & MacLure, 1997, p. 49). Collaborative research is messy, often contingent, rarely emancipatory, and always underpinned by intra-and inter-personal conflict (see Percy-Smith et al., 2019). Critical reflexivity is a basic requirement in this context simply because there are no guarantees for what happens in a process of this kind (Pedersen and Olesen, 2008, Arieli et al., 2009, Olesen and Nordentoft, 2018). Finally, if, as professional researchers, we aim to work in places of significant social exclusion and contribute to a socialisation of meaning that'restores to knowledge its value as the basis of community' (O'Neill, 1972: xi), then we may have to reconsider our minimum expectations of what must be 'done' for an enquiry to count as'research'. For as much as this represents a challenge to our ways of working and capacity for self-reflection and critical insight, it is also a challenge to the professional identity of the academic researcher.

Title Participating in Social Exclusion: a reflexive account of collaborative research and researcher identities in the field Type Article URL https://clok.uclan.ac.uk/34321/ DOI ##doi## Date 2020 Citation Newitt, Simon and Thomas, Nigel Patrick orcid iconORCID: 0000-0002-5310-9144 (2020) Participating in Social Exclusion: a reflexive account of collaborative research and researcher identities in the field. Action Research .

2018). Finally, if, as professional researchers, we aim to work in places of significant social exclusion and contribute to a socialisation of meaning that'restores to knowledge its value as the basis of community' (O'Neill, 1972: xi), then we may have to reconsider our minimum expectations of what must be 'done' for an enquiry to count as'research'. For as much as this represents a challenge to our ways of working and capacity for self-reflection and critical insight, it is also a challenge to the professional identity of the academic researcher.

Title Participating in Social Exclusion: a reflexive account of collaborative research and researcher identities in the field Type Article URL https://clok.uclan.ac.uk/34321/ DOI ##doi## Date 2020 Citation Newitt, Simon and Thomas, Nigel Patrick orcid iconORCID: 0000-0002-5310-9144 (2020) Participating in Social Exclusion: a reflexive account of collaborative research and researcher identities in the field. Action Research .

Introduction Peer-based interventions are a feature of prison health services and there is an established literature around peer education, and to a lesser extent peer support, in the contexts of incarceration. Given the high prevalence of poor physical and mental health in the prison population (Enggist, M<unk>ller, Galea, & Udesen, 2014;WHO, 2008), combined with exposure to risk factors detrimental to health both prior to and within the prison setting (de Viggiani, 2006;Plugge, Douglas, & Fitzpatrick, 2011), interventions delivered by inmates for inmates offer a means to reduce risk factors and improve health for this population. Devilly et al (2005) summarized the value of peer programs in terms of benefits to inmates from accessing credible sources of knowledge and positive role modelling, benefits to peer educators gained through their role, and organizational benefits including increased service capacity as well as the contribution to maintenance of good order in the prison. There are a wide range of peer programs in this heterogeneous field of practice. A survey conducted in England and Wales by the Prison Reform Trust in 2002 found that around 7% of inmates were engaged in some form of peer support. Since then there has been an increase in the applications for peer programs (Edgar, Jacobson, & Biggar, 2011;Snow & Biggar, 2006). The evidence base has grown with a small number of reviews on the effectiveness of peer education (Devilly et al., 2005;N. Wright et al., 2011) and also international comparisons of service provision (Daigle et al., 2007). More recently a large mixed method systematic review, conducted by the authors, assessed the effectiveness and costeffectiveness of peer interventions in prison settings (J. South et al., 2014). This systematic review uncovered a diverse range of peer interventions, including both peer education and peer support as well as other types of peer program. There was considerable variation in terms of intervention mode, health topic, type of setting, target population, and in some cases, theoretical models. Treating the included studies as a homogenous whole would have undermined the validity of the conclusions. Therefore a typology of prison-based peer interventions, accompanied by working definitions, was developed in order to group interventions so that data synthesis could take place (Bravata, McDonald, Shojania, Sundaram, & Owens, 2005). The typology may have wider application in building the knowledge base for correctional health care because it provides a framework for understanding peer programs, their similarities and distinguishing features. The aim of this paper is to present the typology, describe how it was developed and discuss its application and value in differentiating types of peer intervention. The paper starts first with a brief introduction on the concepts of peer education and peer support. --- What is a peer intervention? Peer interventions are based on the principle of homophily and therefore seek to utilize social and communicative processes occurring between those who have similar demographic characteristics or sets of experiences for the purpose of achieving health or social goals (Chiu & West, 2007;Harris et al., 2015). The social influence of peers (Parkin & McKeganey, 2000) forms the basis for development of therapeutic or affirmative relationships that enable health promotion, prevention or care activities to proceed more effectively with a given target population (Dennis, 2003). Reach is a key concept, as network membership offers opportunities to connect with under-served and marginalized communities (Chiu & West, 2007). Peer education and peer support are normally distinguished from each other on the basis of different aims, emphasis and also different traditions. Peer education has been defined as a process of education and information sharing occurring between individuals from the same age group or from similar social backgrounds (Milburn, 1995;Sriranganathan et al, 2010). Various theoretical perspectives have been offered to justify peer education; Turner and Shepherd (1999) listed Social Learning Theory, Social Innoculation Theory, Role Theory, Differential Association Theory, Subculture theories, and Communication of Innovations Theory. In health promotion, there has been a strong critique of peer education in terms of poor application of theory to intervention design and evaluation (Milburn, 1995;Turner & Shepherd, 1999) and lack of definitional clarity over the term 'peer' (Parkin & McKeganey, 2000;Shiner, 1999). There have been questions about whose agendas are being served when peer education is used in an instrumental rather than empowering fashion (Frankham, 1998;Milburn, 1995), a point also made in the context of peer education in prisons (M.W. Ross, 2011). Peer support concerns different forms of support provided and received by those who share similar attributes or types of experience. Dennis (2003), in a key conceptual paper on peer support in health care contexts, built on this definition to argue that peer support involves emotional support, informational support in terms of advice and feedback, and appraisal support facilitating self-evaluation and problem-solving. These facets of support are then applied to help the recipient cope with actual or anticipated stressors. Dennis went on to argue that peer support can lead to better health due to the direct effects of improved social relationships on wellbeing, through buffering mechanisms that enhance coping skills, or through the mediating effects of building self-efficacy and positive reinforcement of positive behaviors. In a realist review of community-based peer support, Harris et al. (2015) concluded that homophily, matching individuals on the basis of shared characteristics, is insufficient, as peer support interventions work best when they promote social interaction that builds trust and bonds in groups and when they give autonomy to peer supporters in how tailored advice and support is delivered. Many of the generalized theories of peer education and support have been applied in the prison literature (see for example Boothby, 2011;Devilly et al., 2005;Snow, 2002); however three points can be made regarding this unique setting. First, peer identities based on shared experience or mutual history of incarceration have been given as a result of coercion not choice. Unlike in civil society where group identities may be hidden or negotiated, incarceration brings a sharp distinction between inmates and prison staff. Second, although peer interventions can reduce barriers to advice and support for inmates (Zack et al., 2004), Ross (2011), drawing on Goffman's notion of the 'total institution' (Goffman, 1961), argued that inmates' lack of agency and resistance to authority can make the delivery of health promotion more difficult as health becomes a 'battleground' where tensions over power and control surface (Ross, 2011p.15-16). Third, peer support can occur through informal networks of prisoners and be a valuable source of assistance without use of formal interventions. Collica (2010) argued that 'prosocial networks' can not only help with adaption to prison life, but also provide a sense of community that may extend on release. Conversely informal peer networks may support risky behaviors through distribution of contraband such as drugs or result in some inmates being socially isolated or bullied (Wheatley, 2007). --- Developing a typology for peer interventions As discussed above, the typology was developed as a framework for categorizing formal interventions as part of a systematic review of the effectiveness and cost-effectiveness of peer interventions in prison settings (J. South et al., 2014). The study used standard systematic review methodology to undertake systematic searching, then to select, appraise and review a total of 57 quantitative, qualitative and mixed method studies reporting health outcomes from peer interventions and one cost-effectiveness study. Results from the review are reported elsewhere, where a full list of included studies can be found (Bagnall et al., 2015). One of the challenges in the review process was dealing with a heterogeneous group of studies that covered diverse intervention types, prison contexts and health topics. It was clear that aggregating all the intervention modes as 'peer-based' would fail to distinguish critical differences in methods; but at the same time an overly cautious approach to grouping interventions would limit the extent to which evidence could be synthesized. Therefore it was decided to draw up an initial categorization framework for intervention modes. These modes would represent the general approach and orientation of interventions and additionally describe the primary role of the peer worker. It was recognized that peer interventions might use multiple methods, such as health promotion campaigns, counselling or advice, within an overall model. Discussion with the advisory and steering groups highlighted the utility of being able to group similar models during the process of synthesis. This was in preference to an alternative grouping of health topics as many interventions aimed at improving general health and reported a range of health and social outcomes. An initial scan of background literature did not identify any existing typologies of peer-based interventions in prisons, although some literature included relevant definitions and also descriptions of types of program found in practice (see for example Daigle et al., 2007;Devilly et al., 2005;Edgar et al., 2011;Levenson & Farrant, 2002). A framework developed from an earlier systematic scoping study on community-based lay health worker roles (J South, Meah, Bagnall, & Jones, 2013) did not provide a sufficiently comprehensive framework to categorize peer interventions within the prison setting. A new typology of peer-based interventions was therefore developed, using existing theoretical and empirical literature, until there was a complete set of definitions for intervention modes covering the included studies in the review. The analytical approach drew on qualitative thematic analysis techniques (Miles & Huberman, 1994), in that initial categories were developed from the literature and refined until the final typology provided the best fit to explain the interventions as reported in the included studies. A staged approach to analysis was adopted: i. Identification of relevant background literature. This included: key papers providing discussion of theoretical or conceptual issues around the nature of peer interventions; theoretical papers offering classifications of peer education and peer support; and publications with description of peer programs in practice. Most of these papers were identified through the review process during initial scoping searches and through contact with experts. ii. All included studies in the review had information extracted on intervention mode, setting and population as part of the review process. Data extraction records indicated where publications contained 'thick' descriptions or definitions of the intervention and also where studies identified the application of a theoretical model. iii. Preliminary definitions of types of intervention were then developed using both background literature and descriptions found in included studies. Some additional literature was identified from reference lists where required; for example, a definition of peer mentoring was sourced through the reference list of an evaluation of a peer mentoring scheme. iv. An iterative process of comparing definitions with reported intervention modes in the included studies was undertaken until the best fit was obtained. Some codes were merged at this stage or defined as sub-categories, for example, specific models of peer support. Where individual studies could not be easily categorized, a brief description of the intervention was given. v. Information on the application of the intervention mode in prison settings was added to the typology to ensure that relevant aspects of program delivery and social context were not lost. vi. The final stage was applying the typology of definitions in coding and grouping studies for the process of review and synthesis. Both the final typology and the categorization of included studies were agreed by all members of the review team. --- A typology of peer interventions in prison settings The --- Peer education Prison-based peer education involves communication, education and skills development occurring between prisoners with the aim of increasing knowledge and awareness or effecting behavior change. This extends the definition of peer education used by Milburn (1995) (Bryan et al., 2006). A number of publications discussed theoretical justifications for peer education in prisons in relation to social influence and reinforcement of positive social norms through peer-based social networks (Bryan et al., 2006;Zack et al., 2004). Risk reduction was a theme around HIV prevention, with recognition of the value of prisoners' experiential knowledge of risk behaviors both inside and outside prison (Collica, 2010;Zack et al., 2004). In the context where functional access to health care in prison might be good, outreach activities were reinterpreted as accessing lay (prison) networks to overcome low literacy and social exclusion (O. A. Grinstead et al., 1999) and improving the credibility of information in the face of resistance to professional advice (M. W Ross et al., 2006). The reach of the peer intervention could extend beyond the immediate target group, as transmission of health messages might occur between prisons as prisoners moved, and potentially further afield to families (Scott et al., 2004). --- Peer support Prison-based peer support involves peer support workers providing either social or emotional support or practical assistance to other prisoners, in line with other forms of peer support in healthcare contexts (Dennis, 2003). Most of the prison peer interventions identified in the review involved peer support delivered on a one-to-one basis in response to prisoner needs or through informal social networks. In contrast, a minority of peer support interventions involved group work, such as self-help groups on substance misuse (Levenson & Farrant, 2002). While the basis for most prison peer support is forming supportive relationships in the context of stressors created by the experience of incarceration, roles can encompass counselling, listening, befriending, carrying out domestic duties for other prisoners (for example fetching meals), liaison with prison staff, translation, providing basic information and signposting to other services (Edgar et al., 2011;Stewart, 2011). A range of peer support interventions involving the provision of emotional support to alleviate stress were identified. The review found two programs used a similar model specifically targeted at suicide and self-harm prevention; the Listener scheme (Davies, 1994;Dhaliwal & Harrower, 2009;Foster, 2011;Richman, 2004;Snow, 2002) and SAMS (Samaritans of Southern Alberta) (Hall & Gabor, 2004). The Listener scheme is a prison suicide prevention scheme that has been widely adopted in adult prisons in England and Wales (Davies, 1994); and in 2006, there were an estimated 1400 Listeners (Snow & Biggar, 2006). The Samaritans, a national mental health charity, select, train and supervise volunteers who then provide confidential emotional support to fellow prisoners who are experiencing distress (Edgar et al., 2011). The review found two other interventions that were focused on the alleviation and prevention of mental distress. The Peer Support Training (PST) program, Canada, was implemented across a number of women's prisons and was described as being based on a holistic, women-centered approach to health care that aimed to be culturally sensitive and to develop the women's autonomy and self esteem (Blanchette & Eljdupovic-Guzina, 1998 A small group of studies (n=3) on prisoner volunteers in US prison hospices was identified in the review (Cichowlas & Chen, 2010;Maull, 1991; K. N. Wright & Bronstein, 2007a, 2007b). Prison hospices were described as being based on a concept of providing a 'decent prison' which entailed maintaining terminally ill prisoners' humanity and dignity (K. N. Wright & Bronstein, 2007a). Prison hospice volunteers worked within a wider multidisciplinary team to provide companionship, practical assistance and social and emotional support to terminally ill patients (K. N. Wright & Bronstein, 2007b). The review found that theoretical justifications for peer support related to the buffering effect against stressors (Dennis, 2003) and the mitigation of mental health risks associated with incarceration and the removal of the prisoner from their normal social networks (Boothby, 2011;Snow & Biggar, 2006). Many of the interventions also combined emotional support with instrumental support, that is practical assistance and care (Ferlander, 2007), for example Insiders (Boothby, 2011) and prison hospice care (K. N. Wright & Bronstein, 2007b). --- Peer mentoring The process of mentoring describes a relationship between two individuals, one of whom acts as a role model and supports the personal or professional development of a mentee (Finnegan, Whitehurst, & Deaton, 2010;Jolliffe & Farrington, 2007). Peer mentoring in a prison setting involves the establishment of affirmative relationships between individual prisoners and ex-prisoners, usually with the primary purpose of guiding personal development and supporting successful transition through release. There is an established literature on peer mentoring in the criminal justice system, where interventions are primarily focused on social goals such as resettlement, social inclusion and prevention of reoffending (Jolliffe & Farrington, 2007;Tolan et al., 2013). The review identified a small number of Scotland involved ex-prisoners or those with history of addictions as life coaches who met prisoners in the prison setting and also outside the gate to allow some continuity of support (Schinkel & Whyte, 2012). --- Bridging roles Bridging roles occur where lay health workers act as cultural connectors in improving access to information, support and health services for underserved communities (Rhodes, Foley, Zometa, & Bloom, 2007). In the review, two distinct interventions were identified where peer workers acted as cultural connectors and where signposting to other services was a major component. Both interventions also had a strong element of informational peer support and were explicitly focused on reducing inequalities. Prison health trainers worked with other prisoners to motivate and support them to adopt positive health behaviors, for example healthy eating or better stress management, and provided information on other health services (Brooker & Sirdifield, 2007;Sirdifield et al., 2007). The role was adapted from a public health initiative, introduced over a decade ago in England, to reduce inequalities by recruiting lay health workers from disadvantaged areas to support individuals around health behavior change (White & South, 2012). Prison health trainers received formal training on health promotion, communication skills and mental health, adapted from a standardized competency framework (Sirdifield et al., 2007). Like the wider health trainer service, a major objective was increasing the skills, qualifications and employability of those who took on a peer worker role. The peer advisors program, also a UK initiative, was focused on housing advice within prison and also during and after release (Boyce, Hunter, & Hough, 2009;Hunter & Boyce, 2009). Peer workers assessed housing needs of new prisoners or those due for release, helped with accommodation and welfare payments, and signposted to other sources of help. Like health trainers, there was a formal qualification and a focus on the personal development and post-release employment of the peer workers. --- Other peer models The review confirmed that this field of practice is diverse with peer interventions being adapted to a range of contexts and populations. It was not possible to categorize four interventions because they had very distinctive components or deviated from existing models in significant ways that were assumed to affect the way the intervention worked. For example, the 'Alternatives to Violence Project' used a specific cascade training model that involved peer education combined with prisoner involvement in project management structures (Walrath, 2001). Another study reported on the peer counsellor role as one component of a formal substance abuse treatment program linked to spiritual care (Chen, 2006). Two interventions, one focused on harm reduction and the other on suicide prevention, had some similarities to peer education and peer support interventions respectively; but the roles described were not sufficiently aligned to justify grouping them with existing models. Peer observers in the suicide prevention initiative watched prisoners who were at risk of suicide, but did not take on the more active peer support aspects of Listeners (Junker, Beeler, & Bates, 2005). A Moldovan harm reduction program had a single focus on improving access to health resources using prisoners to distribute condoms, needle exchange supplies and information booklets (Hoover & Jurgens, 2009). It was possible informal peer education occurred alongside the distribution activities; but this was not the focus of the intervention. Therefore it could not be categorized as peer education. --- Discussion Peer-based interventions are complex interventions with a number of inter-related components relating to the selection, preparation and supervision of peer workers, their subsequent roles in care or prevention and the nature of interactions with the target population. The typology presented here provides a framework for categorizing interventions reported in an international literature and describing, where possible, their main features and theoretical underpinnings. It cannot be viewed as a comprehensive classification or taxonomy, nonetheless the typology does provide a means of distinguishing different intervention modes within a transparent framework related to the prison setting. This builds on earlier work, published more than a decade ago, that described existing models in practice (Devilly et al., 2005;Levenson & Farrant, 2002). While a previous systematic review highlighted the role of peer education (N. Wright et al., 2011) The typology describes four major intervention modes that utilize the social influence brought by peers. Prison is evidently a unique setting but peer education and peer support draw on a set of justifications and principles of design that have a long history in health promotion and healthcare contexts (Dennis, 2003;Milburn, 1995). Similarly, prison peer mentoring fits within a wider field of mentoring (Jolliffe & Farrington, 2007;Tolan et al., 2013). What appears critical in the context of correctional health care is the significance of peer identity for a population that is marginalized and experiencing barriers to good health. Justifications for peer education relate less to traditional notions of'reach', but to credibility and tacit knowledge (Zack et al., 2004) and, for peer support, the ability to empathize with those experiencing stressors generated by incarceration (Boothby, 2011;Snow & Biggar, 2006). This mirrors the conclusions of Harris et al (2015) that effective community-based peer support requires peers to share experiential knowledge as equals and to form social groups and bonds. A further issue is limits to confidentiality which vary depending on legal jurisdiction and may affect the application of peer mentoring. In the USA, there are clear guidelines on privacy through the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule, which means it may be unsuitable for non-medical professionals (peers) to be involved in the support or management of prisoners with specific health conditions for fear of breaching individuals' health status (Barraza et al., 2015). In other countries, peer workers may be able to speak confidentially with other prisoners, but may face pressure from staff to disclose the nature of their contact (Jaffe, 2012). --- Limitations The typology was developed from a systematic review of quantitative, qualitative and mixed methods studies (J. South et al., 2014) as a heuristic tool to help categorize studies so appropriate synthesis could occur. The systematic review process included systematic searching and selection; and non-evaluative studies were excluded due to the focus on effectiveness. This meant that additional literature had to be sourced to build the typology and this literature was not selected in a systematic fashion, more in the manner of purposive sampling to gain further illumination where gaps in descriptions existed. A non-linear, iterative approach to literature searching is advocated by Finfgeld-Connett & Johnson (2013) for qualitative reviews that build knowledge or generate theory as opposed to assessing effectiveness. The final typology was refined through to an inductive process of defining, checking and sorting until saturation was reached and categorizations stood. The typology was developed from the 57 included studies in the main effectiveness review. It is likely that a scoping review (Arksey & O'Malley, 2005) that took a more inclusive approach to searching and study selection would have uncovered further types of peer intervention in prison settings. The majority of interventions described in the typology worked with male, adult prisoners (one exception being the Canadian PST program) and more research is needed to examine the application of peer programs for young offenders and female inmates. The research team were keen to gather grey literature through contacts with experts and practitioner networks in the UK (Woodall, South, Dixey, de Viggiani, & Penson, 2015) as there was an assumption that some interventions would not be reported in the formal academic literature. Grey literature can broaden evidence sources (Bravata et al., 2005); however it can also be context specific and it was not possible to extend that search into other countries. Contact with international networks would have generated additional interventions as this is a heterogeneous field of practice. There is undoubtedly scope for more international comparisons about interventions and practice. The sampling bias towards UK and also North American peer interventions is a major limitation of the typology. There are a number of potential explanations for the geographical spread and dominance of certain types of interventions which could affect transferability and generalizability. Whether and how peer interventions are implemented will reflect differences in legal systems between countries, differences in penal policy, types of institutions and the demographics of prison populations, and differences in the practice of correctional health care and the organization of health systems more broadly. Despite similarities between several UK and non-UK peer support interventions, it cannot be assumed that specific programs presented in this paper are widely implemented. An international task force on suicide prevention in prisons compared eight countries and found marked differences in policy and practice as to whether peer programs were used (Daigle et al., 2007). The typology may also reflect publication bias, including country or language bias (Song et al, 2010), as well as variations in research capacity and funding between countries that influence whether intervention studies are undertaken. Overall more research would be needed to test the transferability of the typology, particularly within countries and settings not well represented in the prison literature. --- Potential applications By defining the main features and identifying underpinning theories of different peer intervention modes, the typology offers a platform for further research and theory development. This is a diverse field of practice and interventions need disaggregating if conclusions are to be drawn about their effectiveness and appropriateness. Bravata et al. (2005) identify the development of standardized definitions of concepts as a core strategy to deal with a broad-based literature. Where detailed accounts of intervention components were reported, as was the case with some of the peer education programs aimed at HIV/AIDS prevention, this allowed for meaningful evidence synthesis between interventions (Bagnall et al., 2015). Conversely, many studies did not report in detail how interventions worked; and fewer still used any explicit theoretical models. The typology provides the basis for developing more sophisticated logic models (Baxter, Killoran, Kelly, & Goyder, 2010) (2011) argue that there need to be many more opportunities for prisoners to undertake active citizenship roles, such as peer support, that might be of benefit to them and others. --- Conclusion The typology presented in this paper provides a framework to map and understand the range of peer interventions in prison settings and the major modes: peer education, peer support, bridging roles and peer mentoring. This typology was developed as a part of a systematic review; and although it is not a definitive list of peer intervention types, a number of specific models from North America and from the UK are identified. It is important to recognize the heterogeneity of peer-based approaches. Not only is there a spread of health topics from mental health issues through to communicable diseases, there are also differences in intervention design, modes of delivery and theoretical underpinnings. One conclusion of this paper is that aggregating peer approaches as a single method is not justified and over simplifies what is evidently a rich and diverse set of practices in health care and prevention. The --- Sifunda, S., Reddy, P. S., Braithwaite, R., Stephens, T., Bhengu, S., Ruiter, R. A., & van den Borne, B. (2008). The Effectiveness of a Peer-Led HIV/AIDS and STI Health Education Intervention for Prison Inmates in South Africa. Health Education & Behavior,35(4), 494-508. doi: 10.1177/1090198106294894 Sirdifield, C., Bevan, L., Calverley, M., Mitchell, L., Craven, J., & Brooker, C. (2007). A guide to implementing the new futures health trainer role across the criminal justice system. Lincoln: University of Lincoln. 2 studies (4%) -UK

Peer interventions delivered for prisoners by prisoners offer a means to improve health and reduce risk factors for this population. The variety of peer programs poses challenges for synthesizing evidence. This paper presents a typology developed as part of a systematic review of peer interventions in prison settings. Peer interventions are grouped into four modes: peer education, peer support, peer mentoring and bridging roles, with the addition of a number of specific interventions identified through the review process. The paper discusses the different modes of peer delivery with reference to a wider health promotion literature on the value of social influence and support. In conclusion, the typology offers a framework for developing the evidence base across a diverse field of practice in correctional health care.

Introduction In many countries, COVID-19 national lockdowns have been the most profound, deep reaching, and significant public health interventions within living memory. Fig 1 provides a logic model describing a high-level overview of lockdown as a complex public health intervention. It shows a range of key contextual elements important to understanding the situation in which lockdown has taken place and it shows the central problem that initial lockdown was intended to resolve (i.e. exponential transmission of. It also highlights the complexity of lockdown as a public health intervention, with multiple, interdependent components, cumulatively working through varied and intersecting mechanisms to elicit a range of intended and unintended positive and negative changes. Within Scotland it is clear that the initial national lockdown intervention succeeded in relation to its primary goal of reducing the exponential transmission of COVID-19 and achieving its intended positive health outcomes (see Fig 1). Similarly, as had been anticipated, lockdowns have led to unintended and negative health consequences. For example, there is emerging evidence concerning the amplification of pre-existing health inequalities [1][2][3], both overall [4,5], and in sub-population specific groups [6] (e.g., among Black, Asian and minority ethnic (BAME) groups, those experiencing socioeconomic disadvantage, and the unemployed). Evidence also suggests a worsening of mental health in adults [7,8] and children [9], along with increases in loneliness and isolation [10][11][12]. Broader impacts on family functioning [13], loss of economic productivity [14], and education [15], including the gendered burden of home schooling have also been reported [16]. In contrast to the emerging evidence of the unintended negative effects of a national lockdown, here we report emerging evidence concerning unintended positive changes. Taking a salutogenic approach which focuses on the factors that support and promote health during stressful conditions [17], we examine the positive adaptation and growth experienced by some individuals. Using cross-sectional data from an online survey, the key objective of the current study is to examine the social patterning of the positive effects of lockdown across a range of domains. Given the large corpus of work concerning the role of structural social factors such as poverty, racism, gender and age in explaining health and illness we hypothesised that our findings would be shaped by these classic determinants of health. --- Method --- Participants and procedure Data collection took place for 23 days from 20 th May 2020 to 12 June 2020, spanning the 9 th to the 12th week of national lockdown in Scotland. This national lockdown period was part of the UK-wide national lockdown that commenced in March 2020. The advice during national lockdown was to'stay at home' and people were told to work from home wherever possible and to only leave their homes for essential purposes. These essential purposes included leaving home for food shopping, for medical purposes or to provide care for a vulnerable person. People were also allowed to leave home for one form of exercise each day. The target population of the survey was adults, aged 18 years or older, currently residing in Scotland, who were interested in sharing their experience of positive change. Participants were primarily recruited through social media advertisements on Facebook and Twitter which directed participants to the online survey on Qualtrics. All materials and procedures were approved by the Ethics Committee of the University of Strathclyde and all participants gave informed consent. The present sample comprised 3342 participants. Participant characteristics are shown in Table 1. --- Measures Sociodemographic and health variables. Participants provided sociodemographic and health data on the following variables: (1) gender, (2) age (18-24, 25-34, 35-49, 50-64, 65+), (3) relationship status (single, married/living with partner, living apart from partner, separated/divorced/widowed), (4) ethnicity, (5) education (high school, college, undergraduate, postgraduate), (6) annual household income (<unk>£16,000, 16,000-29,999, 30,000-59,999, 60,000-89,999, £90,000+) (7) employment status (employed, inactive, unemployed), (8) overall health (very poor, poor, fair, good, very good), (9) risk status for COVID-19, e.g., aged 70+ or have an underlying health condition (yes, no), and (10) COVID-19 diagnosis (yes diagnosed, suspected, don't know, no). Positive changes. We measured positive changes using an expanded version of the positive events subscale of the Epidemic-Pandemic Impacts Inventory (EPII) [18]. We utilised 21 items to assess positive changes that participants may have experienced across a number of domains (e.g., relationships, physical activity, sleep, work). The measure that we utilised can be found via the project's Open Science Framework page https://osf.io/nwh48/. Participants were asked "Since social distancing restrictions were introduced, what has changed for you?" with the response options of "yes", "no" or "not applicable" (NA) across each domain. Example items included "more appreciative of things usually taken for granted", "improved relationships with family and friends" and "increase in exercise or physical activity". A positive score for each participant was computed by scoring 1 for a 'yes' and zero for 'no' on the 21 questions. A total score was computed which comprised of the sum of the 'yes' responses for each participant. This was then converted to a percentage score by dividing the total score by the sum of 'yes' and 'no' responses. NAs were removed from the analysis since individuals could not increase their score by responding to a question which did not apply to them. A higher percentage positive score indicated a greater proportion of positive changes. The scale was found to have good internal consistency (Cronbach's <unk> =.75) in the current study. --- Statistical analysis Exploratory univariate analysis, taking each socio-demographic factor in turn, was performed to determine which factors were associated with the positive change scores. Between group scores were analysed using t-tests or ANOVA. Factors independently associated with positive change were then determined using a multiple regression model with stepwise variable selection in which variables are sequentially entered into the model. All analyses were done using Minitab (version 18) at a 5% significance level (adjusted for multiple comparisons were appropriate using the Tukey method). --- Results --- Descriptive statistics The sample characteristics are shown in Table 1. In addition, a graph of the distribution of positive change scores is shown in Fig 2. Scores ranged from 0-100 with a mean of 47.2% (SD = 20.8). Table 2 presents the proportions of people reporting yes, no, or not applicable at the item level of the positive change measure. From this it can be seen that the positive changes that were most commonly reported were: being more appreciative of things usually taken for granted (82.6%), more time doing enjoyable things (67.4%), more time in nature or being outdoors (65.3%), paid more attention to personal health (61.7%), increase in exercise or physical activity (53.9%), and more quality time with partner or spouse (53.3%). --- Positive change analysis Univariate analyses were used to identify factors significantly associated with positive change with post-ANOVA comparisons where appropriate. Table 3 shows the results. Females reported significantly higher levels of positive change than males. In relation to age, we found that there was evidence of a difference in the mean positive change score between the age categories, with the older age group (65+) demonstrating the lowest level of positive change, and significantly lower than those aged 18-24. Similarly, there was evidence of significant differences in the mean scores across each of the relationship status groups, with those married or living with their partner exhibiting the highest level of positive change. Those in the employed group had higher levels of positive change than those in the inactive and unemployed groups (although the comparison with unemployed was not statistically significant due to the small number in the sample). When considering ethnicity, there was no evidence of a difference in positive change scores when comparing white and non-white participants. Similarly, for education, there was no evidence of a difference between the groups in terms of their positive change scores. For household income, there was no significant differences in positive change scores across the groups. However, there is a notable trend, with positive change score increasing with increasing household income levels. In relation to health, there was a significant effect of self-reported health, with those who reported their health to be'very poor' having the lowest level of positive change and significantly lower compared to each of the other groups (poor, fair, good, very good). In addition, those that reported being at higher-risk of contracting COVID-19 had a significantly lower positive change score than those not at high-risk. Finally, there was no evidence of any difference in positive change scores based on COVID-19 diagnosis. Multivariate analysis utilising stepwise regression showed that age, gender, relationship status, and self-reported health were all significantly associated with positive change. When considering the coefficients (see Table 4), it is shown that males reported a positive change score that was 6.1% lower than females. The older age group (65+) had a positive change score that was 7.5% lower than the younger age group. In terms of relationship status, those who were married or living with a partner had a score than was 3% higher than those who were single. When examining self-reported health, those who were in very poor health had a positive change score that was 24.5% lower than those in poor health, and 29.4% lower than those in very good health. --- Discussion The present study is the first to explore the social patterning of positive changes experienced during COVID-19 national lockdown. Referring back to Fig 1, there is clear evidence that unintended positive change has taken place as a result of lockdown, at least for some groups of the population. The important role of time was highlighted in the positive changes that had been made by the majority of the sample. Lockdown seems to have afforded people with more time to spend on activities they value. For example, the majority of the sample reported that they had been able to spend more quality time with their partner. In addition, participants reported that they had been able to spend more time doing enjoyable things, spend more time in nature or the outdoors, and increase their physical activity. Lockdown also seems to have provided participants with the time to reflect and the majority of participants reported that they were now more appreciative of things usually taken for granted. However, we found evidence of differences in the amount of positive change people had experienced, based on sociodemographic and health variables. Those groups with higher levels of positive change were females, those from younger age groups, people who were married or living with their partner, those who were employed, and those reporting better health. The phrase 'we are all in this together' has been used, both domestically and internationally, throughout the pandemic to highlight the sense that COVID-19 is uniting us in shared experiences. However, there is a growing evidence base on the inequalities associated with COVID-19. Our findings fit within this emerging literature and point to the fact that while some groups were able to take advantage of lockdown as an unexpected opportunity to make positive changes in their lives, other groups were not. Similar findings on the inequalities associated with adverse experiences during lockdown have been reported [3], with the experience of more adverse events being related to socioeconomic position (consisting of household income, education, employment status, and housing). In addition, research on the experience of adverse mental health during COVID-19 has also shown the frequency of abuse, self-harm and thoughts of suicide/self-harm to be higher among women, BAME groups, those who were unemployed and those in poorer physical health [5]. Complementing this work, we also find that the experience of making positive changes in lockdown is shaped by many of these key sociodemographic factors. Together these findings indicate the enduring nature of health inequalities and evoke key concepts from complex adaptive systems perspectives within public health [19,20]. Despite the enormity of structural and social change that the national lockdown brought, there appears to be no sense of reaching a 'tipping point' in which the self-organising system that drives inequalities was radically disrupted or dramatically changed. In fact, emerging evidence suggests the opposite, there is clear evidence of negative feedback loops ensuring the system returned to stasis, reiterating inequalities along very familiar lines across a broad range of outcomes, for example, COVID-19 related morbidity and mortality, in addition to positive and negative psycho-social change. We believe that our study is the first to report on the social patterning of positive changes during a period of COVID-19 national lockdown. The study also has the strength of a large sample size, and the inclusion of a wide range of sociodemographic factors. However, there are limitations. Most notably, as our participants were primarily recruited from social media our sample is not nationally representative of the Scottish population. In particular, in comparison to Scottish census data it is clear that we have an over-representation of female participants and those educated to University level. However, the sample has a good age distribution and the ethnicity and household income levels of the sample is broadly reflective of the Scottish population. A further consideration relating to recruitment via social media is that we may have reached a different type of participant than if we had been able to employ more traditional recruitment methods. However, as the study was conducted during national lockdown, we were restricted in the recruitment methods that were available. In addition, the sampling method employed was purposive. Participants responded to study adverts which asked them to share the positive changes they had made during lockdown. We used this sampling strategy deliberately as we wanted to recruit participants who had experienced positive change in order for us to examine the processes behind these positive experiences. However, the amount of positive change being reported by participants in our study may not be typical of the experiences of the general population. In addition, the study is cross-sectional in nature and so provides only a snapshot of the positive changes people were experiencing at a particular stage of the lockdown, and cannot, at this stage, provide data on whether these positive changes were maintained over time. It is also important to consider the that the positive changes experienced by participants within the context of a national lockdown in Scotland may be different from the positive changes that people living in other national lockdown contexts experienced. As noted above, time was central to many of the positive changes that people made. National lockdowns across the board are likely to have afforded many people more time as time commitments such as commuting and many forms of socialising were removed. This extra time is likely to have provided many people with an opportunity to reflect, and as noted by the participants in our study to be more appreciative of things usually taken for granted. In this regard, our findings are likely to be applicable to other national lockdown contexts. However, they may differ from national lockdown contexts where stricter restrictions were imposed on time outdoors and time allowed for exercise. Within the national lockdown in Scotland people were allowed to leave their homes for exercise and many of our participants noted that they had been able to spend more time in nature and had increased their physical activity levels. Indeed, recent research has reported that moderate-to-vigorous physical activity levels increased during the national lockdown in Scotland [21]. These types of positive change would not have been possible in countries with stricter national lockdowns where people were not allowed to leave their homes for exercise. --- Conclusion The present study reports preliminary evidence relating to the social patterning of selfreported positive change during lockdown. The data reported here are part of the larger mixed-methods CATALYST project which seeks to understand how people have initiated and maintained positive change across a number of domains, during lockdown, and as restrictions have been eased. The aim is to share this learning through intervention development work, in order to facilitate positive health change in others. From the results of the current study, we can see that there are sub-populations and communities where it may be particularly important to target these interventions, in order to provide opportunities for health change amongst those who may benefit most. --- All data files are available from the Open Science Framework, http:// doi.org/10.17605/OSF.IO/NWH48 --- Author Contributions Conceptualization: Lynn Williams, Leanne Fleming, Madeleine Grealy, Xanne

Multiple studies have highlighted the negative impact of COVID-19 and its particular effects on vulnerable sub-populations. Complementing this work, here, we report on the social patterning of self-reported positive changes experienced during COVID-19 national lockdown in Scotland.The CATALYST study collected data from 3342 adults in Scotland during weeks 9-12 of a national lockdown. Using a cross-sectional design, participants completed an online questionnaire providing data on key sociodemographic and health variables, and completed a measure of positive change. The positive change measure spanned diverse domains (e.g., more quality time with family, developing new hobbies, more physical activity, and better quality of sleep). We used univariate analysis and stepwise regression to examine the contribution of a range of sociodemographic factors (e.g., age, gender, ethnicity, educational attainment, and employment status) in explaining positive change.There were clear sociodemographic differences across positive change scores. Those reporting higher levels of positive change were female, from younger age groups, married or living with their partner, employed, and in better health.Overall our results highlight the social patterning of positive changes during lockdown in Scotland. These findings begin to illuminate the complexity of the unanticipated effects of national lockdown and will be used to support future intervention development work sharing lessons learned from lockdown to increase positive health change amongst those who may benefit.

Note on Transliteration There is considerable confusion about the transliteration of Arabic names. Many people whose Arabic names are mentioned in this paper are known in English-language publications by names with self-chosen spellings. When applicable, self-chosen transliterations will be used, while placing between brackets the spelling according to the IJMES transliteration system (e.g., Hamdi Zaqzouq [H. amd<unk> Zaqz <unk>q]). Western and Coptic names spelled in Arabic should not be transliterated and are provided in their common spellings. --- Introduction The paper discusses how interreligious dialogue can be reached through both study and friendship. The paper aims to answer the following questions: How can we expand our own social bubble, see the world from different perspectives, and contribute to interreligious dialogue in social relations and daily life? How did this experience influence religious engagement and activities of the author? To this end, the paper combines a literature review with the author's personal narrative of events that changed his perspectives on truth and spirituality, making him more aware of the commonalities between peoples of different beliefs, and leading him to a lifelong commitment to interreligious and intercultural dialogue in the Netherlands, Israel, Egypt, and the Middle East more generally. The author grew up in a conservative Christian Reformed family in the Netherlands, in a deeply pillarised Dutch society, and experienced its de-pillarisation (the terms pillarisation and de-pillarisation refer to the specific process of modernization of Dutch society). A personal tutor encouraged a life of involvement with different religious communities and meeting with leading religious leaders (Christians, Jews, Muslims) and scholars. This encouragement motivated the author to work in mutual understanding; and reporting about interreligious tensions, while always remaining independent of religious and political leadership. These experiences impacted his personal search from a pietistic orthodox Reformed Christianity to intellectual curiosity in Christianity, Judaism, and Islam (in this order), which influenced his spiritual development. In all three religions, an orthodoxy attempts to address social and political issues, while holding on to revealed truths with claims to the one and only truth, resulting in seeking protection in one's own social bubble, with the possibility that this can develop into fanatism and violence (Goud 2023, p. 52). Many people tend to seek protection in social bubbles with clear cultural or religious boundaries between "us" and "them," believing that "we" are right, and "they" are wrong, and considerable time and energy within these structures is spent on providing a relatively safe space for those with shared outlooks, solidifying shared identities, and providing respite from the challenges of the exterior world (Larson and Shady 2017, p. 3). Building bridges of cooperation needs genuine friendships across the boundaries of these social bubbles. Intercultural friendships are prerequisites for interreligious dialogue that, in turn, are "fundamental to reducing intergroup conflict, fear and prejudice" (Carmichael 2017, p. 28). The first part of the paper discusses the Dutch context and focuses on the Reformed church tradition in the Netherlands, including the orthodox Christelijke Gereformeerde Kerken (Christian Reformed Churches)-in which personal piety and ethics play a big role and the author grew up. The Gereformeerde Kerken in Nederland (Reformed Churches in the Netherlands) and Vrije Universiteit Amsterdam (Free University Amsterdam), founded in, respectively, 1886 and 1890 by Rev. Dr. A. Kuyper (1837-1920) in opposition to liberalism, became overwhelming liberal over time, with theologian Harry Kuitert (1924Kuitert ( -2017) ) as a major exponent of liberal theology and philosopher Sander Griffioen (b. 1941) as an exponent of orthodox Reformed thinking, both teaching at the Free University Amsterdam. Kuitert, his student Goud writes, was 'combative' in not wanting to accept handed-down truths from previous generations without searching and believed his faith had to be based on openness, personal convictions, and experiences which made him depart from traditional truths, insights, and teachings (Goud 2023, pp. 18-19, 39) which clashed with the proponents of orthodoxy due to different presuppositions; human logic versus human logic with divine inspiration. Griffioen has been a lifelong member of the Vereniging voor Calvinistische Wijsbegeerte (Society for Calvinist Philosophy), which influenced many Christian thinkers opposing religious liberalism. Liberalism changed the traditional notions of personal piety. Secular philosophies, including nationalism came up and merged in religious societies with personal religious convictions, creating new boundaries to "the other." After an overview of debates in the Netherlands, the debates between orthodoxy and liberalism in Israel and Egypt are discussed since these are the countries the author lived most of his life and engaged in local debates that involved Judaism, Christianity and Islam. In his personal account (Sections 7 and 8), the author explains how political events, social changes, including the debate between orthodoxy and liberalism, and experiences of interreligious engagement in the Netherlands, Israel and Egypt have exerted an impact on interreligious dialogue. Both literature and personal experiences demonstrate that debates are often clouded by advocacy and self-defensive stances which complicate the road towards mutual understanding. In the conclusion, the author explains what lessons have been learned. --- Social Bubbles: The Balancing Act between the Search for Protection and Dialogue Cultural differences help us to distinguish between "us" and "them" which is the basic characteristic of a social bubble. Culture, Kuitert writes, can be described as a way of life that people share with others, both spiritual and material, that developed in time and place. Religion is part of culture that seeks the anchoring of religious certainties that explain human experiences, like joy, fear, and pain, that all humans share and, in religious universities with a focus on strengthening the faith of one religion. This includes Christian theological universities worldwide, but also such a venerable institute as al-Azhar, the main centre for teaching Islam in Egypt, with a strong international focus since one finds here Muslim students from all over the world. Within the "Christian" language, we find a multitude of differences. Anglican Archbishop Rowan Williams writes that the overarching unity of all Christians is that they all interact with canonical texts that are compiled in the Bible, either through reading it or having the text read and explained to them. All Christians interpret these texts within their historical and cultural context, resulting in different ways of interaction, shaping patterns of worship, teaching, and ethical discourse (Williams 2017, p. 29). In the same vein, we see a multitude of differences in the "Jewish" and "Islamic" languages. The term "fundamentalism" is problematic since both the media and politicians have, in the case of Islam, associated fundamentalism with such labels as extremism, violence, and terrorism (Khatab 2011, p. 17). Such labels are associated to ideological biases, Catholic Sufi-Islam expert Giuseppe Scattolin (b. 1942) states, arguing that historical facts always need to precede ideological arguments. A first requirement in dialogue is using the same terms for the same realities across religions (Scattolin 2020). Both orthodox and fundamentalists, Kuitert explains, believe their scriptures are revealed by God and believe they know what God's will for humanity is. Larson and Shady bring in the category of religious exclusivists, those who believe that their religion is the only way to God. Orthodox believers are usually exclusivists, but are often able to present their faith in humility and make practical compromises without giving up basic tenets of faith. Fundamentalists, however, resist religious change, refusing to compromise because compromises mean relativity (Kuitert 1994, pp. 86-87;Pronk 2006, p. 43;Larson and Shady 2017, pp. 12-13). Orthodoxy can change. Their desire to stick to the truth of their forefathers is not immune to changes that have become unavoidable, with migration and modernised communication making our world increasingly diverse and interconnected with religious identities that are continuously in flux (Venter 2018, p. 72). Fundamentalism has a definite negative connotation in the West. Australian Muslim scholar Sayed Khatab (b. 1950) explains this is very different for Islam since knowing the fundamentals of one's religion is honoured. Several scholars describe Islamic fundamentalism as a combination of Islamic devotion and political activism, often linked to revivalism in the light of Western political and cultural dominance. Muslim fundamentalists believe religion is flexible and has something to offer all generations. Khatab explains that Islamic fundamentalism is not necessarily radical or reactionary, and in no way does it inherently lead to violence and terrorism (Khatab 2011, pp. 14-19). Khatab's definition of fundamentalism matches Kuitert's definition of orthodoxy, while Khatab's concept of'reactionary' matches fundamentalism. This paper will, therefore, speak about Islamic orthodoxy or conservatism instead of fundamentalism, unless a refusal of compromising is at play. Also, extremism and terrorism need to be explained. Dutch historian and terrorism expert Beatrice de Graaf (b. 1976) explains terrorism as the outcome of seeing life as a struggle between good and evil, with extremists seeing themselves in the centre of that struggle to influence history (de Graaf 2021, p. 13). Acceptance of difference, between adherents of different religions and within religions, cannot be separated from building friendships beyond our social bubbles and is a prerequisite for interreligious dialogue. The goal of interreligious dialogue is to become "theologically bilingual," understanding the language of another faith community in the broadest sense. This includes understanding people with both orthodox and liberal views. Religious convictions of the other need to be taken seriously, which means that we have to accept that civil life includes various religions and beliefs (Larson and Shady 2017, pp. 8-9;Kuitert 1994, p. 58). Anna Wilson, senior program coordinator at CollegePoint (USA), highlights three essential virtues for effective interfaith engagement: receptive humility, reflective commitment, and imaginative empathy. Receptive humility means acknowledging the limitations of our own religious views. This can be difficult when it comes to doctrinal beliefs and is a challenge for anyone convinced of the "absolute and final truth" of one's own convictions. Seeing that we often seek fault in others' religious beliefs and instead should engage in open questions is the beginning of humility. In reflective commitment, we need to put all beliefs on the table and apply Socratic scrutiny and rigorous critical thinking. It should be possible to admire an aspect of another religious tradition without weakening our commitment to our own. Receptivity may lead us to change own views and assumptions. In imaginative empathy, we learn intellectually about another religion and its adherents, as well as display a willingness and make sincere efforts to penetrate into the religious mindset of the other and understand the other from within. We need to understand before we criticize, and when we criticize, we need to be informed. Critique should be rooted in "factual truth." The virtues of humility, reflective communication, and imaginative empathy can only mature in the context of face-to-face encounters and budding relationships with real religious others (Wilson 2017, p. 106). American astronomer Carl Edward Sagan (1934Sagan ( -1996) ) adds that we only can understand the social reality around us through "a set of successive approximations." Continuous research into our own recent or more distant past can improve our self-knowledge (Sagan 1996, p. 254). In opening our social bubbles, we should take both factual truths and faith seriously, which is the opposite of avoidance. Reducing all traditions to their lowest common denominator of shared values is such a strategy (McNeal 2017, pp. 74-96). Many strong believers in a particular religion believe that interfaith dialogue creates a risk for participants, but this does not need to be the case, Amber Hacker of Interfaith Youth Core (USA) argues (Hacker 2017, pp. 71-73). Another major misconception is that many people engaged in interreligious dialogue believe religious exclusivists should be excluded, but they too should be invited to participate since exclusivist beliefs can still be held with humility and an awareness of one's own fallibility (Larson and Shady 2017, p. 13). Griffioen states that dialogue only can succeed if interlocutors are able to depend on each other's sincerity and the integrity of each other's convictions. In dialogue, he writes, we also need to be able to talk about inconsistencies and contradictions in the precious convictions we hold. We need to be able to see things we believe to be evident, but that belongs to the category of presuppositions (Griffioen 2022, p. 73). McNeal provides a model for interfaith engagement, based on Jewish philosopher Martin Buber and Croatian theologian Miroslav Volf (b. 1956), and calls this inclusion, respect for interpersonal and intellectual boundaries, promoting a shared reality where all partners in the dialogue seek to understand each other's position, even if they do not entirely agree with it. We best come to understand ourselves in dialogical relationship with the other. Inclusive dialogue is described as the effort to seek "to break down boundaries and develop deep relationships with other people and with things that others have created, such as texts and works of art." It greatly helps if people of different faiths experience mutual events. Every religious believer should be able to share his or her own truth and understand other people's efforts to interpret their scriptures. The person engaged in dialogue should be able to both learn and teach, which results in genuine friendships that provide the most "concrete and reciprocal" experience of inclusion. Martin Buber made a sincere effort to practice the inclusive approach in the dialogue between Jews and Arabs, who dispute the right to the Holy Land on foundationally different views. Buber does not present a theory for how to evaluate the truth of competing views, nor does he argue that the truth of one's view is irrelevant. He, however, argues that in friendship, we do not seek to impose our ideas on others, including our religious beliefs. In this process of dialogue, we should be able to become an advocate for the other in his fight against religious prejudice. This includes Islamophobia that is often fuelled by inaccurate representations of what it means to be a practicing Muslim. If a person has had no meaningful interaction with Muslims, he/she may easily succumb to inflammatory anti-Muslim sentiment (McNeal 2017, p. 88). One may add anti-Semitism and other efforts to provide a distorted view of people different from us. The authors of From Bubble to Bridge are working with university students. College years are a critical time for examining deeper faith, as the intellectual life of the student is also maturing. Openness to pluralism and diversity needs to result for a Christian in an ecumenical orientation. Learners view humble, authentic, and appropriately self-revealing teachers and facilitators as trustworthy. When difficult topics are encountered, we need to look first at what we have in common (Poppinga 2017, p. 123) Fear, ignorance, and misunderstanding are too often leading to isolationist policies, hateful speech, and even violence. Interreligious dialogue will inspire us to be good neighbours by replacing fear with empathy and love (Larson and Shady 2017, pp. 182-84). --- The Split of the Dutch Reformed Bubble: Orthodox and Liberal Do social bubbles provide protection? The orthodox Reformed believed so, but saw their part in society shrinking, often blaming people with liberal theological views for causing secularisation. Religious liberals, in turn, believed the orthodox were to be blamed for holding on to certainties that violate science and human reasoning, and saw this as a major reason for people leaving the church. We will see how this worked out in the struggle between the orthodox and liberals in the Netherlands. Griffioen defines faith as a commitment to religion. True faith, Griffioen argues, is given by God and lives in us, as the New Testament says. Religion leaves human freedom in place. It is always possible to say no (Griffioen 2022, pp. 46-47). This definition is related to Griffioen's faith in the Bible as inspired by God. Griffioen's views are in line with classical Reformed faith, while Kuitert came to see all religions as a human construct (Pronk 2006, pp. 7, 12). I have chosen to contrast Reformed orthodoxy with the theologically liberal views of Kuitert because both are clear about their presuppositions. Furthermore, Kuitert was highly influential. He used his life after his pension in 1989 to search into what faith really is, using scientific knowledge and logic as his primary tools to separate facts from imagination. In the past, many believers, he found, blurred these two domains. Logic, however, teaches us that we should treat imagination and reality as two distinct domains (Pronk 2006, p. 144). The growing resistance of Kuitert to orthodoxy and vice versa cannot be explained without a brief history of the Dutch Reformed tradition that stems from the Nederduits-Gereformeerde kerk (Dutch Reformed Church), formed in 1579 as a state church during the war of independence from Catholic Spain that became known as the Tachtigjarige Oorlog (Eighty Years'War, 1568' War, -1648)), and became the dominant provider of collective morality in the Netherlands (a formulation borrowed from Wallet 2021, p. 5). The Dutch Reformed Church accepted the Belgic Confession of 1561 that states in article 36 that the government's task is to promote church services and remove and destroy false religions. 1 This Confession is, until today, part of the confessional documents of the different Reformed churches in the Netherlands. It is even referred to in article 1 of the program of principles of the Staatkundig Gereformeerde Partij (SGP, Reformed Political Party), formed in 1918. The Dutch Reformed Church was deeply influenced by the theology of John Calvin, who desired a theocracy, cooperation between the church and government without government interference, in issues of faith of the church. 2 During the 18th century Enlightenment period, ideas about human autonomy; observing the world with our senses; and independent scientific reasoning, without belief in the moral codes provided by God through revelation, were promoted, resulting in fierce Reformed resistance to these new ideas (Buisman 1992). Yet, the republic abolished the state church in 1795 that was renamed Nederlandse Hervormde Kerk (Netherlands Reformed Church). The influence of the Reformed Church on public affairs further declined with the constitution of 1848 and the restoration of the Roman Catholic hierarchy in 1853. The church had not only lost influence over the state, but also faced divisions between liberal and orthodox streams, resulting in multiple splits and unifications since the 19th century that gradually reduced the orthodox stream, despite all efforts to keep the faith, to a ever declining minority. In 1834, the first conservative secession from the Netherlands Reformed Church took place. The secession of 1886, led by Rev. Dr. Abraham Kuyper (1837-1920), was the largest, taking with him around 10% of the members of the Netherlands Reformed Church, resulting in the formation of the Gereformeerde Kerken in Nederland (Reformed Churches in the Netherlands). Some of the secessionists of 1834 joined Kuyper's church, while others remained independent and in 1892 formed the more conservative Christelijke Gereformeerde Kerken (Christian Reformed Churches) (van't Spijker 1992). The church secessions in the Netherlands became, because of the large numbers of people following them, a mobilising force for political action. In 1879, Kuyper formed the Anti-Revolutionary Party (ARP) to oppose the dominant liberal politics of his days. The name 'anti-revolutionary' expressed resistance against 'ni Dieu, ni maitre' (no God, no master), the motif of the French Revolution (1789-1799) (Goudzwaard 1979, p. 59). Kuyper also established the Free University Amsterdam, schools, and other organisations on a Reformed basis, which aimed at creating safe places or bubbles that greatly reduced contacts with people outside their circle, which created the Reformed pillar, in which members of all Reformed churches cooperated. The Catholic pillar developed in the 1890s when they clashed with the liberals over government funding for religious schools, in which they found an ally in the ARP. In 1904, a Catholic party was founded. Political cooperation with the Catholics, along with other issues, split the ARP in 1908 and resulted in the more conservative Christelijk Historische Unie (CHU, Christian Historical Union). The second breakaway, with conservative members from both ARP and CHU, resulted, in 1918, in the staunchly conservative SGP party. The system that developed became known as'verzuiling' (pillarisation). 'Zuilen' (pillars) were the names given to extensive networks of similar-minded organisations with broad claims on the identity of their members. Members of a pillar placed a strong emphasis on relations within the own group, resulting in a sharply separate life and worldviews that resulted in Reformed, Catholic, socialist, and 'neutral' pillars (van Dam 2014, p. 33). Kuyper developed the concept of societal'soevereiniteit in eigen kring' (sphere souvereignty), with each sphere or sector responsible for its own activity area. The created order includes the family and communities for education, worship, and many other areas of life. The state should not interfere in these spheres, but focus on public justice. These ideas were further developed in the Vereniging voor Calvinistische Wijsbegeerte (Society for Calvinist philosophy) that was founded in 1935. In 1947, the Society established a foundation for the maintenance of endowed chairs in 'Calvinistische Wijsbegeerte', in 1995 renamed Reformatorische Wijsbegeerte (Reformed Philosophy) at different Dutch universities. Reformed Philosophy rejects the thought that humans can discover the truth through human efforts alone. It needs God's revelation. Calvinist (Reformed) philosophy was popular in the circles of the ARP and other groups that stemmed from this Calvinist political approach (Veerman and Bremmer 1979). Pillarisation was firmly established before the Second World War, but the war, the holocaust, the establishment of the state of Israel, and the cold war marked major changes in American and Western European thinking. With the American support for rebuilding Europe also came American cultural influences. Around 1900, practically all citizens in the Netherlands belonged to a church. This was still the case in 1945, but decline set in after the war. In 1966, 67% of Dutch citizens considered themselves to be members of a church. This percentage has dropped to 30% in 2012 (van Rooden 1996;de Hart 2014, pp. 105-6). Changes are not only about reduced church membership, but people no longer seeing guidance in Christian moral values. In 1979, 43% of respondents to research titled Opnieuw: God in Nederland (Again: God in the Netherlands) saw no connections between their most important values and the Christian faith. The remainder of the people questioned believed their Christian faith contributed to a larger or smaller extent to the values they believed to be important, or they did not know (Goddijn et al. 1979, p. 26). Bart Wallet (b. 1977) describes the processes of 'Verzuiling' (pillarisation) and depillarisation as a historical phenomenon in the Netherlands that explains the demise of the privileged position of organised religion as the main provider of collective morality (Wallet 2021, p. 6) Billy Graham (1918Graham ( -2018) ) witnessed the decline of organised religion in the Netherlands and, in 1954 and1955, organised evangelisation campaigns attracting tens of thousands of people. Other American evangelists also visited the Netherlands, witnessed the changing cultural climate in Europe, and wished to stem the tide (van Mulligen 2014, pp. 44, 55-69). Religious influences did not go one way. Abraham Kuyper's political and theological views and the philosophers of the Society for Calvinist philosophy had a significant impact on the Reformed community in the USA and Canada that, in 1967, founded the Institute for Christian Studies in the Kuyperian stream of the Reformed tradition. 3 All churches were searching to match old church traditions with science and logic, creating a wide diversity in responses. In 1953, the Christian Reformed Synod appointed B.J. Oosterhoff (1915Oosterhoff ( -1996) ) as professor of the Old Testament. He published several studies that were interpreted by the conservative wing of the Christian Reformed Churches for relativising the authority of revealed Scripture and giving in to 'the spirit of the age'. Oosterhoff and fellow professors at the Christian Reformed Theological University in Apeldoorn engaged in a balancing act to maintain unity in the church. At the same time, Evangelism campaigns led to the beginning of a new conservative Christian bubble: at the one hand, the formation of Evangelical churches that attracted members from the traditional Reformed churches, while on the other hand, orthodox Reformed church members created new organisations to protect adherence to the 16th-17th confession documents of the Dutch Reformed Church. In 1966, the magazine Bewaar het Pand was established. Around this magazine a group with the same name was formed. The name refers to the admonition of the apostle Paul's first letter to Timothy 6: 20-21: "Timothy, guard what has been entrusted to your care [read the church]. Turn away from godless chatter and the opposing ideas of what is falsely called knowledge, which some have professed and in so doing have departed from the faith." Not science, but teaching from the Bible, infallible and divine, without allowing text criticism to play a role, needs to have prevalence since this will protect the church from heresy and liberalism. Member churches are held to decisions of the Synod. Members of Bewaar het Pand opposed allowing local churches to appoint women in positions of teaching and leadership in the church, which created deep divisions in the church and a balancing act between the most conservative wing in the church and more liberal-minded churches to maintain unity (de Heer 2000; van Heteren 2022). 4 Other churches saw similar developments, but this did not stop the demise of organised religion, which greatly impacted the leading Christian democratic parties, the ARP, CHU, and Katholieke Volks Partij (Catholic People's Party, KVP), that had dominated politics in the first half of the 20th century. They saw their electorate rapidly dwindle in a very short period. In the elections of 1965, these three parties obtained 76 seats in the Parliament of 150 seats. This dropped to 69 in 1967, 58 in 1971, and 48 in 1972. The decline continued after the merger with only 15 seats in 2021. The Netherlands transformed from a Christian society to a mostly secular society. In orthodox Reformed circles, one can describe this as a decline of "almost biblical proportions" (Wallet 2021, p. 5). The Dutch Reformed split into two main camps: seeking protection in newly established conservative organisations, while others sought hope in religious liberalism. Many believed in cooperation between Protestants and Catholics, which resulted in 1980 in the ARP, CHU, and KVP merging into the Christen Democratisch Appèl (CDA, Christian Democratic Appeal Party). The ARP believed their members would be able to contribute, with their Reformed vision on politics, in the new party (Veerman and Bremmer 1979). A substantial number of orthodox members opposed the direction party leadership chose and, in 1975, formed the Reformatorische Politieke Federatie (RPF, Reformatory Political Federation). Founding members of the RPF accused the CDA of not resisting the spirit of that time (van Mulligen 2014, p. 72). The split throughout the Reformed ranks was profound. More conservative members of the Reformed churches turned to one of the many organisations in the Evangelical movement, where people believed in the revitalisation of religion based on orthodox religious notions (Vellinga 1995), while the de-pillarisation in the orthodox Reformed churches was slower because of a strong focus on personal principles (van Tillo 2017, p. 98). Once orthodox Reformed organisations such as the Nederlandse Christelijke Radio Vereniging (NCRV, Dutch Christian Radio Association), established in 1924 as a conservative Reformed radio broadcaster, were impacted by liberal Christian views. Criticism of the NCRV resulted in 1967 in the formation of the Evangelische Omroep (EO, Evangelical Broadcasting), which aimed to form a bulwark in the fight against secularisation and provide the good news of the Bible to the widest audience possible, but it yet had to obtain government recognition (Vermaat 2007). Founders, including former Roman Catholic priest turned conservative Reformed pastor Herman Hegger (1916Hegger ( -2012)), were greatly inspired by the campaigns of Billy Graham and other American preachers and saw ecumenism as a threat to the message of Jesus Christ and the foundation of the state of Israel in 1948 as a fulfilment of Biblical prophecies and prelude to the return of the Messiah. The 1967 six-day War between Israel, Egypt, Jordan, and Syria that resulted in bringing large areas under Israeli control were interpreted as God's hand in history (Vermaat 2007, p. 35;van Mulligen 2014, p. 60). A similar dissatisfaction was seen with the Dutch daily Trouw, established in 1943 as a Reformed newspaper, resisting Nazi ideology, in line with the political ideals of the ARP; but, beginning in the 1970s, the publication embraced de-pillarisation (Prenger 2018). Rev. Jan Hendrik Velema (1917Velema ( -2007)), widely recognised as the most influential Christian Reformed theologian after the Second World War and sometimes nicknamed 'the pope' (van Mulligen 2014, p. 84), deplored the departure of Trouw and ARP from their initial conservative Reformed roots and, in October 1968, established Koers that was entirely focused on orthodox Reformed views. Velema joined the EO in 1968 and played a major role in providing the EO with sufficient members that were needed for government recognition (Vermaat 2007, p. 56). The resistance to the liberal developments at Trouw provided in 1971 the impulse to form the Reformatorisch Dagblad (RD, Reformed Daily), a conservative Reformed daily newspaper. The founders wanted to halt the secularisation in their own circles, which was praised by J.H. and his brother W.H. Velema, J.P. Versteeg, and other leading theologians of the Christian Reformed Churches (Roos 1996). Van Tillo (b. 1937) describes the developments leading to the formation of the EO and RD as the rise of restorative or restorationist societal impulses (van Tillo 2017, pp. 96-97). The term'restorative' indicates a wish to return to the old order. It is also possible to speak in more positive terms of a religious renewal and political activism reaching a new high (Wallet 2021, pp. 10-11). Griffioen served between 1976 and 1979 at the Institute for Christian Studies in Toronto, Canada; between 1979 and 1991 as professor of Calvinist Philosophy at Leiden University; and between 2002 until his retirement in 2006 as professor for Intercultural Philosophy at the Free University Amsterdam. Griffioen argues, in line with Kuyper's souvereignty sphere, that a pluralist ethos is inherently impossible and, hence, the multicultural society is best described as a society with directional diversity, in which rival traditions pursue recognition. When challenged, different ways of life are under pressure to provide self-justifications. When these ways of life are not provoked, the choice of a direction is likely to be more a matter of habit than of articulated claims. Argumentation is by nature divisive, because it is bound to stir up dormant differences that may result in dissolving society into an archipelago of islands, an image Griffioen borrowed from Lyotard and Kant (Griffioen 1994). Orthodox Reformed and Evangelical Christians realized that they needed to strengthen mutual ties. In 2000, the RFP merged with the Gereformeerd Politiek Verbond (Reformed Political League, GPV) and formed the ChristenUnie (Christian Union), conservative in ethical issues and progressive in social and ecological issues. The merger capped thirty years of development toward a new orthodox Reformed pillar in society (van Mulligen 2014, p. 255). Harry Kuitert (1924Kuitert ( -2017) ) grew up in an orthodox family and became throughout the years a major exponent of liberal theology, grew up in a deeply pillarised society aimed at protecting Reformed orthodoxy. He not only witnessed the process of de-pillarisation, but also played a major role in this and opposed re-pillarisation as it was formed by the EO and other orthodox Reformed institutions. Kuitert challenged Christian orthodoxy in a way that no Dutch Reformed theologian before him had done. He wrote numerous bestselling theological books, in which he presented information that was known to theologians, but not thought over in a way that was accessible to a wider audience. He responded to questions in lectures about his books and in thousands of letters. It was his method to seek the debate and initiate the thinking process with others. During this process, Kuitert further developed his views (Pronk 2006, pp. 110, 144;2016, pp. 400-1). In an interview with Gerrit-Jan Kleinjan (b. 1983) on his 90th birthday in the Dutch daily Trouw, he says "all books I have written over time are records of a search, each time a step further. I did not know where I would end up. A search is only a search if you do not know where it ends. Otherwise, it is not sincere searching." Dutch Remonstrant theologian Eginhard Meijering (b. 1940), lector of the history of theology at Leiden University and since 1980 a member of the prestigious Royal Netherlands Academy of Arts and Sciences, wrote that anyone who wants to understand the changes in theological views in the Netherlands must read the books of Harry Kuitert. He described Kuitert's book of 2005 as the end of a development that distanced him from traditional Christian faith but sees him also as a scholar who challenges Christians to think about what matters in Christian

This paper argues that interreligious dialogue through study and friendships across the religious divide makes participants less susceptible to religious and cultural misinformation that is often used to maintain social bubbles, in which members draw clear boundaries between "us" and "them". Differences between social groups can culminate in a struggle between "good" and "evil" that can escalate into tension and violence. Preventing tensions and conflicts requires respect for differences, willingness to engage in dialogue, and a sound understanding of what religion is and the historical processes that have determined its development, distinguishing between empirical facts and images to which believers adhere. Because the author is a Dutch sociologist turned journalist from a conservative Christian family involved in interreligious dialogue in the Netherlands, Israel, and Egypt, the literature review presents contemporary religious developments in all three countries. The literature review is flanked by the author's personal narrative on the events that changed his views on truth and spirituality, making him more aware of the commonalities between peoples of different beliefs and leading him to a lifelong commitment to interreligious and intercultural dialogue.

thinking process with others. During this process, Kuitert further developed his views (Pronk 2006, pp. 110, 144;2016, pp. 400-1). In an interview with Gerrit-Jan Kleinjan (b. 1983) on his 90th birthday in the Dutch daily Trouw, he says "all books I have written over time are records of a search, each time a step further. I did not know where I would end up. A search is only a search if you do not know where it ends. Otherwise, it is not sincere searching." Dutch Remonstrant theologian Eginhard Meijering (b. 1940), lector of the history of theology at Leiden University and since 1980 a member of the prestigious Royal Netherlands Academy of Arts and Sciences, wrote that anyone who wants to understand the changes in theological views in the Netherlands must read the books of Harry Kuitert. He described Kuitert's book of 2005 as the end of a development that distanced him from traditional Christian faith but sees him also as a scholar who challenges Christians to think about what matters in Christian faith (Meijering 2006, pp. 7-12). Goud states that Kuitert meant a great deal to believers and nonbelievers of his and subsequent generations, to be fully free to believe or not believe, without the guilt of not believing what they were told to believe (Goud 2017). Dutch Protestant and Catholic theologians elected Kuitert in 2004 as the 7th most influential theologian in the 20th century (van Hooydonk 2004). No Dutch protestant theologian since Abraham Kuyper sold as many books as Kuitert (Harinck 2017, p. 19). Delpher, a digital archive of Dutch newspapers, shows some 4000 articles referring to Kuitert in Dutch media between 1990 and 1996. Delpher is incomplete for later years, but the number of references in the given period is staggering. Kuitert's doubts started early in his career. In 1968, he publicly challenged the literal understanding of the creation story in Genesis and called this a myth (Kuitert 1968), to which Netherlands Reformed pastor G. Visee (1908Visee ( -1976) ) responded in 1969 with an apologetic booklet Verstaat Prof. Kuitert wat hij leest? (Does Prof. Kuitert understand what he reads?. Visee refers to 2 Peter 1: 16, "For we did not follow cleverly devised stories (Visee adds between brackets myths) when we told you about the coming of our Lord Jesus Christ in power, but we were eyewitnesses of his majesty." Visee refused historical criticism of the Bible since neither Jesus, nor the Apostles, doubted its historical validity. What matters is that they preached the salvation of God (Visee [1968(Visee [ ] 1969, pp. 16, 66), pp. 16, 66). Arguments between Kuitert and Christian orthodoxy came to a peak in the years following his retirement in 1989. In 1994, Kuitert concluded in Zeker Weten (knowing with certainty) that since evolution is based on the survival of the fittest, we can no longer maintain that God has a plan for our world, discarding the concepts of seeing God's hand in history, divine revelation, or inspiration, dear to Christian orthodoxy. There are many conflicting revelations, whose human origins can be traced. They may have value for the believers of a faith tradition, but since it is a matter of faith only, it is not providing us with historically reliable information for the world we live in (Kuitert 1994, pp. 55-65). Kuitert argues that factual beliefs, beliefs in religious scriptures that claim to be grounded in history, need to be tested, and if these turn out to be incorrect, we need to review our conceptions of faith. When a large part of the factual beliefs of a religious worldview are undermined and religions claim that accepting impossible things are the pinnacle of piety, then believers drop out. Maintaining displays of faith that are not in line with reality causes one to live in two separate worlds. The only way to overcome living in two worlds is through accepting that displays of faith are put into words by people in a particular time and culture, in which they have formulated their religious certainties and why (Kuitert 1994, pp. 32-42). Kuitert notes substantial similarities among the Abrahamic religions Judaism, Christianity, and Islam. In all three, God is a transcendent personal God. God is one, is the Creator who maintains his creation and rules. Everything that happens, happens according to his will. Humanity is not subjected to fate or gods that contradict each other. The Creator is a righteous judge who also shows mercy. It is possible to communicate with him. Within these broad similarities, there are also numerous differences, not least because all three religions also claim their books were revealed by God and, therefore, have special status. Differences not only exist between these three religions, but also within each of these religions (Kuitert 1994, pp. 136-38). Since Kuitert expressed in Zeker Weten his faith in a mystical experience with God, his book was appreciated by many in the conservative flank in the church (Pronk 2006, p. 67). In Jesus, the Legacy of Christianity, Kuitert critiques the orthodoxy for their faith in the historicity of the gospels, which he sees as stories of faith, giving meaning to Jesus' death, but he also realizes that human beings tell stories because they have meaning for the person telling them (Kuitert 1998, pp. 11-53, 238). The role of science is to provide facts and leave the subjective meanings to the believers. Kuitert is certain Jesus lived, preached, and was crucified, but does not believe in the virgin birth and miracles, including the physical resurrection of Jesus. Faith in resurrection is, in his view in 1998, believing that friendship with God is eternal, which will not end with death (Kuitert 1998, pp. 122, 203, 237, 242). A key fact to Kuitert was that Jesus was Jewish, adhered to the Jewish faith, and criticised the people of his days, but not Judaism. Since a Jew cannot see himself as the Son of God in the Trinitarian understanding, Jesus cannot have seen himself as such (Kuitert 1998, pp. 153-54;Pronk 2006, pp. 72-92). Kuitert's arguments shattered one by one key orthodox notions of faith. It is impossible to speak about the world of God without metaphors. The language of faith in Judaism, Christianity, and Islam consists, from A to Z, of metaphors. Metaphors can be misused or become a trap because interpretations are given that were not intended by the original users. Dogmas are equally human since it is possible to see how dogmas follow the piety of past generations, and once a dogma has been established, piety has to adjust to dogma. All dogmatic expressions, treasured so much in orthodoxy, need to be seen in culture and time, but since they are part of our history, they cannot be removed, but they can be reinterpreted (Kuitert 1998, pp. 174-76, 200). Piety, described by Kuitert as devotion, dedication, and veneration, should be respected. Fighting piety is denial of what someone experiences, and that kills each form of communication. We have to accept what people feel. That is the necessary basis for talks whereby we do not need to agree. Kuitert argues in favour of more self-criticism: the realisation of the relativity of faith that, in his view, can go together with faith. He argues that all people are God's people, regardless of what faith they adhere to. That leaves space for relations with believers of other religions (Kuitert 1998, pp. 310-13). Kuitert also believes churches have responded in a wrong way to secularisation, which many church leaders described in terms as unhinged autonomy and degradation of society. Such denunciations, however, do not help. Believers need to realise that religions are linked to morality and philosophies that have been built on those of previous generations, such as the influence of the ethical philosophy of the Stoa in the Apostle Paul's letters (Kuitert 1998, pp. 281, 296-301). Faith needs to move people, Kuitert writes, since if it does not move me, it is not part of myself. Maintaining something as true is insufficient. Faith that moves, but is not linked to truth, is also insufficient, the Apostle Paul says when he writes about love in 1 Corinthians 13. Faith that moved Kuitert is found in Matthew 25: seeing the face of God in people in need and seeing in the New Testament a call to unite humanity through abolishing ethnic and cultural borders. Kuitert sees the church as a place for social contacts, providing people with security, pastoral care, and dignity, to make them dedicated and trust. Leaving the church is not leaving Christianity, which has deeply permeated Europe throughout its history, but the church should still pass on faith to next generations since Christian faith will not survive without institutions (Kuitert 1998, pp. 246, 265, 276, 282-91;Groeneveld 2000). In later books, Kuitert discarded space for a personal experience with God. Pronk sees the tipping point in his theology in his book Over religie; aan de liefhebbers onder haar beoefenaars (About religion; to the to the enthusiasts among its practitioners). Kuitert searches for the origin of religion in human history and now believes that first there were humans, then religion, gods, and God. Our images of God are the product of human imagination, which makes knowing God beyond our human ability (Kuitert 2000, p. 94). In 2005, Kuitert goes again a step further in expressing doubts in Hetzelfde anders zien. Het Christelijk geloof als verbeelding (Seeing the same differently. The Christian faith as imagination). In 2006, he, however, still left the possibility open that one can feel secure in God's hand (Kuitert 2005;Pronk 2006, pp. 67, 113, 156). The enlightenment separated fact and fiction, which Kuitert took to its limits in his book Alles behalve kennis (All except knowledge). Kuitert defines knowledge as anything in our physical world that we know for certain and cannot be denied without being exposed. If we do not know, we should not speculate (Kuitert 2011, p. 27). The practice of science consists of eliminating what is not true and establishing what is. Kuitert relegates anything that is not proven factually true to the area of imagination. Theology has its place, but as a continuous process of giving meaning to a continuously changing world, which is an entirely human phenomenon and differs from religion to religion (Pronk 2016, p. 422). Kuitert saw his work as taking church goers out of the 'house of bondage' since religions prescribe what you can and should do in the name of God. In Kuitert's view, no one can speak in the name of God (Pronk 2006, p. 141;Kleinjan 2014;Kuitert 2011, p. 25). The concept "house of bondage" is a Biblical metaphor used for the people of Israel in Egypt prior to the exodus to the promised land. Kuitert was averse to absolute truths, but appreciated religion as a search for wisdom, as his appreciation for Augustine showed since he did not present theology as science, but as sapienta (wisdom), a way of living (Kuitert 2011, p. 48). Pronk has seen Kuitert's correspondence with thousands of people and noted that, despite repeated orthodox criticism, he was ready to correspond with anyone, including Rev. Herman J. Hegger, who believed the Bible was God's Word. Their correspondence became cold and culminated on 25 October 2006, in an open letter of Hegger to Kuitert in the Dutch Daily Trouw, in which he argued that intuition comes before knowledge and leads to God, who is, in Hegger's view, the only Purpose and Sense, who provides humanity with hope (Hegger 2006). Hegger asked Kuitert how he can be certain that he will not be judged by God. Kuitert responded that Hegger can have his intuition, but not impose his intuitions, as if these were absolute truths, on others. That is an effort to rule over someone else's faith. Hegger, Kuitert concluded, should stop threatening people with the judgement of God (Kuitert 2006). Kuitert's lifelong search for the secret of faith, with the tools of science, historical research, and logic, and the responses from his opponents resulted in the loss of faith in religious authorities and certainty about a life hereafter (Pronk 2016, pp. 400, 422). Kuitert undermined the foundations of orthodoxy, resulting in orthodox criticism. Meijering criticised Kuitert's Hetzelfde anders zien for turning faith into humanism, which makes the proclamation of the church irrelevant. Meijering opposes fundamentalism, but feels closer to orthodoxy than to Kuitert in believing in a world hereafter and God revealing himself through history, including Jesus Christ. Christians, Meijering believes, should not change the faith tradition as handed down, but a debate about the foundations of the Christian faith is needed (Meijering 1999, pp. 195-210;Meijering 2006, p. 16). The key difference between Kuitert, other liberal thinkers, and orthodoxy is in rejecting or accepting the concept of revelation, seeing God's hand in history, and, by extension, seeing the Bible as the revealed Word of God, through which God speaks to humans. Knowledge of God, orthodox believers argue, cannot be obtained through rational thinking only, but also needs feeling. Leading Christian Reformed theologian Willem Hendrik Velema (1929Velema ( -2019) ) explained that belief in God requires that people study the Bible to understand what God is communicating to us humans today, engage in prayer, and allow God to speak to us in our lives. Internal spirituality is dependent on knowing that God loves us. This faith should permeate our lives and is evidenced by how we live (Velema 1990). Meijering agrees that we cannot proof revelation, but states that we also cannot discard it. Certain beliefs could be a scientific possibility, not a scientific certainty. Meijering accepts the evolution theory, but is convinced that our world is not an accidental product of an inevitable process, but created by God with a purpose. Even if we see God through images, we remain sinful people who may know they can trust in God's grace (Meijering 2006, pp. 22-39). Life is already a sign of living in the Kingdom of God. The test for our acts should be the neighbour who needs us. Jesus, Meijering writes, preached that anyone who wanted to enter the Kingdom of God had to convert, making believers responsible for their behaviour, including care for life on earth and fighting injustice (Meijering 2006, pp. 46-67). Radical Orthodoxy, developed by James K. A. Smith (b. 1970) and others in opposition to religious liberalism on the insights of the Dutch Reformational tradition of Abraham Kuyper and the Society for Calvinist philosophy, and summarised by Amos Yong (b. 1965), believes that it is not possible to separate faith (providing meaning) and reason since no nation exists without an ideology. That leads to the question of how dialogue can proceed on tradition-specific terms. Is dialogue between persons who do not share the same presuppositions possible? How can we consider the encounter of the diversity of religions in our time? (Yong 2007, pp. 236-41). Kuitert considered these questions and responded that truths of religions through revelations do not work, since then that religion is always right (Kuitert 1998, p. 308). Yong points to contradictions between different beliefs, constructions that in themselves seem reasonable, but in comparison seem to be a paradox. This observation matches Kuitert's definition of religion. Yong, however, goes further and states that since beliefs and practices are intertwined, religious traditions are effectively shielded from immanent critiques attempted by outsiders. Smith resists the blurring of the lines between the church and the world. Yong sympathises with Smith, but also believes no theological vision exists that can successfully answer all questions. Revelation only can be understood as knowledge of God that has been mediated through the created order. It comes down to the human experience of the encounter with God. The "testimony to the wondrous works of God can be received only through a multitude of voices, which all provide a perspective" that needs to be "discerned amidst, by, and through the community of faith." Yong states that the work of the Holy Spirit sets the Church, not individual churches, apart from other communities. He admits the practices of the historical church are messy and that the lines between the church and the world "can never be hard and fast in actuality." Identities are never pure, and there is no 'absolute other', but any authentic encounter and dialogical encounter will always be with those who have been brought near by the Spirit. In this encounter, Christians can bear witness to the coming of the Kingdom of God that will de-absolutise all human claims in the end. Yong believes this approach opens the opportunity to engage in immanent critiques of other faith traditions and makes it possible that we are transformed through our encounter with those in other faiths (Yong 2007, pp. 242-50). The orthodox contribution to the interfaith encounter includes apologetics, defending the faith against the polemics of others, but Christian apologetics must speak truthfully about, rather than bear false witness against, religious others. Yong recognises that believers of other religions have their quest for truth. Interfaith encounters may influence and impact the lives of others, "but there should also be every expectation that authentic interfaith interaction will result in personal transformation as well." Interfaith dialogue will inform Christian thinking theologically "by in-depth reflection on and with those in other faiths. Theology by and for the church in the twenty-first century cannot proceed in isolation as if others were absent" (Yong 2014). Interesting is Sander Griffioen's observation that one of the central themes of his tutor J.P.A. Mekkes (1898Mekkes ( -1987) ) was that God's revelation comes to all humankind and subjects every dimension of culture to a radical critique (Griffioen 2017, p. 30). Griffioen focused in his most recent book on good and evil in our world and believes the good cannot be separated from a Giver (Griffioen 2022, p. 19). Griffioen does not make any reference to Kuitert in his book, and when asked, responds that Kuitert's statement that religion is a human construct is trivial if you do not ask where the speaking about God originated, that is, divine inspiration. Griffioen does not believe in a literal six-day creation period and does not find this relevant in describing God as the Creator of our world. 5 Kuitert's growing conviction of faith as a human construct and as a consequence of the absence of absolute truths created a distance to his Protestantse Kerk in Nederland (Protestant Church in the Netherlands), formed in 2004 following a merger of the vast majority of the Netherlands Reformed Church, the vast majority of the Reformed Churches in the Netherlands Kuitert was born into, and the Evangelisch-Lutherse Kerk in het Koninkrijk der Nederlanden (Evangelical Lutheran Church in the Kingdom of the Netherlands). Theologian Lieke A. Werkman, who earned her PhD with Kuitert, saw, in 2004, in him a deeply religious human being, but deplores he had lost confidence in the church as an institute. People need a social structure. It helps them and does good to the world through, for example, diaconal work. Kuitert had an insufficient eye for this (Veltman 2005, pp. 28-29). Yet, in 2006, Kuitert still saw a need for the church as an institute. In his later work, he sees no problem in people abandoning church. In an interview in 2014, he criticised how the concept of church was conceived and put into practice and believed this had to digress in an "enslavement of souls" (Kleinjan 2014). Kuitert's last books amounted to agnosticism, not knowing God exists or not, and with this, discarding the experience of faith within established institutions, which went for many too far. Werkman argued that Kuitert was too convinced in the rationality of his own thoughts, which made him conclude that speaking about God was not only human, but 'only' imagination and projection. 'How do you know?' Werkman asks. Kuitert's work results in humility in speaking about God, but for Werkman, does not need to lead to a farewell of God (Werkman 2020). Dutch Jesuit priest Hans van Leeuwen SJ blamed Kuitert for his focus on human weaknesses in the search for God, but not seeing the experience of faith: people who undergo a touch that is possible because humans have a natural sense of God. Nobody has ever seen God, but what humans try to put in words reflects their sense of God (van Leeuwen 2017). Heino Falcke (b. 1966), award-winning professor of radio astronomy and astroparticle physics, believes in God. Humans are trying to create an image of God, but the universe arouses curiosity and teaches humans humility. Humans may become the conductor of God's blessings (Falcke 2020). The ebbing of faith made Pope Francis, who, of course, did not mention Kuitert, assure an audience of priests, seminarians, and pastoral workers "that good pastoral ministry is possible if we are able to live as the Lord has commanded us, in the love that is the gift of his Spirit" (Arnold 2023). That is a focus on living a Christian life that had been undermined by a rationality that, for committed Christians, had been taken too far. Liberal critique of orthodoxy is profound, but orthodox responses show that science and logic do not have all the answers. Revelation turned out to be a key concept to protect orthodoxy, not only in Reformed and Catholic Christianity, but also in Judaism, Coptic Orthodoxy, and Islam. Orthodox rabbi Moshe Peleg does not question God's hand in Scripture either and sees the Torah and rabbinic literature as "tools for life," an aid to humanity to face the big questions in life. 6 (Shenouda 1988;Tadros 2013, pp. 9-10). Muslim scholar Muhammad Abu-Laylah argued in a book used at Azhar University that God speaking through the Qur'an and Islam should not be questioned (Mulder 2022). Kuitert's books demonstrate the human origin of religions that involved various political influences, providing us with canonical scriptures, tradition, and dogmas, in which facts and imagination have been mixed, aiming at girding desired codes of conduct. The orthodox defence in turning to revelation to substantiate believed factual claims that violate science and historical critical research alienated many people and turned Kuitert into a leading figure, taking Reformed Christians out of their 'house of bondage'. Dutch history shows the orthodox Reformed have long been a political force to be reckoned with. The decline of faith after the Second World War greatly reduced the appeal of Christian democratic political parties, which, in turn, impacted policies that were intended to support faith-based policies. The discussions between Kuitert and his critics show that religion cannot depend on the search of factual truths and logic only. Real faith, in the words of W.H. Velema, allowing God to speak in our lives, is based on personal experience that moves people and determines how people live. Discussions about religion, orthodoxy, and politics took a very different turn in Judaism and Israel. --- Judaism and Israel: Religion as a Political Factor Unlike the orthodox Reformed, who saw their influence dwindle in the Netherlands, orthodox Jews saw their influence, both religiously and politically, grow in Israel, leading to a deeply polarised Israeli society. The current state of Israel and Messianism are deeply intertwined. The Israeli success in the June 1967 war boosted messianic views to an unprecedented height, making many Christians and Jews believe modern Israel is the revival of ancient Israel in Biblical times. Messianism took various forms, but all resulting in support for Israel. The dispensationalists among American Evangelicals, promoting a "literal" or "straightforward" reading of biblical prophecies that minimise allegorical or "spiritualized" interpretations, interpret Jesus' prophecy that "Jerusalem will be trampled by Gentiles until the times of the Gentiles are fulfilled" (Luke 21:24) as a sign that Israel will embrace Jesus as their Messiah before his second coming to earth. Israel's victory in 1967 was also widely celebrated by American Jews, who collected over USD one hundred million in support for Israel. The elated responses made Israel's eloquent Minister of Foreign Affairs, Abba Eban (1915Eban ( -2002)), publish his widely popular My People, The Story of the Jews (1968), underscoring the link between ancient and modern Israel, in which Zionism plays a major role. Jewish orthodoxy has long been divided over mixing faith with politics, which changed over time. This paper will present the views of an Orthodox opponent to mixing faith and politics with Jewish support for Evangelical messianism since that was politically opportune in the advancement of Zionism. Jerusalem-based Orthodox Rabbi Lion Wagenaar (d. 1979) 8, born in Germany and surviving Auschwitz, expressed his opposition to the euphoria following the June 1967 war in correspondence with German author Helmut Spehl (b. 1930) 9 between August 1967 and February 1970. Wagenaar believes Zionism violates the basic tenets of Jewish faith. "Judaism as a faith forbids to set up a Jewish state as a political entity until apocryphal times," the return to Jewish statehood always has been God-centred, never a political design that humans had to carry out. God is just, but Zionism and the state of Israel were founded on and continue to promote myths, political and military means that violate Old Testament principles of justice. Being Jewish is not based on a blood band, but on faith, a mindset of living holy. The Jewish people were chosen to be a nation of holiness, bringing the nations to the faith in one God. With Wagenaar, there is no convergence between Christian orthodoxy and Jewish orthodoxy. He criticises the apostle Paul for diverting from Judaism since he placed the focus on faith instead of living according to God's requirements. Wagenaar would have most likely agreed with most of Kuitert's views in his book about Jesus, but not his later views on religion in general. Wagenaar criticises Western political double standards and sees the Jewish state as a Christian creation since Christian nations wanted the Jewish state and provided substantial support. The Muslim world did not drive out Jews, but the Christian world did. Wagenaar's criticism also concerns lies of Israeli politicians, such as the claim that Israel is the only hope for Jews in need. Zionists lured Arab Jews to Israel because Israel needed them. Wagenaar does not call for the dismantling of the state of Israel, but his views show a deep resentment of linking faith with politics (Wagenaar and Spehl 1970, pp. 22-27, 40-41, 63, 112, 129). Where Wagenaar displays knowledge of Jewish and Palestinian history, Billy Graham does not in his 1970 film His Land. Calvin College scholar Bert DeVries found his film full of unproven assumptions, such as that the founding of the State of Israel "was literally foretold by the biblical prophets, and that the creation of Israel is an important step in God's timetable, a step that brings us closer to the return of Christ." Claims do not have to be accurate to have impact, and impact it had on Evangelical Christians in the USA, who believed that rallying to the support of Israel would bring the second arrival of Jesus Christ closer. The 1967 war showed Graham God was on Israel's side. The identification of prophecy with modern Israel and the silence about Israel's history between ancient and modern Israel resulted, in DeVries' views, in a dangerously slanted portrayal of Israel that justified conquering land and that Arab claims on Palestine are not worth mentioning (De Vries 1971). The American Jewish Committee (AJC) saw the film would be able to rally support for Israel and helped make Graham's film an international success. Billy Graham became the leading evangelical supporter of Israel through the mid-1970s. In later years, Graham was taken over by a host of other evangelists and pastors who advocated evangelical Christian Zionism (Hummel 2018(Hummel, pp. 1128-46)-46). Supporting Israel became responding to God's will (Mearsheimer and Walt 2007, pp. 107-8, 132-39), a view that greatly impacted churches in the Netherlands (Snoek and Verkuyl 1988, pp. 7-8). It is, at this point, needed to present Jewish and Christian messianism in a historical context and see how this intersected in the late 19th century with the secular political Zionism of Theodor Herzl (1860-1904) that led to the establishment of the state of Israel and influenced modern-day Jewish orthodoxy. Robert Eisenman (b. 1937) describes the events leading up to the messianic movement that followed Jesus of Nazareth, who was preaching the Kingdom of God. Jesus' crucifixion by the Romans was a shock to his followers and was interpreted in the context of messianic beliefs, the destruction of Jerusalem and the Second Jewish temple in 70 CE, and Greco-Roman philosophies in the first centuries CE, which deeply influenced the formation of the Christian church (Eisenman 1997) that further departed from Judaism, which will be described under the section of Egypt. Both Eisenman and Kuitert describe the departure from Judaism to an extent that made Wagenaar state that Islam is closer to Judaism than Christianity (Wagenaar and Spehl 1970, p. 42). Messianic movements presenting followers with hope for a utopian world have come up throughout history, but none was as impactful as the one around Shabbetai Z. evi (1626-1676) who lived in the Ottoman Empire in a period of Jewish humiliation and persecution in a society that was deeply religious. Old eschatological visions were mixed with new elements. Z. evi's messianism even had an impact on Jews and Christian millenarian circles in the Netherlands, England, and Germany. Many Jews sold houses and property to journey to the Holy Land. When the Ottoman Sultan authorised his arrest and Z. evi converted under pressure to Islam, Z. evi was presented as a tragic, but still legitimate, redeemer. Hundreds of Jews followed him in converting to Islam, but most did not. After this death, it was speculated that he had been the suffering Messiah, rather than the final redeemer. It took years for Jewish orthodoxy to regain control. Shabbateanism only finally disintegrated in the early 19th century (Scholem 1954). Both Eisenman and Scholem demonstrate that religious developments always need to be studied in the context of time and location, which made Kuitert question the orthodox belief in God's hand in history. With the Enlightenment, absolute trust in religion greatly reduced. Secular ideologies, including nationalism arose in the West. The souvereign nation-state became the objective to strife for. Nationalism has often been interwoven with religious predicates, the nation as a holy entity. Service and even death for the nation have been elevated to the level of sacrifice and martyrdom, impacting Zionism. In the same period European powers conquered land from a greatly weakened Ottoman Empire and encouraged ethnic and religious groups to break away from their empire and form their own nation states, starting with European guarantees for Greek independence in 1830 (Alter 1989, pp. 101-2). Woodrow Wilson (1856Wilson ( -1924)), the American president from 1913 to 1921, argued that the principle of selfdetermination should be rigidly applied, with every nation having the right to establish its own state (Alter 1989, pp. 10-11). The reduced trust in traditional religion led to religious liberalism that resulted in various forms of orthodox resistance, including the orthodox Reformed and Evangelical Restorationism, which is the belief Christians should try to emulate the life of the apostolic early church since this would be a purer and more ancient form of the Christianity. Restorationists were calling for, and willing to sponsor, the emigration of Jews to Palestine as a precondition for the Second Coming of Jesus Christ, while simultaneously seeking to convert them to Christianity, Gershon Shafir writes. The political elite in Europe came to see religion as a tool to increase their influence in the Ottoman Empire. Russians became the patrons of the Orthodox and the French of the Catholics, but since the protestant numbers were small and the British wanted to gain a foothold in Palestine, the narrative of a Jewish return to Palestine was encouraged to justify their ambitions, "long before vague Jewish messianic aspirations became a concrete Zionist project, and long before Jewish voices proclaimed Jews to be a nation rather than a religious group" (Shafir 2017). Cohen describes the Zionist labour movement from its earliest days that initially saw itself building a revolutionary class as the agent of national liberation for the Jewish people. Early Zionists, in line with the nationalist beliefs in their days, came to see the Hebrew language as a critical element of cultural authenticity, linking modern Zionists to the Jews in antiquity. The First Zionist Congress in Basel (1897) linked the call for a Jewish national home in Palestine to Israel in antiquity, encouraging Jews to settle here (Cohen 1987, pp. 55, 86). Under the influence of Eastern European Jewish orthodoxy, religious convictions gradually became more important, forming religious Zionism. During the First World War, the British government tried to obtain support from both Arabs and Jews, resulting in an

This paper argues that interreligious dialogue through study and friendships across the religious divide makes participants less susceptible to religious and cultural misinformation that is often used to maintain social bubbles, in which members draw clear boundaries between "us" and "them". Differences between social groups can culminate in a struggle between "good" and "evil" that can escalate into tension and violence. Preventing tensions and conflicts requires respect for differences, willingness to engage in dialogue, and a sound understanding of what religion is and the historical processes that have determined its development, distinguishing between empirical facts and images to which believers adhere. Because the author is a Dutch sociologist turned journalist from a conservative Christian family involved in interreligious dialogue in the Netherlands, Israel, and Egypt, the literature review presents contemporary religious developments in all three countries. The literature review is flanked by the author's personal narrative on the events that changed his views on truth and spirituality, making him more aware of the commonalities between peoples of different beliefs and leading him to a lifelong commitment to interreligious and intercultural dialogue.

the protestant numbers were small and the British wanted to gain a foothold in Palestine, the narrative of a Jewish return to Palestine was encouraged to justify their ambitions, "long before vague Jewish messianic aspirations became a concrete Zionist project, and long before Jewish voices proclaimed Jews to be a nation rather than a religious group" (Shafir 2017). Cohen describes the Zionist labour movement from its earliest days that initially saw itself building a revolutionary class as the agent of national liberation for the Jewish people. Early Zionists, in line with the nationalist beliefs in their days, came to see the Hebrew language as a critical element of cultural authenticity, linking modern Zionists to the Jews in antiquity. The First Zionist Congress in Basel (1897) linked the call for a Jewish national home in Palestine to Israel in antiquity, encouraging Jews to settle here (Cohen 1987, pp. 55, 86). Under the influence of Eastern European Jewish orthodoxy, religious convictions gradually became more important, forming religious Zionism. During the First World War, the British government tried to obtain support from both Arabs and Jews, resulting in an exchange of letters in 1915-1916 promising Arab indepen-dence in return for an Arab revolt against the Ottomans and, in the Balfour Declaration, a "national home for the Jewish people" in Palestine, using the religious narrative of the Jewish return to Palestine to safeguard British imperial interests in the Middle East after the pending demise of the Ottoman Empire (Shafir 2017). The promotion of the religious narrative ignores anything that does not fit that narrative, such as debates about possible large-scale conversions to Judaism in 8th-10th century Khazaria, north of the Caucasus, first suggested by German Orientalist Karl Neumann (1793-1870) and later further researched, since that undermines the claim of a direct line between the inhabitants of ancient Israel and Jews with roots in Russia (Falk 2017). Following the Ottoman defeat, Palestine became a British mandate, and the narrative of Jews returning to their homeland was promoted with success. Emigration increased. Land acquisitions, mostly from large absent landowners, led to clashes with local Palestinians that, in turn, resulted in discussions about and proposals for partition. David Ben-Gurion (1886-1973), at the time the Executive Head of the World Zionist Organisation and chairman of the Jewish Agency in mandate Palestine, proclaimed Israeli independence on 14 May 1948, in accordance with the 1947 United Nations partition plan. The Arab League was opposed to the UN plan and the establishment of Israel. Several Arab countries invaded Israel one day after the declaration of independence, which was immediately de facto recognised by the USA. Other countries followed. Israeli independence was followed by a massive exodus of Palestinians. The war ended in an armistice, with a border beyond the lines drawn in the UN partition plan (Eban 1972, pp. 347-58). Orthodox Chief Rabbi Isaac Herzog (1888-1959) boycotted the declaration of independence. He wanted a Jewish state with Jewish religious laws and had worked for years on a constitution for the new state, based on biblical laws and believing in Israel as a theocracy. The secular leadership at the time, however, did not want Israel to be controlled by religious laws (Polak 2023). Between 1948 and 1967, successive labour governments focused on strengthening Israel, not fearing military confrontations with their Arab neighbours, and, in 1956, joined Great Britain and France in an attack on Egypt following Egypt's nationalisation of the Suez Canal, benefiting Israeli military developments. In the same period, Israel made all efforts to stimulate Jewish emigration to Israel, knowing well that this would strengthen their hold on the land (Dayan 1976). A major turning point was the Six-Day War in 1967. Israel marched into Jordanian-held East Jerusalem and allowed soldiers and the orthodox to pray at the surviving Western Wall of the second Jewish temple. The Westbank, Gaza, Sinai, and the Golan heights were taken. The rapid occupation of areas that once were part of ancient Israel strengthened a messianic stream in Judaism and Christianity and created openings for political Islamism in the Arab World. The war deeply intensified the Israeli-Palestinian conflict. This is, Sigal Samuel writes, not a story of how religion drives conflict, but how conflict impacts religion (Samuel 2017). The war reverberated in the Netherlands, resulting in massive support for Israel, in particular, in orthodox Reformed churches, leading to discussions about God's promises for Israel and what this meant for the church in the Netherlands (Snoek and Verkuyl 1988). The war also resulted in 1969 in the establishment of the Nederlands Palestina Komite (Netherlands Palestine Committee), which saw the Israeli conquest of Arab lands as a colonial occupation. In 1973, Egypt and Syria tried to regain lost land in the October War. Their initial success resulted in an Israeli nuclear alert, which made President Nixon order on the same day an American airlift to replace all of Israel's material losses. Only this support enabled Israel to push back Egyptian and Syrian armies. Oil-producing Arab nations responded with an oil boycott of pro-Israel countries, including the USA and the Netherlands (Gutfeld and Vanetik 2016) In November 1977, during the tenure of Menachem Begin (1913Begin ( -1992) ) as the head of the government, Egyptian President Anwar al-Sadat unexpectedly visited Jerusalem, resulting in peace negotiations and peace with Egypt in September 1978. Begin, prior to the foundation of Israel the leader of the Zionist militant group Irgun, was the first Likud politician who became Prime Minister. His ascension to power indicated the growing strength of Jewish nationalism and orthodoxy which greatly impacted the non-Jewish inhabitants of Israel. In 1994, British author William Dalrymple (b. 1965) travelled around the Arab World and Israel, documenting a diminishing Christianity. During the war of independence, around 55,000 Christian and 650,000 Muslim Palestinians fled or were driven from their homes. In 1922, around 52% of the population of Jerusalem was Christian, reduced to under 2.5% in 1994. Armenian Bishop Hagop said his community had not received one single building permit since 1967. Israelis changed the Old City into a Jewish city. Christian ruins, including the ruins of the biggest monasteries ever discovered in the Middle East, have been looted and covered under soil, but the ruins of the tomb of a 15th century rabbi and ancient synagogues were preserved. Dalrymple notes that probably on no other site on Earth, the distant past is so politicised as in Israel, referring to a statement of Israeli archaeologist Shulamit Giva, who accused Israeli Biblical archaeology of being a tool in the hands of the Zionist movement [attempting] to find a connection between ancient Israel and modern Israel. Dalrymple refers to the early Ottoman period in Jerusalem, when interreligious interaction was abundant and unimaginable today (Dalrymple 1999, pp. 311-38). Dalrymple's sad account was made before religious nationalists further strengthened efforts to Judaize East Jerusalem and Palestinian areas. Israeli, Egyptian, Jordanian, American, and European leaders knew the 1996 elections between Israeli Prime Minister Shimon Peres and his opponent Benyamin Netanyahu (b. 1949) would be crucial for the region. Peres received international support during an international summit in Sharm el-Sheikh, Egypt, on 13 March 1996, yet Netanyahu was elected with a very narrow margin. Until today, Israeli politics has been dominated by Netanyahu, who, in December 2022, formed Israel's most religious nationalistic government since Israel was founded. Israel defines itself as democratic and Jewish. Palestinian MP Ahmad Tibi (b. 1958) prefers to formulate this differently: democratic for Israeli Jews and Jewish for Israeli Palestinians. The influence of the secular labour party greatly declined. Ultra orthodoxy has grown tremendously, largely because orthodox women give birth to an average of close to seven children, three times as many as with secular Jews. In 2023, the ultra-Orthodox make up close to 14 percent of the population and are expected to grow in the coming decades to 30 to 40 percent. They live in their own bubble in their own quarters with their own schools, where religious education dominates their outlook. The ultra-Orthodox that are critical of Israel and Zionism still exist but have lost much of their influence. The younger generation of orthodox accepted the idea of a greater biblical Israel. Jewish colonists in Palestinian territories that were occupied in 1967, many of whom are orthodox, are today represented in the Israeli government. They see the Palestinian population in these areas as "an error" and want to divert greater sums of money to further colonisation. Israeli historian Yuval Harari (b. 1976) warns that Israel is a regional military power with nuclear arms, ruled by a government consisting of extremists that openly disseminate racist views and expansionist objectives that can set the entire region ablaze (Polak 2023). --- Egypt: Christian and Muslim Orthodoxy In both the Netherlands and Israel, we see the orthodoxy attempting to steer politics in line with their belief system, while protecting their belief systems through providing education within their own social bubbles. De-pillarisation has crushed many of the institutions that aimed at protecting orthodoxy in the Netherlands. The orthodox bubble in Israel, on the contrary, is growing. Developments in Egypt differ markedly from the Netherlands and Israel since Egypt is both profoundly religious and impacted by both Christianity and Islam in their search to find and preserve religious truth. The Coptic (meaning Egyptian) Orthodox Church has been the main Christian denomination throughout Egypt's history. The small Protestant and Catholic churches attribute their roots mostly to Western influences since the 19th century. Religion was hijacked in the 20th century for political purposes, either through the Islamist slogan 'Islam is the solution' or Islamophobe claims in the West that present slanted descriptions of non-Muslims in Islamic societies as evidence of Islam's intolerance (Scott 2010, p. 3). The section will provide examples of modern Islamophobic writers who frequently refer to a religious past in Egypt that their audience in the West is mostly uninformed about, with Western scholars warning of their simplified narratives that serve political objectives. Following this overview, the main events that shaped the Coptic Orthodox belief system that was completed before Islam entered Egypt in the 7th century will be described. In the 19th and 20th centuries, Egypt became deeply influenced by the West. Both the Coptic Orthodox Church and Islam experienced religious revival, strengthening conservative religious sentiments in society. Egypt has been ruled by autocratic regimes since 1952 that, until the revolution of 25 January 2011, have used Machiavellian methods to use or oppose religious sentiments when it suited them. After 2013, when Islamists were removed from power; successive governments tried to reduce the influence of politically motivated revivalist Islam as much as possible. Various modern authors, such as Bat Ye'or (b. 1933), attributed the decline of Christianity throughout the ages to an almost continuous persecution of Islam through a system of culture and religious laws (Ye'or 2001). Contemporary political activists, Copts and non-Copts, living in the West, present a very dark picture of Christian life in Egypt. Paul Marshall (b. 1948) writes about 'Egypt's Endangered Christians', Magdy Khalil about 'The Ordeal of Arab Christians', and other authors attribute blame to 'radical political Islam' (Thomas et al. 2004). Several conservative private think tanks, such as The Gatestone Institute, claim Muslims persecute Christians. Their objective is to report on various subjects, including threats to the United States, events in the Middle East, and their possible consequences for the USA. 10 Philip Jenkins (b. 1952) deplores many people have an insufficient eye for how religious change happens and do not see that globalisation, encounters with other faiths, and the dilemma of living under hostile regimes were also issues Christians in the past have grappled with. Some Muslim regimes have been inconceivably brutal, others mild and accommodating. That diversity suggests, Jenkins notes, that persecution and violence are not inherent in the faith of Islam, but are related to circumstances in particular times and places. One needs to ask why some native churches disappeared and others, like the church in Egypt, survived. Looking only at Islam is insufficient. "To some extent also decisions taken by churches themselves determined whether they died or lived." The Coptic Orthodox Church in Egypt better adapted to the changes than churches in North Africa. Jenkins attributes this to its network of monasteries and villages churches. In addition, Egypt was spared many of the conflicts that were fought between different rulers and dynasties, while government control was weak in Upper Egypt, which left Christians largely to their own internal rule (Jenkins 2008, pp. 4, 34-35, 236-37, 242). Rachel Scott notes that modern relations between Copts and Muslims are linked to global conflicts and tensions (Scott 2010, p. 196). She warns against the tendency in the West to see Islam or Islamists as a monolithic bloc, assuming the divinely revealed law cannot be changed and, hence, that Islamic tradition is fixed. Such beliefs hamper discussions. Islamists, as all religious people do, engage with the foundational texts of their religion. Muslims do this with the Qur'an, hadith [h. ad<unk>th], and Islamic jurisprudence that are used to legitimise and understand current realities. These responses come also, within the same Islamist movement, with considerable diversity. The invention of tradition is an ongoing process and is affected when rapid transformation undermines social patterns. Scott's thesis illustrates the complex ways in which Islamic tradition is modified, reinterpreted, and changed in response to the circumstances of the moment. Their organisations are made up of members with different views and agendas. Policy statements can reflect which group has gained the upper hand (Scott 2010, pp. 5, 10-11). Jenkins' and Scott's observations contrast starkly with authors like Bat Ye'or, Marshall, Khalil, and Ibrahim and Coptic Solidarity, which show views on Muslim-Christian relations that are never far away from political convictions. Rev. Dr. Andrea Zaki Stephanous notes that religion and politics are intricately intertwined in the Arab World (Stephanous 2021, p. 8), contrasting greatly with countries, such as the Netherlands and Israel, that have been deeply influenced by the Enlightenment in separating religion and state and viewing the role of religion in society, although the orthodox in Israel are making efforts to increase the influence of religion (Polak 2023). These contrasts make Egypt a great example for a study about the complexities in Muslim-Christian relations throughout the ages that are relevant for our understanding of interreligious dialogue today. The first three centuries of Christianity are known in the Egyptian church as the 'era of persecution'. Unlike the popular view today, these persecutions were more periodical outbursts of persecution that gave the Coptic Orthodox Church many of its martyrs (Davis 2004, pp. 21-42). Roman persecution ended with the emperor Constantine (272-337 CE), who used Christians to tip the balance of power in his favour during a civil war against other contenders of the throne. Constantine found a highly divided Christianity. Two major groups were the Arians, stressing God's unity at the expense of the notion of the Trinity, and the Orthodox, who stressed the notions of the deity of Christ and the Trinity. Statements Eusebius of Caesarea (ca. 263-339 CE) attributed in his biography about the emperor to Constantine, like seeing a distinction between the Father (God) and the Son (Jesus), indicate sympathies with some Arian beliefs. Eusebius was an orthodox bishop and, for a while, advisor of the emperor who called for the Council of Nicaea (325 CE), since it was in Constantine's political interest to see the uniting of Christians who saw God as the ruler of the cosmos and Earth and the emperor as his representative on Earth, which gave him powers no Roman emperor in the third century had-remarkably, the representative of God who was not interested in spreading the gospel beyond the borders of his empire (Eusebius of Caesarea 2012). Arianism was defeated at the Council of Nicaea, but never fully disappeared. The decisions made at this council influenced to a large extent how the church developed in later centuries (Kuitert 1998). Interestingly, Islam presents a view of Jesus that was and is much closer to Arianism than trinitarian Christology (Suermann 2020). The political interest in supporting the missionary dimensions of Christianity and later Islam only developed in later centuries (Goddard 1996). The Arab conquest of Egypt, 639-642 CE, was a watershed moment for Egypt. They called the mostly Christian inhabitants "Qibt," a name derived from the Greek Aegyptus, which became our word Copt. Mariz Tadros calls the usage of the name Copt of significant socio-political importance (Tadros 2013, pp. 23-24), which was underlined by an Egyptian Ambassador in the Netherlands who, at the opening of an exhibition of icons, stated that he was proud to be a "Muslim Copt," signifying that both Muslims and Christians in Egypt are Egyptian (Watson 2000, p. 6). The Arabs brought Islam to Egypt. Egypt's Christians had no idea of what religion this was, but they rapidly noticed that the major differences between their orthodox Christian faith and this new religion was in how they viewed Jesus, a prophet with a special status, very different from their notions of the deity of Christ and the Trinity, as has been reflected in early debates between Egypt's Christians and Muslims (Suermann 2020). Islam can be seen as a further development of Arianism, growing further away from Christianity, with early Muslim rulers stressing their differences from the Orthodox faith that was held in the Byzantine Empire. The continuity and differences between these three religions, as well as the claim all three make on the divine inspiration of their canon, make it interesting to study the origin and further historical developments of Islam. The focus of Western and some Muslim scholars of religion on the historical critical method of research, however, is not appreciated by many Muslim scholars. Eildert Mulder (b. 1949) presented the draft of his book review of a book of Emilio Platti (1943Platti ( -2021)), De Koran herontdekt (The Qur'an rediscovered) (Platti 2020) to Azhar scholar H. assan Muh. ammad Waj<unk>h (Wageih 2022), who does not believe all outcomes of the historical method and referred to Muhammad Abu-Laylah's book Al-Qur " <unk>n al-Kar<unk>m min al-ManZ. <unk>r al-Istishr<unk>q<unk>. Dir<unk>sa Naqdiya wa Tah. l<unk>liya "Alif-l<unk>m-m<unk>m, Zalik al-kit<unk>bu l<unk> rayba f<unk>hi hud<unk>n lil-muttaq<unk>n" (The noble Qur'an: From the orientalist perspective. This is the book about which there is no doubt, a guidance for those conscious of Allah) (Mulder 2022). The critique of orthodox Muslim scholars on rationalist approaches to the study of divine scriptures appears to be similar to those of orthodox Christians and Jews, regardless of their denomination. The focus on a rationalist approach of religion was uncommon (but not absent) during most of Egypt's history since the arrival of Islam. Egypt, despite periods of interreligious tensions, also never saw Muslim-Christian relations degenerate into a sectarian civil war. Makari's book is a testimony of the lessons of history that can help to address tensions (Makari 2007, p. 3). Copts experienced a period of religious revival during the Fatimid period, until Caliph al-Hakim (985-1021) made an end of this with an intensity and brutality that was one of the worst in Egyptian history and saw a large drop in the number of Copts, as many converted to Islam (Tadros 2013, pp. 26-27). Christianity was long a force to be reckoned with in the Muslim world. Until as late as the eleventh century Asia was the home of at least one-third of the world's Christians, with Africa perhaps home to 10 percent. During the twelfth and thirteenth centuries, Christians in the Middle East experienced a widespread cultural renaissance (Jenkins 2008, pp. 4, 32). History is showing ups and downs for local Christians, but throughout history, the number of Christians also declined. Philippe Fargues (b. 1948) andYoussef Courbage (b. 1946) provide in Christians and Jews Under Islam an insight into the demographic changes that took place in previous centuries. Interestingly, the percentage of Christians slightly grew during the 19th century, but declined after the First World War, mostly due to instability and regional conflicts (Fargues andCourbage [1997] 1998). The percentage of Christians has been stirring intense political debate since Copts have been disputing the credibility of the data presented by Egypt's Central Agency for Public Mobilization and Statistics (CAPMAS). The last nationwide census dates to 1986 and indicated that Copts made up 5.6 percent of the population. Expatriate activists claimed the Copts constituted between 15 and 25 percent of the Egyptian population. Elsässer notes "The desire to build a case that would shock into action a Western audience seemed to tend toward exaggeration, simplification, and selective perception" while serious research uniformly concluded that the CAPMAS figure must be fairly accurate (Elsässer 2014, pp. 76, 161, 247). The huge differences in presenting Coptic population figures did not exist at the Coptic Congress in 1911. Coptic representatives then demanded more significant representation based on taxes paid (Mikhail 1911, pp. 28-29). Muslims organised a counter congress and argued that the Copts sought power disproportionate to their numerical size in the nation (Monier 2021, p. 24) which they, nevertheless, obtained from Egyptian nationalist leader Saad Zaghloul (1859-1927) to foster unity between Muslims and Christians to push the British colonialists out of the country. Copts remained prominent in Egyptian politics until the 1952 coup d'état of Gamal Abdel Nasser. From this moment their political influence greatly declined while voices of discrimination accompanied by substantially higher population claims increased (Wakin 2000, pp. 21-25). Since Pope Shenouda was elected in 1971, Coptic counter-narratives to the dominant national unity discourse gained prominence. Pope Shenouda was more assertive than his predecessors and did not hesitate to challenge the president publicly about issues he felt the government had responded inadequately to issues concerning Coptic Christians (Elsässer 2014, pp. 81-84). Pope Shenouda's assertiveness coincided in the 1970s with the establishment of the American Coptic Association, their campaigns for Coptic rights with increasing the alleged Coptic proportion to 20%, never providing any evidence. 11 Al-Kiraza, the official Coptic Orthodox Church magazine, edited by Pope Shenouda, adopted a similar claim in 1977 (Tadros 2013, p. 32). In 2002, Metropolitan Bishoi [B<unk>sh <unk>y], the influential Secretary of the Holy Synod, stated "President Mubarak spoke some time ago about 10 percent of the population so let's keep that number as a guideline" (Hulsman 2002). In 2008, Pope Shenouda publicly claimed Copts made up 15 percent of the population (Bayy <unk>m<unk> and Ramad<unk>n 2008). It is plausible to attribute the differences between CAPMAS counting and church estimates to the "the inconsistency of position," a term coined by Egyptian sociologist and human rights activist Saad Eddin Ibrahim which links claims of higher Coptic population percentages with claims about inequality from the moment their political influence declined which did not match their economic influence (al-Shaykh 2000). Ibrahim noted that "Copts earn on average 30% more than Muslims" (Marshall and Assad 1999, p. 80). Discrepancies lead to tensions. Islamists believe Copts exaggerate their number in a bid for disproportionate power, while Copts, in turn, believe Muslims deflate their numbers to undermine their presence and weight in the country. The CAPMAS stopped recording religion in the censuses since these debates gave them a headache (Scott 2010, p. 8). In 2012, extensive research was carried out to investigate Christian claims, resulting in an estimate between 5 and 6 percent. French demographer Philippe Fargues contributed to this report and disagrees with researchers who call CAPMAS figures "estimates". Their figures may have a margin of error, he said, but it is still based on counting. The estimates Christians provided are mostly politically motivated guesses (Hulsman 2012). Tadros argues the government has data and blames the government for lack of transparency in releasing credible data. The failure to release available data "adds fuel to the fire of rumour and suspicion." (Tadros 2013, pp. 30-35). A Lebanese Christian scholar opined in 2015 at a conference at Vienna University that one should not dispute Christian population estimates since all Arabs exaggerate (Hulsman 2015). Inflated population claims and claims of persecution or discrimination often go hand in hand, indicating political objectives, as Scott earlier noticed, which need more digging into Muslim-Christian relations in Egypt's contemporary history. Just as in the Netherlands, Egypt's orthodox Christians resisted religious liberalism since this came up in the 19th century and called for revivals in line with the Bible and at times tradition, so also Muslims did. The difference, however, is that European orthodox Christian responses addressed European liberalism. Nineteenth-century Coptic Orthodox and Muslim responses had to address Western liberalism that colonial powers had brought to their countries with efforts to undermine the Ottoman empire, as is obvious in the writings of Sayyid Jam<unk>l al-D<unk>n al-Afgh<unk>n<unk> (1838/1839-1897), who referred to Muslim religious scriptures in seeking answers to Western encroachments on the Muslim world. The collapse of the Ottoman Empire in the First World War was followed by Western dominance over protectorates that were predominantly Muslim. Islamic thinkers responded to these political changes, not rejecting modernity, but calling for liberty, social justice, equality, and solidarity. With the fall of communism, the focus point of world politics became Islam, which led to various responses, some of them militant (Khatab 2011, pp. 20-23). In 1952, colonel Gamal Abdel Nasser [Jam<unk>l --- " Abd al-N<unk>s. ir] (1918-1970) removed the deeply unpopular king with his cabinet that depended to a large extent on the political power of both Muslim and Coptic landlords. The land reform that followed destroyed the basis of the 2000 wealthiest landlords, who could otherwise have challenged the regime. Nasser's principal opponents during his reign were the Muslim Brothers, making them the prime targets of political arrests and subjecting them to political sadism. During 1961 and1966, he initiated a socialist transformation (Waterbury 1983, pp. 341-42, 423-24). The Muslim Brotherhood radicalised in this period, as exemplified in the writings of their ideologue Sayyid Qut. b (1906Qut. b ( -1966)), who developed a strong Manichean approach in creating a sharp distinction between good (Islam) and evil (all else); unbelief, also of Muslims; and belief. A true Muslim, Qut. b argued, is committed to the establishment of an Islamic order and state. Nasser, who saw his writings as an attack on the regime, had him arrested and executed (Vatikiotis 1988, p. 66). His works, however, live on in Islamist circles and became the basis of even more radical thoughts (Berman 2003). After Nasser's death in 1970, President Anwar al-Sadat gradually released Islamists from prison and used them to dismantle the secular/leftist powerbase of his predecessor in an effort to impose a new economic policy, resulting, Nadia Ramsis Farah explained, in a transition crisis. In November 1971, Pope Shenouda had become the head of the Coptic Orthodox Church. His predecessors avoided confrontations with the state, but Pope Shenouda, a theologically conservative leader with a history in the revivalist Coptic Sunday School Movement, was more assertive and thought to voice the Copts political demands. Muslim-Christian clashes started in 1972, with the burning of a small building in Khanka, north of Cairo, that the pope had turned into a church without having a license. Such clashes had not been seen during Pope Shenouda's and Sadat's predecessors. President Sadat requested Dr Jamal al-'Utayfi, the Deputy Speaker of Parliament and confidant to the president, to form a fact-finding committee to investigate what happened. Al-'Utayfi's committee detected an over-sensitivity of Muslim and Christian religious leaders regarding publications about religious subjects and highlighted three key issues that repeatedly led to sectarian tensions: the licensing of church buildings, missionary activities, and censorship of the publication of religious books (al-'Utayfi 2009). Al-'Utayfi's report and recommendations were excellent and repeatedly referred to in Egyptian media as the very points that needed to be addressed, but most recommendations were not implemented, human rights activist Saad Eddin Ibrahim wrote 36 years later. If they had been implemented, many sectarian incidents in the following years could have been avoided (Ibr<unk>h<unk>m 2000(Ibr<unk>h<unk>m, 2008)). Coptic writers at the time frantically argued for a secular order, in which a plural society could develop-an allegiance to the nation, not to a religion. Their voices drowned in the increasing polarising voices. Islamic groups strengthened their influence on university campuses and, in January 1977, clashed with Coptic Christians in Upper Egypt. They were trying to pressure the government into accepting the literal application of Islamic law, which was strongly opposed by Pope Shenouda. Clashes escalated in the following years. In May 1980, the government proposed a constitutional amendment to make the Shari'a (Shar<unk> " ah) the source of legislation. Farah describes this amendment as the worst blow in Muslim-Christian relations during his reign. Sadat thought to silence Pope Shenouda by accusing him publicly of initiating and intensifying religious strife, which did intensify more strife (Vatikiotis 1988, p. 68;Farah 1986, pp. 1-5), culminating in June 1981 in the arrest of around 1500 people, including Islamists, political activists, and intellectuals of all colours, as well as 120 Christians, including 8 bishops and 24 priests. Pope Shenouda was put under house arrest in the Monastery of B<unk>sh <unk>y. Not long after, Sadat and Bishop Samuel, then head of the Committee of Bishops that had temporarily replaced Pope Shenouda, were killed by Muslim militants during a military parade on 6 October 1981 (Watson 2000, p. 85). The tensions had interrupted the dominant pattern of the Christian community's survival that, through the ages, had been based on fostering relationships with Muslim rulers (Vatikiotis 1988, pp. 66-67). Sadat's successor Hosni Mubarak (1928-2020) gradually released leaders imprisoned by Sadat. In January 1984, Pope Shenouda's monastic arrest was lifted, allowing him to preside over the Coptic Orthodox Christmas celebration on January 6. The policies of Nasser and Sadat had contributed to the increase in Islamic political violence, but also factors outside Egypt played a major role. Western dominance, of which Israel is seen as an extension, and Western military adventures in the Muslim world are widely resisted and contribute to growing extremism. An excellent example is Usama bin-Laden's interest in jihad that was triggered by the Soviet invasion of Afghanistan in 1979. His movement could develop thanks to the support of the USA, Saudi Arabia, Egypt, and Pakistan for his fight against the Russians in 1986-1989 (Khatab 2011, pp. 94-97). Not only Western politics, but also Islamic theology and ideology, are important factors in the process of radicalisation. Bin-Laden's al-Qaida attracted many Egyptians, using the intellectual framework known as Salafism, pietistic in focus, but sharing much of the rejectionist worldview of the jihadis, with a widespread antipathy toward communication and contact with non-Salafis and non-Muslims. Al-Qaida and other radical movements borrowed ideas from earlier Islamic movements, capitalising on social, economic, and political constraints in the Muslim world, seeing their ideology and activities as a defence of Islam. In doing so, they used selected religious narratives from the past and gave these new, but perverted, interpretations. Many of the audiences they reach out to, Khatab concludes, are unable to distinguish between truth and ideological propaganda. Khatab believes jihadism can be eradicated at its roots through defining the nature of the conflict and providing support to the mainstream Islamic community in struggling against it (Khatab 2011, pp. 237-48). We should distinguish here between Salafism and the Muslim Brotherhood. Where Salafism is pietistic and tends to be non-political when they are politically weak. This enabled them to grow in local village mosques all over the country. The Muslim Brotherhood is political activist and more pragmatic without tampering with their basic ideology (Durie 2013). The government and church established in the 1980s some cautious contacts with the Muslim Brotherhood. Some of the younger and more impatient members joined the militant al-Jam<unk> " a al-Isl<unk>m<unk>yyah and Jihadist movements and, in the 1980s and 1990s, attacked police, Christians (in particular, jewellers, because they needed money), and sometimes tourists, with the purpose of harming Egypt's tourism industry-all in hopes of pressuring the Egyptian government to apply the Shari'a more strictly. After the November 1997 terrorism attack in Luxor, killing 58 tourists, the Egyptian government cracked down on Islamic militancy. The government was unable to address widespread poverty and left social care largely in the hands of Muslim and Christian religious organisations, including the Muslim Brotherhood, which improved their public image. The Egyptian government was walking a tightrope. Expanding Jewish settlements in occupied Palestinian areas, the Palestinian Intif<unk>dah with harsh Israeli responses, and the USA-led invasion of Iraq ( 2003) had strengthened Islamist and anti-Western sentiments (Elsässer 2014). Sectarian tensions came back. Coptic researcher Peter E. Makari, describing the Mubarak period, is convinced that we should not interpret these as a clash between the West and the East, or between Christianity and Islam, but rather between what he calls "more conservative and extreme elements in all religions that adopt exclusivist claims and intolerant attitudes toward the other and other adherents of religions

This paper argues that interreligious dialogue through study and friendships across the religious divide makes participants less susceptible to religious and cultural misinformation that is often used to maintain social bubbles, in which members draw clear boundaries between "us" and "them". Differences between social groups can culminate in a struggle between "good" and "evil" that can escalate into tension and violence. Preventing tensions and conflicts requires respect for differences, willingness to engage in dialogue, and a sound understanding of what religion is and the historical processes that have determined its development, distinguishing between empirical facts and images to which believers adhere. Because the author is a Dutch sociologist turned journalist from a conservative Christian family involved in interreligious dialogue in the Netherlands, Israel, and Egypt, the literature review presents contemporary religious developments in all three countries. The literature review is flanked by the author's personal narrative on the events that changed his views on truth and spirituality, making him more aware of the commonalities between peoples of different beliefs and leading him to a lifelong commitment to interreligious and intercultural dialogue.

needed money), and sometimes tourists, with the purpose of harming Egypt's tourism industry-all in hopes of pressuring the Egyptian government to apply the Shari'a more strictly. After the November 1997 terrorism attack in Luxor, killing 58 tourists, the Egyptian government cracked down on Islamic militancy. The government was unable to address widespread poverty and left social care largely in the hands of Muslim and Christian religious organisations, including the Muslim Brotherhood, which improved their public image. The Egyptian government was walking a tightrope. Expanding Jewish settlements in occupied Palestinian areas, the Palestinian Intif<unk>dah with harsh Israeli responses, and the USA-led invasion of Iraq ( 2003) had strengthened Islamist and anti-Western sentiments (Elsässer 2014). Sectarian tensions came back. Coptic researcher Peter E. Makari, describing the Mubarak period, is convinced that we should not interpret these as a clash between the West and the East, or between Christianity and Islam, but rather between what he calls "more conservative and extreme elements in all religions that adopt exclusivist claims and intolerant attitudes toward the other and other adherents of religions who seek reconciliation, peace, and justice for all" (Makari 2007, p. xx). The terminology used by Makari reflects a possible liberal bias in linking conservatism with 'extreme elements' and 'intolerant attitudes', as opposed to the liberal approach of openness to all. Emigration substantially increased with the Muslim-Christian clashes in the 1970s and has continued ever since. Christian emigration is related to economic factors, escaping sectarian violence, fear for a country that is dominated by an Islamist philosophy, and a more secured life in the West. Just before the Egyptian Revolution of 2011, Coptic businessman Mounir Ghabbour [Mun<unk>r Ghabb <unk>r] published with Ahmed Osman a book expressing fear for a disappearance of Christians from the Middle East, linking this to Islamism (Ghabbour and Osman 2010, pp. 175-89). Not long after publication, various Arab countries were plagued with revolutions and civil war, in which Islamists played a dominant role that indeed spurred Christian emigration. Ghabbour and Osman's book confirms the thesis of Makari that clashes were not between Christians and Muslims, but related to efforts of Islamists to turn Egypt and other countries into states with a greater role for Islam in the public domain. Andrea Zaki Stephanous' (b. 1960) view of political Islam is in line with Ghabbour and Osman. He, however, adds the perils of Israel for Egypt's Christians since also Israel blurred the lines between religion and politics, providing justifications for militant Islamists to create an Islamic state with similar blurred lines. The foundation of the state of Israel claiming justification of land appropriations on Old Testament prophecies and the doctrine of land and covenant of God with his people resulted in many Egyptians seeing the book as legitimising war crimes and murder for the sake of his chosen people with theological disputes within Egypt's churches (Stephanous 2021, pp. 10-18). Tadros describes the increase of sectarian violence against Christians, Baha'is, and Muslim Sufis between 2008 and 2011, that, alongside huge discrepancies between the rich and poor, fraudulent elections, and police brutalities to suppress (perceived) opposition, became some of the catalysts for the January 25 Revolution in 2011. The weeks following the uprising showed the highest degree of national unity between Muslims and Christians since the Egyptian revolution against British occupation in 1919. Christians hoped that the country could change to an inclusive democracy, distinct from a majoritarian (Muslim) rule, Tadros writes. The revolution, or uprising, led to the removal of President Hosni Mubarak and a political settlement between the army and the Muslim Brotherhood, the strongest political entity at the time, to facilitate a fairly smooth accession to political power, while the army would receive impunity from accountability (Tadros 2013, pp. xi-xii). During the Sadat years, Islamists pushed article II of the constitution, stating that the Shari'a is the main source of legislation. That was insufficient for them. In later years, they argued for a stricter application of the Shari'a. This makes the July 2011 poll of F<unk>t. ima al-Zan<unk>t<unk> and Muh. ammad al-Ghaz<unk>l<unk> into what Egyptian respondents found of maintaining, amending, or annulling Article II of the constitution of great interest. Only one-third of the respondents had heard of Article II, unawareness of a key article that had been the focus of many public discussions since the 1970s. Of Muslims who knew of this article, the overwhelming majority wanted to keep this, while the overwhelming proportion of Christians would rather let go of this article. The next indicator was the Parliamentary elections in 2011/2012, registering a higher voter turnout than any of the previous elections since Nasser's coup d'état in 1952. Parties that were outspoken Islamist (Salafi and Muslim Brotherhood) obtained 65.3% of the votes. The third indicator is the first round of the 2012 Presidential elections, during which Islamists candidates obtained 43.26% of the vote. During the second round, an army officer ran against Muslim Brotherhood candidate Muhammad Morsi [M <unk>rs<unk>] (1951-2019), who won, although disputed, the elections, primarily because many Egyptians did not want a president with a military background. The data show a large percentage of floating voters, with a rapidly declining support for Islamists. During the first months, cooperation between Islamists and non-Islamists appeared to be possible, resulting, for example, in October in a multi-party delegation with Islamists and their fiercest ideological opponents to the Netherlands. Coptic Orthodox Pope Tawadros II (b. 1952) took office on 18 November 2012; major sectarian clashes had not yet taken place. These developments made Tadros publish Copts at the Crossroads; The Challenges of Building Inclusive Democracy in Egypt, with a preface dated January 15, expressing hope for a new era. This was not a blind hope. Tadros noted, for example, that many Copts did not trust a Brotherhood rule, resulting in emigration, although the numbers are disputed (Tadros 2013, p. 2). Tensions built up with debates on a new constitution. Islamists pushed through a new constitution with a strong Islamist character. Non-Islamists opposed, which led, George Mas<unk>h. a, member of the Constitutional Assembly explained, to rapidly escalating tensions between Islamists and non-Islamists (Serôdio 2013) ultimately resulting in massive demonstrations and the removal of President Morsi. It is obvious that the al-S<unk>s<unk> government wants to push back Islamism. In July 2015, the president gave a landmark speech about the need to renew the religious discourse and linked this to counterterrorism (Kamal 2015). Reducing Islamism also comes with reducing poverty, in the past providing Islamists with a fertile soil, but this turned out to be far more difficult than changing the religious discourse. The percentage of Egyptians living under the poverty line increased from 27.8% in 2015to 32.5% in 2018. In February 2021, President al-S<unk>s<unk> (b. 1954) sparked a storm among conservative Muslims when he instructed verses from the Qur'an and sayings from the Hadith be struck from textbooks. Changes become visible in religious education at Egyptian schools, emphasising religions' common denominators and tolerance. The struggle for the religious soul of Egyptians is over a century old and will not rapidly disappear (Elsässer 2014). In conclusion, religious developments cannot be discussed in isolation from political and social circumstances. The impact of organised religion as the main provider of collective morality greatly reduced in the Netherlands, despite orthodox efforts to hold their ground. Israel started as a predominantly secular country and became more orthodox, which also gained increasing political power that includes hardcore radicals. Islamism in Egypt grew in number and radicalism since the Nasser years, which is to a large extent related to poverty, education, suppression, and frustrations about efforts of Western powers to change the Islamic world according to their agenda. There are no indications that the direction of religious adherence in each of these three countries will change any time soon, which makes interreligious dialogue of paramount importance to reduce division and religious motivated violence. --- Expanding My Bubble through Travel and Friendships In this section, my personal narrative begins. I travelled to places and met with leading religious, academic and political leaders of all denominational backgrounds, that my parents could only vaguely have imagined from news or movies on TV. This was a major part of my formation. I was raised in a Christian Reformed family during a period in which the old Reformed pillar crumbled and many orthodox Reformed, including my parents, sought salvation in a new orthodox Reformed pillar. My family belonged to church of Rev. J.H. Velema. I attended his catechism classes where traditional Reformed faith was reinforced. We believed that what we were taught was the norm and that all other beliefs were deviations from the truth. This did not mean that other people were bad, but they lacked knowledge of the truth, and that necessitated evangelism and missionary work to bring them to the truth. Israel's victory in the June 1967 war created in our Reformed bubble a euphoria that was seen as the hand of God restoring Israel, which was a sign that the arrival of the Messiah was nearby. The newly founded EO played a major role in this euphoria, presenting ancient and modern Israel as the people of God. My parents were among their first members and promoted membership to anyone in their Reformed Christian circle. My father corresponded with and supported former Catholic priest Rev. H.J. Hegger, who represented all the values that were important to my father: an anti-Catholic conservative Reformed pastor who became one of the leading founders of EO and a leading opponent to liberalism. My father liked Hegger's critique on Kuitert without having read any of his books. I started a newspaper collection about Dutch media reporting about Israel, which I maintained until after the October War in 1973. The collection shows an Arab-Israeli conflict with a decisively pro-Israel bias, characteristic of Dutch media reporting at the time. The October War made me believe Israel needed support. That belief brought me in 1974 to Israel, where I further dug into faith issues, meeting Jews and Palestinians. My discovery of Christian Palestinians led to traveling around the Arab World and discovering ancient churches that struggle with the phenomenon of emigration; culminating in settling with my family in Egypt in 1994, focusing on Muslim-Christian relations. I will describe how I continuously tried to make sense of conflicting opinions and beliefs through actively looking for people who were explicit exponents of such conflicting beliefs and befriending them. Bit by bit, my initial beliefs shattered, my bubble expanded, meeting a great variety of different believers, Christians, Jews, and Muslims, both orthodox and liberal, with people living their faith in sincerity and others using religion to justify certain behaviour to achieve certain interests. My initial convictions turned out to be na<unk>ve. I no longer see good and evil as spiritual powers outside us, but the consequence of choices we make that may positively or negatively affect others. Friendships resulted in asking more questions and more study and confronting friends with newly developed views, which brought me to the limits of what one can believe in good faith and what not. My initial focus on Israel changed. Many members from my church had been called to missionary work; others had been called to serve Christian media or otherwise serve the Kingdom of God, and I felt the call to work for peacebuilding. In December 1974, I became the leading founder of the Werkgroep Midden-Oosten (Middle East Study Group), which became a vehicle to meet interesting people on topics of interest, such as Prof. Oosterhoff. The choice of the name showed a wider interest than Israel alone. In 1975, I travelled overland to Israel with the intention to meet as many Middle Eastern Christians as possible in Istanbul, Antakya, Syria, and Jordan. A new fascinating ancient world had opened to me. In Israel I met with Orthodox Jewish rabbi C.J. Auwendijk in Metula, on the border with Lebanon. He was armed with a riffle to protect himself and the area from marauding Palestinians, but also spoke about peace and God's promise of land to the Jews. Zionism was God's hand in history, and Palestinians, he believed, would have to accept that. I also met with Palestinian-Arab-Christian-Israeli Greek Catholic priest Elias Chacour [Shaq <unk>r] (b. 1939), who also spoke about peace, yet addressing numerous injustices against Palestinians, both in the past and contemporarily. It seemed that God's hand in history was used to justify a turn in history that was favourable to one particular group. Willem van 't Spijker (1926van 't Spijker ( -2021)), professor of church history at the Christian Reformed Theological University, saw my interest in Israel and Arab Christianity and advised me in 1976 to contact retired Dutch diplomat Daniel Van der Meulen (1894-1989) since he was a committed Reformed Christian, had a great interest in Arab Christianity, and believed in Muslim-Christian dialogue. Van der Meulen had served between 1915 and 1948 in the Netherlands Indies and Saudi Arabia and had an impressive network of leaders in the Arab World (van der Meulen 1977). Van der Meulen became the advisor of the Middle East Study Group and encouraged me to travel more and meet more people. I discussed the various study options with Daniel Van der Meulen, and given my interest in the position of Christians in the Muslim world, I chose development sociology at Leiden University. Traveling and meeting people captivated me. In September 1976, I travelled over land to Athens and took the boat to Alexandria. I had no idea that my time on the ferry would open opportunities to meet with other youth. Coptic Evangelical youth Adel Soliman Safangy invited me to stay with his family in Alexandria. Young Muslim Medhat Ismail [Midh. at Ism<unk> " <unk>l] (1951-2023) invited me to stay with his family in Cairo. Both families became friends. Adel later emigrated to Canada, as so many educated young Copts have done. My first time in a Muslim family happened to be during Ramadan. It was a humanising experience, enjoying joys and sorrows together. The Muslim was no longer an abstract entity, but had obtained a human face. In Cairo, I found a spiritual home in the Anglican Church, met with Christian missionaries, some focused on reaching out to the African refugee community, while others believed they had to reach out to Muslims. I understood their motives, although that was not the path I saw for my life. Egyptians I met were yearning for peace, not out of love for Israel, but with a widespread awareness that more wars would be disastrous for the country. I appreciated this sentiment that strengthened my desire to play a role in peacebuilding. Van der Meulen introduced me to Egyptian sociologist Dr. El-Sayid Yassin [al-Sayyid Y<unk>s<unk>n] (1993-2017), who, between 1975 and 1995, was head of the influential Al-Ahram Institute of Strategic Studies. Al-Ahram newspaper in 2017 described him as "one of the most prominent and influential writers on Egyptian politics in the years prior to the 2011 revolution" (Al-Ahram 2017). That visit was eye opening. Yassin instructed a researcher at his centre to give me a first introduction to Egyptian society and politics. Van der Meulen also introduced me to Dr. Piet Dirksen (1928Dirksen ( -2022)), a Dutch scholar at the time teaching Old Testament at the Evangelical Theological Seminary in Cairo (ETSC), who gave me an introduction to Egyptian Christianity. In 1976-1977 I spent a year in Israel, first in Nes Ammim, Israel, established in 1963 to foster ties between Christians and Jews, and later kibbutz Ramat Hashovet, established on socialist grounds. I used my time in Israel to meet with many different people advocating dialogue and used information and connections to advocate peace building and dialogue through the Werkgroep Midden-Oosten. At Leiden University, I pursued any subject I could find in the line of my interest, including Islam, comparative religion, and Middle Eastern Studies. Seeking dialogue and Christian commitment went hand in hand. I was active in church and the Christian student group Ichthus; and followed lectures in Reformational Philosophy with Prof. Dr. Sander Griffioen, addressing questions about the relation between science and faith. My work for the Middle East Study Group continued during my entire studies. My professors encouraged this engagement, and I was offered space at our faculty to host speakers and debates. In November 1977, months after I started my study, President Anwar al-Sadat [al-S<unk>d<unk>t] made his historic visit to Jerusalem. I was elated and visited the Egyptian Embassy, where Deputy Ambassador Muh. ammad Al-Ghat. r<unk>f<unk> was open to meetings and questions and provided me with information about the peace process that Sadat's visit had initiated. The Camp David Accords followed in 1978, and the Israeli-Egyptian peace was signed in 1979. During my student days, I became a member of the 'Anti-Revolutionaire Jongerenstudieclubs' (Anti-Revolutionary Youth Study Clubs, ARJOS), the political youth movement of the Reformed ARP believing in political idealism rooted in Christian convictions. I rapidly became a member of the Foreign Affairs Committee, in which I was for years the Middle East expert. I came to know several members of Parliament and saw the process of political negotiations about the merger between three confessional parties ARP, the CHU, and the KVP, into the centrist Christian Democratic Appeal (CDA) and believed, after initial hesitations this should make it possible for people leaning to the left and right to cooperate. I was taught that the realisation of the current state of Israel was prophesied in the Old Testament or Torah. This belief was reinforced by the EO and numerous Christian pro-Israel advocates and groups. In the summer of 1981, I went to Israel with the purpose of speaking with Jews and Christians about these Biblical promises and learned about different interpretations of the Scriptures that mixed with political interests. I visited Egypt every single year after my first visit, mingled with Egyptian youth, both Muslim and Christian, mostly stayed with Egyptian families, and found the country, its history, and its people fascinating. In 1981, I found a divided nation with Islamists clashing with Christians who expressed deep mistrust of their intentions and met with Coptic Orthodox Bishop Samuel (1920Samuel ( -1981)), who asked me how these Muslim-Christian tensions were reported in the West. I was impressed by the bishop's sincere wishes to live in harmony with Muslims in Egypt. A few weeks later, on October 6, Bishop Samuel was killed with President al-Sadat when they watched the annual military parade. I was devastated. The slayings made me more determined to focus on dialogue. Another defining moment was the Turkish military coup d'état in 1980, which heralded a new exodus of Syrian Orthodox and Armenians from Eastern Turkey to Istanbul and Europe. Bert Dorenbos (b. 1942), director of EO from 1974 to 1987, was at the time deeply concerned about anti-Christian discrimination and persecution in Eastern Turkey and, around 1981Turkey and, around -1982, formed a committee to study and publicise the plight of Armenian and Syrian Orthodox Christians in Eastern Turkey. His aim was political, pressuring Dutch politicians to facilitate the arrival and acceptance of Christians from Eastern Turkey in the Netherlands. One of the members of this committee was Dirkjan Groot, founding director of Dorcas, a Christian ministry established in 1980 that supports projects that uplift disadvantaged Christians around the world. I was asked to become the lead researcher for this committee since I was already known in various churches in the Netherlands for my work on Christians in the Middle East and was politically active in the CDJA. I contacted numerous organisations and experts, including Henk Glimmerveen (1923-2020), a leading human rights activist and authority on this subject at the time. I believed in providing humanitarian support, but had growing misgivings about the prejudices I found within my Christian friends about Muslims and Islam. I saw the influences of politics in both Turkey and the Netherlands on religion, and I no longer accepted to attribute the tensions in Turkey only to Muslims or Islam. In 1982-1983, I spent an academic year on a field study of small farmers in a small Muslim village near Fariskur, Damietta [Dumiy<unk>t. ], which interrupted the work of our committee. I was used to attending church every Sunday. In Cairo, I had met with Coptic Orthodox Bishop Musa (b. 1938), consecrated in 1980 as the first Bishop of Youth, who told me of Father Boulos al-Hadidi [B <unk>lus al-Had<unk>d<unk>] (1935[B <unk>lus al-Had<unk>d<unk>] ( -2005) ) in Damietta, and decided to attend weekly services in his church in a city with only a small number of Christians. Regular meetings at his home about faith fascinated me because the Orthodox teaching was Bible-based, just as I had been taught in my Christian Reformed Church. Father Boulos' explanation that Bible and tradition go hand in hand made sense to me. I found the history of the church in Egypt going back to the early church after Jesus' life on earth fascinating. I have met with many young Christians wanting to leave Egypt, and each time, they explained that they would have insufficient opportunities to advance in life if they remained in Egypt. Many also did not want to stay in a country where public life is fully dominated by Islam. Emigration motives were mostly economical since descending from a Christian lower-or middle-class family often would not help them to create a better life in Egypt, where being part of a well-to-do family helps to advance in life. Sadly, for many youths, the only way to migrate to the West was through claiming persecution and applying for asylum, resulting in numerous claims that were either exaggerated or not true, but it often worked in the West, where many people did not trust Islam. Many Christian persecution stories that I later investigated were deeply impacted by this mechanism. I met with Dutch Jesuit priest Henk Van Ruijven, S.J. who invited me for visits to different places in Egypt where the Catholic church was active, including Minia [Miny<unk>], and introduced me to his fellow brother Frans Berkemeijer, S.J. (b. 1939), a strong advocate of dialogue, and Coptic Catholic Bishop Antonios Naguib [Naj<unk>b] of Minia (1935Minia ( -2022)). The bishop later became Patriarch and Cardinal and always remained supportive of the dialogue work I carried out in later years. Fr. Henk treasured personal friendships, regardless of someone's religious or denominational affiliation, and showed that the needs of Muslims and Christians were not much different; both suffered from poor economic conditions, poor education, and poor medical circumstances. Fr. Henk was concerned with individual people, showed compassion, irrespective of their beliefs. He helped me a lot to gain an understanding for Egypt and Egyptians. During this study year, Copts spoke a lot about the house arrest of Pope Shenouda III (1923-2012) in 1981. I befriended Dr. George Habib Bibawi [H. ab<unk>b Bib<unk>w<unk>] (1938-2021), professor of church history at the Coptic Orthodox Seminary, who was close to Fr. Matta al-Maskin [Matt<unk> al-Misk<unk>n], an influential church reformer in these days. Bibawi "accused Pope Shenouda of being ignorant of early church teachings and accused him of heresy" (Guirguis and van Doorn-Harder 2011, p. 186). Bibawi told me during these days that it was better Pope Shenouda had been removed from power since he saw him as a firebrand, who had used his position to push President al-Sadat into concessions for the church, but by doing so, had not only alienated the president, but also ruffled the feathers of many Muslims, which, in his view, was a major cause of the escalations into bloody collisions between Muslims and Christians. I felt sympathy for the positions of Fr. Matta al-Maskin and Dr. Bibawi, who argued for less political activism on the part of the head of their church and more separation between church and state since that would reduce tensions in society. However, I did not want to hear only stories critical of Pope Shenouda's handling of church-state relations, but to gather a different point of view. I was told that, in the UK, an Anglican priest by the name of Fr. Dr. John Watson (1939Watson ( -2014) ) had become extremely active in advocating for the release of Pope Shenouda, and I decided to visit him after my return to the Netherlands. Watson was adamant that no government should interfere in the internal policies of any church, and, thus, Pope Shenouda's monastic arrest was an anathema to him. Watson was an excellent and critical writer and used his access to the Archbishop of Canterbury to advocate for the release of Pope Shenouda, making him much loved by the Copts in the UK and the USA. We too became friends and frequently exchanged views about the church in Egypt. I tried to reconcile the opposing views about Pope Shenouda. Watson was an excellent sparring partner for this. After my return to the Netherlands, I picked up work with the committee that resulted in a 205-page report on Christian minorities from Eastern Turkey, and was presented to the Dutch Parliament on 14 February 1984. Work on the report made EO director Dorenbos instruct producer Pee Koelewijn to make a film about the last Armenians in Anatolia, Turkey with the intent to use this to lobby in Parliament to accept more Christian refugees from Turkey. I was unhappy about this production since I believed relevant context was left out for the sake of advocacy. While the EO focused on persecution claims, I wanted to investigate opportunities to support the remaining Syrian Orthodox continue in their traditional homeland. My report to parliament was greatly appreciated by Syrian Orthodox Bishop Julius Yeshu <unk>içek, since 1979 Archbishop of Central Europe. For my wish to seek support for the church in Tur Abdin, he showed less interest. He once explained to Henk Glimmerveen and me how he was growing his diocese by encouraging Syrian Orthodox to leave Turkey for settlement in Europe. I found this to be a selfish attitude, which damaged the Tur Abdin church since his encouragements contributed to the dwindling of the local church. My involvement with Christians from Turkey made me write my master's thesis under the supervision of Prof. Griffioen about factors leading up to the Armenian genocide in 1915 taking the lives of around 1.5 million people (Raheb 2021, pp. 65-72). I studied the growth of nationalism among Armenians, Turks, and other nations in the multi-religious and multi-linguistic Ottoman Empire, with foreign powers stirring up nationalist sentiments that aimed at weakening or destroying the Ottoman Empire. Both nationalist Armenians and nationalist Turks wanted to create national states dominated by one religious group, both claiming many of the same territories. This conflict had little to do with religious convictions, but rather with ethnicity tied to language and culture and so breaking away from the Ottoman Empire. Armenian nationalists were in the majority deeply secular, not showing much interest in living a pious Christian life, but used the label of Christianity for a decisively political purpose. My earlier experiences and thesis had altered my outlook on Christianity in the Muslim world, placing me in opposition to forms of nationalist ideologies in which ethnicity, linguistic identity, and religious heritage were fused to an extent that clashes with people with different nationalist and religious identities became inevitable. My studies at Leiden University had broadening my view of the world in which I had grown up. My interest was to contribute to the perseverance of the church in the Arab World, and this continuation of the Christian presence needed, in my opinion, dialogue, education, and development, not only for Christians in the Arab World, but for all. My study made me focus on empirical facts, intellectual trends, and the social relations between people, including the historical, political, cultural, religious, and economic aspects of societies, as well as social change, regardless of whether facts and analysis were convenient for particular groups or in line with prevalent convictions. After I graduated in 1984, I went for Dutch Interchurch Aid to Tur Abdin in Southeastern Turkey, to describe the position of the local Syrian Orthodox Church and make inquiries on what could be done to help the church remain in Tur Abdin. I was welcomed by Syrian Orthodox Bishop Timotheos Samuel Aktash (b. 1945) in the fifth-century Monastery of Mor Gabriel. I loved to see the monks, the school with dedicated young Syrian Orthodox students participating in the liturgy. The bishop took me to beautiful villages with ancient churches. It deeply struck me that the bishop lamented the efforts of Bishop <unk>içek to encourage Syrian Orthodox from Tur Abdin to move to Europe since this destroyed centuries-old local communities. The bishop had convinced me that if this community would disappear, that also their monasteries and churches would crumble. 12. Dutch Interchurch Aid supported the bishop's views and funded a second visit, leading me to Syrian Orthodox Bishop Yohanna Ibrahim [Y <unk>h. ann<unk> Ibr<unk>h<unk>m] (b. 1948) of Aleppo andH.H. Patriarch Mor Ignatius Zakka I Iwas (1933-2014) in Damascus, who both deeply deplored the departure of Syrian Orthodox from Tur Abdin and supported efforts for a development project. Dutch Interchurch Aid was unable to obtain the needed funding, but the visits provided much information on the demographic decline of the Syrian Orthodox in Tur Abdin. Bishop Aktash did not give up and was able to find other support. Churches, monasteries, and houses have been renovated; development projects were initiated; and pilgrimages to the heartland of the Syrian Orthodox Church in Turkey are made, which kept the local church alive. 13 Bishop Yohanna Ibrahim later spoke at the Apostolaat Oosterse Kerken (Apostolate Eastern Churches) in Tilburg, a Catholic organisation creating understanding for Eastern Orthodox churches, and argued that the future of the Syrian Orthodox Church lay in the Middle East, not in Europe nor North America. The Syrian Orthodox who had emigrated to Canada in the decades prior to the Second World War had disappeared in Canadian society, through mixed marriages and secularism. The current Syrian Orthodox Church in most Western countries consists mostly of first-and second-generation immigrants, with practically all priests coming from Tur Abdin and Syria. Since Europe and North America had become highly secularised, he did not believe the number of people being called to the priesthood would greatly increase in the West. Orthodox clergy in the West are making all efforts to maintain their communities, but it will not be easy. In the overwhelmingly Muslim Arab World, however, Christians are maintaining their own identity and culture in a region where they have been present since the early days of Christianity. Syria and other Arab countries in the 1980s were ruled by authoritarian rulers who accepted religious diversity, as long this would not challenge their rule. No one could have expected at that time that the Egyptian Revolution of January 2011 would be followed by an uprising of Sunni Muslims against the Alawi-dominated rule in Syria. Syrian Christians became major victims in this civil war since they had supported the Alawi rule. Bishop Yohanna was a true shepherd for his people and did not want to flee the violence of the civil war. I met the bishop again in 2012 at the opening of the King Abdullah bin Abdulaziz International Centre for Interreligious and Intercultural Dialogue (KAICIID) in Vienna, Austria. He believed he was still able and was obliged to talk with different warring parties to protect his own community as far as possible. Bishop Yohanna was not na<unk>ve, but followed what he believed was necessary for his church in Aleppo. Bishop Yohanna disappeared in 2013 while traveling with Greek Orthodox Metropolitan Boulos Yazigi [B <unk>lus Y<unk>zig<unk>] (b. 1959) of Aleppo to Latakia to negotiate the release of two kidnapped priests. No one knows which group kidnapped them on the road from Aleppo to Latakia. No one heard from them after this kidnapping. It is widely presumed they were killed, but nothing is certain. The destruction of Syria is a tragedy, but I do not think blaming Islam for the killings of Christians is right. Instead, this is a political conflict that uses religion to mobilise communities and justify violence. I am convinced that any religion can be used to encourage people to do good, but at the same time to commit horrendous crimes. Exposure to the views of Syrian Orthodox and later other Christian leaders in the Middle East made me realize that I had to be cautious with claims of discrimination and persecution made by Christian migrants from the Middle East, and I understood that I should always verify such claims with information obtained from local leaders. During my study year in Egypt, I had spoken to people about returning to Egypt for work with Coptic development projects through the Bishopric of Ecumenical and Social Services (BLESS). I met with Bishops Athanasius and Marcos (b. 1944), but things were to change. President Mubarak released Pope Shenouda from his monastic arrest, who, in turn, relieved Bishop Athanasius of his position and consecrated Bishop Serapion as the head of BLESS, who discontinued the talks for my position at his bishopric. Bishop Athanasius had been one of the committee-of-five who ruled the Coptic Orthodox Church after President Anwar al-Sadat had sent Pope Shenouda in exile to the Monastery of Bishoi, which was seen by Pope Shenouda as disloyalty. It was years before the two church leaders were reconciled. With this change, it was impossible to obtain a position at BLESS. In this period, I asked the church council of the Christian Reformed Church of Leiden for permission to become a member of the Coptic Orthodox Church in Egypt since I had become deeply impressed by the church, many of its bishops, priests, and members. I was not intending to leave the Christian Reformed Churches, but wanted to be a member of both churches, one in the Netherlands and another in Egypt. It took months of discussions in both Egypt and the Netherlands. Coptic Orthodox Metropolitan Bishoi (1942-2018) of Damietta spoke about rebaptism, while I argued, in line with my upbringing, that there is only one baptism. I spoke about the procedures with Dr. Isaac Fanous [F<unk>n <unk>s] (1919[F<unk>n <unk>s] ( -2007)), the

This paper argues that interreligious dialogue through study and friendships across the religious divide makes participants less susceptible to religious and cultural misinformation that is often used to maintain social bubbles, in which members draw clear boundaries between "us" and "them". Differences between social groups can culminate in a struggle between "good" and "evil" that can escalate into tension and violence. Preventing tensions and conflicts requires respect for differences, willingness to engage in dialogue, and a sound understanding of what religion is and the historical processes that have determined its development, distinguishing between empirical facts and images to which believers adhere. Because the author is a Dutch sociologist turned journalist from a conservative Christian family involved in interreligious dialogue in the Netherlands, Israel, and Egypt, the literature review presents contemporary religious developments in all three countries. The literature review is flanked by the author's personal narrative on the events that changed his views on truth and spirituality, making him more aware of the commonalities between peoples of different beliefs and leading him to a lifelong commitment to interreligious and intercultural dialogue.

-Sadat had sent Pope Shenouda in exile to the Monastery of Bishoi, which was seen by Pope Shenouda as disloyalty. It was years before the two church leaders were reconciled. With this change, it was impossible to obtain a position at BLESS. In this period, I asked the church council of the Christian Reformed Church of Leiden for permission to become a member of the Coptic Orthodox Church in Egypt since I had become deeply impressed by the church, many of its bishops, priests, and members. I was not intending to leave the Christian Reformed Churches, but wanted to be a member of both churches, one in the Netherlands and another in Egypt. It took months of discussions in both Egypt and the Netherlands. Coptic Orthodox Metropolitan Bishoi (1942-2018) of Damietta spoke about rebaptism, while I argued, in line with my upbringing, that there is only one baptism. I spoke about the procedures with Dr. Isaac Fanous [F<unk>n <unk>s] (1919[F<unk>n <unk>s] ( -2007)), the famous iconographer of the Coptic Orthodox Church, who introduced me to Fr. Antonios Am<unk>n of the St. Marcos Church in Cleopatra, Heliopolis, Cairo. Fr. Antonios asked for a letter from the Christian Reformed Church of Leiden stating that I was baptised with water in the name of the Father, Son, and Holy Spirit by an ordained minister who was ordained through the laying on of hands and a prayer to receive the Holy Spirit. I travelled to the Netherlands, met with the church council and Rev. Gerard den Hertog (b. 1949), and obtained the needed letter. Fr. Antonios went with this letter to the Coptic Orthodox Cathedral in Abassiya [ " Ab<unk>ssiya], Cairo, to ask permission to accept me as a member of the Coptic Orthodox Church, which they did, but I had to receive the Holy Mairun (oil) since this had not been administered to me in the Christian Reformed Church. Fr. Antonios anointed me with the Holy Mairun at the baptismal in his church, witnessed by my Dutch friend Eildert Mulder (b. 1949), after which he led the liturgy and preached about conversion in fact being a baptism. Bishop Musa was informed about this procedure, approved of it, and gave me the name 'Brother Cornelis.' There was no Coptic Orthodox Church in the Netherlands at the time, and becoming a member of both churches did not come up in discussion in Egypt. With the establishment of the Coptic Orthodox Church in the Netherlands in 1985, however, some members claimed that a dual membership of two different churches in one country was not possible. Bishop Marcos of France (1923France ( -2008)), the first European to be consecrated bishop in the Coptic Orthodox Church, 14 knew of my dual membership and asked me to join monastic life, seeing in me a potential successor to his bishopric in France. We both knew only Pope Shenouda could make that decision, but since most members in his diocese were non-Egyptian, it would be hard for an Egyptian to succeed him. I appreciated his trust in me, but declined (Hulsman 2008). I had come to see myself as ecumenical, being a link between the Coptic Orthodox Church and people coming from different traditions, but not in the position of a cleric. I had applied in October 1986 for the position of director of the Christelijke Emigratie Centrale (Christian Emigration Centre). Most members of the board were affiliated with the Anti-Revolutionary Party (ARP), and after the merger with two other Christian parties to the CDA, were actively involved in this political party. Reformed ARP politician Wil Albeda (1925-2014) had played a major role in the formation of the CDA and believed during his term as Minister of Social Affairs in 1977-1981 that providing emigration consultancy based on religion belonged to the past. During my tenure as the last director of the Christian Emigration Centre, I carried out several tasks: providing potential Dutch emigrants with information, advice, and referrals to relevant institutions about and in different emigration countries; working on my international church network for emigration; initiating exchanges with young people from Dutch emigrant communities abroad; starting a program to facilitate the emigration of refugees; building relationships with different embassies. I used my contacts with journalists for media publications, lobbied with other Dutch emigration centres at the Dutch Parliament, began documenting the history of the Christian Emigration Centre in a book, and arranged for the archives of the Christian Emigration Centre to be transferred to the Historisch Documentatiecentrum (Historical Documentation Centre of Dutch Protestantism) at the Free University Amsterdam (de Wit 1993). Instead of the centre simply being abolished, we reached a compromise with the Ministry of Social Affairs to merge the four emigration centres in 1991 in the Nederlands Migratie Institute (Netherlands Migration Institute, NMI), with the added task of remigration of migrant workers who wanted to return voluntarily to their home countries. I suggested to set up the Stichting Dienstverlening Emigratie Nederland (Netherlands Emigration Foundation), providing paid emigration services to make it self-sustainable and became its director, starting on 1 January 1994. The Netherlands Migration Institute abolished its emigration consultancy activities and thereafter only focused on remigration. It was hard work, but my interest in contributing to dialogue in Egypt had the overhand. --- Working in Egypt: Addressing Politically Motivated Images of Muslim-Christian Relations During my time in the Dutch emigration service, I frequently travelled to Egypt and promoted in the Netherlands knowledge about the church in Egypt and seeking support for Egypt's poorest Christians. During my travels I came to know Sawsan. We married in Egypt in 1988 after which she came to the Netherlands where we got three children (in 1998 our fourth child was born in Egypt). In the summer of 1994, Jos M. Strengholt (b. 1959), a well-known Dutch freelance correspondent for different Christian media in Egypt since 1988, asked me if I could take over his function since he would leave Egypt. I liked the idea of working for Christian media since that would enable me to focus on the position of Christians in Egypt and surrounding countries and engage in dialogue with the purpose of playing a role in reducing Christians leaving Egypt and the Arab World. I believed, at the time, this opportunity to return to Egypt was a call of God. The editors of the EO, TROS Television Radio Broadcasting Foundation, and RD Jos worked for told me they did not want a time lapse between his departure and my arrival. I would have to be in Egypt by 1 October 1994. This afforded me very little preparation time indeed. My announcement to resign as director of the Netherlands Emigration Foundation came as a shock to the board and staff. The experience with emigration consultancy, political lobby work, and fundraising turned out to be an excellent preparation for the uncertainties I would later face in Egypt. I also worked with the Katholiek Weekblad (Catholic Weekly), News Network International (later succeeded by Compass Direct) and Christianity Today in the USA. The focus of my media reporting was on Christians living in a predominantly Muslim society. It became a period of growing dissatisfaction with American Coptic political activists attributing social ills and tensions to Islam and (Islamist) Muslims that found its way in many Western Christian organisations and media and fuelled Islamophobia. Fr A few years after my family had moved to Egypt, the EO decided to end work with correspondents in the Arab World. Working for them was my main source of income, which led to a financially difficult period that prompted me to look for other sources of income. During this period Dirkjan Groot of Dorcas asked me if I would investigate the persecution of Christians in Egypt and report back to Dorcas, as this would help Dorcas conduct a fundraiser for persecuted Christians in Egypt. Dorcas would pay for this work. I asked if I would be permitted to write about the wider context and show nuances, but Dirkjan did not want nuance because that would not help his advocacy and fundraising activities. I declined. In 1995, the Dutch Christian organisation Open Doors asked me to investigate the stories of Christian human rights lawyer, Morris Sadek [Maurice S. <unk>diq] (b. 1942) about Christian girls in Egypt being kidnapped by Muslims and being forced to convert to Islam. Initial relations with Morris Sadek were good, and his stories sounded convincing, but, as time elapsed, I learned that S. adek met in most cases with fathers and brothers of converted girls in his office in Shubra, Cairo, and never made the effort to visit families on location to discover the various factors that led to conversions. I spent over one year working on this report. I wanted to understand the facts and learned through lots of interviews and discussing results with church leaders how complex reasons leading to conversions can be. Gradually, I discovered that for Morris Sadek, truth was subordinate to his belief that no Christian should ever convert to Islam, and when this happened, it always had to be the result of Muslim pressure or deception. I was surprised that Coptic activists, just like Sadek, were not at all interested in any background information, but continued in their belief that screaming "murder" would be the best way to stop or at least reduce the number of conversions to Islam taking place. My wife Sawsan played a significant role in this research, helping me to understand stories told in the wider Egyptian cultural context and receiving people for interviews at home. Open Doors introduced me in 1996 to Fieldstead and Company, the organisation of the wealthy Ahmanson family founded in Orange County, California, USA. They had been funding News Network International before it collapsed and were interested in my work on conversions of Christian girls in Egypt to Islam. Roberta Green Ahmanson told me she wanted to replace News Network International which had a focus on religious freedom in general, by a new organisation that would exclusively focus on persecution of Christians. This became the start of Compass Direct, co-funded by both Fieldstead and Company and Open Doors. I did not agree with the exclusive focus on the persecution of Christians. The Ahmansons were citing sources of Christian persecution based on information provided by Coptic activists and in the media, while I was speaking from personal experiences and research in Egypt that did not match those sources. Despite our differences, the Ahmanson's and their staff remained extremely courteous. Much of their information at this time came from Dr. Paul Marshall, who had previously worked with Dr. Griffioen at the Institute for Christian Studies in Toronto where Marshall was still based. Marshall at that time was working with Lela Gilbert on his book Their Blood Cries Out: The Untold Story of Persecution Against Christians (Marshall and Gilbert 1997). Fieldstead and Company provided a supportive environment for Marshall's work. The book, dealing with many different countries, including Egypt, was mainly based on the work of advocacy organisations, media reporting and advocates and experts from around the world that told a particular narrative about Christians and persecution (Marshall and Gilbert 1997, pp. xvii-xix) but not fieldwork. Marshall had, at the time, never visited Egypt, and, thus, his sources about Egypt were all second hand. The book became a best seller and a source of information for many people. After visiting Orange County, the Ahmansons flew me to Washington, DC, where they had arranged my stay in the Willard Intercontinental Hotel near Capitol Hill and the White House and arranged meetings with some congressional staffers about preparations in the House of Representatives for what later became the International Religious Freedom Act (1998). Just as my contact person at Open Doors had done before I left for the USA, inquiries were made if I could testify in Congress about the persecution of Christians in Egypt. However, those responsible first needed to be sure I would present a view in agreement with their perspective. I was well received, but I was not comfortable with their line of thinking in lobbying for the International Religious Freedom Act. After I had returned to Egypt, I expressed reservations about this act in various articles. In my estimation, a significant number of individuals and organizations involved with lobbying on behalf of the International Religious Freedom Act (1998) were at least partially driven by a Christian missionary agenda. As a Christian, I did not oppose Christian mission work, but I believed that it was important to provide a balanced view of the complex situations faced by Christian minorities in the Middle East. Later, in 1996, I met with Open Doors founder Anne Van der Bijl (also known as Brother Andrew, 1928Andrew, -2022) ) and told him that of course I wanted to support persecuted Christians and advocate human rights, but believed this had to be in the context of a better understanding of Muslim-Christian relations, including systematically following Egyptian media reporting about Christians in Egypt, engaging with Muslims and learn of their views about Christians, which later turned into a database. Anne Van der Bijl welcomed my aspirations and described this work as God's calling for me. Lutheran pastor and scholar of Coptic Church history Otto Meinardus, used to visit Egypt regularly to maintain his connections with Coptic Orthodox Church leaders and collect data for new articles and books. During each visit, I helped him as he gave me great insights into understanding the Egyptian Church and its traditions. Beliefs that I initially thought were certainties began to waver. He showed me how traditions were not as fixed as I initially believed, but changed over the generations under the influence of interests, struggles or other factors. Meinardus explained the difference between popular faith and official faith. Popular faith tends to be syncretistic. One can see this, for example, in Egypt in the similarities between the celebration of saints in the Coptic Orthodox Church and Muslim Sufis. Official faith, however, is what is taught by the clergy or other experts in a particular religion and is shielded by canonical religious texts (Meinardus 2002). Part of Coptic Orthodox faith is the widespread belief in miracles. Some have been officially sanctioned, such as the miraculous displacement of the Muqattam Mountains during the reign of Pope Abraham (between 975 and 978 A.D.); other miracle stories belong to the realm of popular faith, such as the apparition of the Blessed Virgin in 1997 in Shentena al-Hagar, which lasted a few weeks and attracted about 150,000 people at that time. My wife and I were among them. I could not believe the light flashes we saw were apparitions of the Holy Virgin as local people believed. This experience made me more cautious of miracle stories. Religious images are not harmless. In tensions between Christians and Muslims, religious images can develop into a stream of poisonous lies, embellishments, and accusations, often published in the Western press that I have resisted since I arrived in Egypt in 1994. That resistance also resulted in threats of those who had created those images (Mulder 2006). I have had numerous discussions with clergy and scholars about the Coptic Orthodox Sunday School Movement, a revival that began in the 1930s and was much opposed by the Orthodox bishops of the time. Reformers knew they only could change the church from within through monastic life. Reformers became monks, later bishops and with Pope Shenouda the first Sunday School reformer had become pope which resulted in consecrating bishops in line with his thoughts each time an old bishop had passed away. Reformers also clashed as we have seen in literature between Fr. Matta al-Maskin and Pope Shenouda neither of the parties thought of either leaving the church or expelling the other party from church which is related to the principle of accepting authority since authority comes from God (Mamd <unk>h. 2009). In 1999, I was asked to write a chapter for a book about the Coptic Orthodox Holy Family tradition (Gabra 2001). It enabled me to delve into the traditions of this ancient church and showed how stories of an ancient and more recent past are created and become relevant in the lives of people who believe in them. It became a confrontation between actual historical facts and wishful thinking and a desired to offer local Christians something to hold unto. Some bishops, including Bishop Dimitrius (b. 1948) of Malawi, insisted that Jesus had actually visited specific locations in Egypt while other bishops did not deny the tradition, but their faith was not tied to the belief that this tradition presented historical facts. Bishop Dimitrius' repeated statements claiming certainty where I saw none created in me more and more doubts about absolute truths. Income from journalism had severely dropped, yet I stubbornly refused to give up the mission I had started. In June 2000, economic problems and extreme work pressures led me to a severe form of pulmonary embolism that brought me very close to death with my wife wishing return to the Netherlands. Yet, after recovery I was asked to teach mass communication at the American University in Cairo which gave new hope that I could continue my mission. Kerk in Actie (Church in Action) gave an extra push to remain working in Egypt, helping us to form an Egyptian NGO and a company fostering mutual intercultural and interreligious understanding through building a database in Egypt. Not long after German NGOs Missio and Misereor joined in supporting this work. Various reports I worked on showed how social problems, cultural factors such as honour and shame, weak government policies but also religion contributed to the complex relationships and tensions between Muslims and Christians. Gradually I became convinced that there is no "good" or "bad": to understand how interreligious tensions can grow and develop, we must instead pay attention to events and understand the interconnection between social and political factors. The book about the Coptic Orthodox Holy Family tradition brought me in December 2002 in contact with Dr. Willem Kuiper, at the time assistant professor of Medieval Dutch Literature at the University of Amsterdam who had found a reference to De Goede Hof (The Good Garden) in Der leken spiegel (The Mirror for Lay People), an encyclopaedia written by Jan Van Boendale (ca. 1279-1350 CE) but was uncertain about its location in Egypt. I recognised in the description the garden around the tree of the Holy Family in Mattariya, once part of the ancient city of Heliopolis and today part of northern Cairo. Kuiper used my information for his article about De Goede Hof (Kuiper 2003). Kuiper explained that in understanding the development of Christianity in Europe we need to understand that in "late antiquity and Medieval times texts are not "descriptive" in the sense that they describe an "actual truth" but "normative": they describe a higher truth, whereby older and well-known texts served as models to steer an intended reception. Reading these text as "actual truths," as has been done by orthodox believers since the Reformation, is resulting in gross misunderstandings. Literature, both worldly and spiritual, is not of all times, but tied to time and place." 15 Kuiper's approach helped me in understanding debates about Christian-Muslim relations since orthodox Christian and Muslim believers so often refer back to their own textual heritage. The Bible, Qur'an and other holy books I came to understand as scriptures that are written by people who saw God's hand in personal experiences and circumstances around them. The texts interact with human feelings such as love, anger, fear and hope that are perennial. Authors have been influenced by literature preceding them even though we may no longer have access to many of these texts from antiquity and the beliefs and circumstances of their times. Scriptural texts were also often influenced by the political circumstances that shaped their context. This suggests that what is written in the holy books is partly related to time and place and partly is wisdom literature that helps us deal with various issues that arise in daily life. Our book on the Holy Family led me to the study of Egyptian locations mentioned in the Bible. In 2007-2008 Egyptologist Dr. Lutfy Sherif [Lut. f<unk> Shar<unk>f] drew my attention to the book, Canaan and Israel in Ancient Times (Redford 1992). Redford showed that Biblical history and the historical/archaeological records often do not match. This did not match with my faith of God inspiring the various Bible authors. If the text was divinely inspired, how could it contain texts that were in violation with the historical/archaeological records? Not all people I came in contact with agreed to my changing views on scriptures. American editor Rick Anderson took the text of the Bible "as absolutely true" and "the infallible word of God." At the time, I corresponded with Dr. Larry Levine, an Orthodox Jew teaching mathematics at Stevens Institute of Technology, New York. Both believed that God is a God of miracles. If the archaeological and historical records do not match with the text, then the text is right, and we must seek for explanations that leave no doubt to the historical accuracy of the text (Anderson 2003). I came from a similar faith tradition, but the ease of various religious leaders to manipulate factual truths led me to stop believing in the absolute certainties that so many Orthodox had taught. My focus shifted from discussions of increasingly elusive certainties to a focus on living together. Another way to address misunderstandings that can evolve into tensions is to listen to the wisdom we find in other religions and cultures. Egyptian philosopher and former minister Hamdi Zaqzouq [H. amd<unk> Zaqz <unk>q] (1933-2020), whom I have met on several occasions, stated that since we live in a very diverse world, it is of paramount importance that we can relate to others who are different from us and compared humanity to sailors on a ship. "We must cooperate in order to sail the ship into a safe harbour. Humanity must cooperate if we want to keep earth inhabitable for our children and grandchildren" (S. al<unk>h. 2004). Since 1997 my wife and I have worked on building a database about the role of religion in Egyptian society resulting in the foundation of Centre for Intercultural Dialogue and Translation company (CIDT) in 2005. This attracted the attention of Prof. Andreas van Agt (b. 1931), Prime Minister of the Netherlands, 1977-1982, who visited Egypt in 2006 and lectured at different universities and the Lions Club about dialogue, met with Egypt's Minister of Foreign Affairs and the head of the Arab League and each time underlining the importance of intercultural and interreligious dialogue. The European funded Anna Lindh Foundation financed improvements to our database with a network with similar minded organisations in Europe and the Arab World which was launched by HRH Prince El-Hassan Bin-T. al<unk>l in Amman, Jordan, 2008, who describe the database as a "vector for change" (El-Hassan Bin-T. al<unk>l 2008). In 2007 the Egyptian NGO Centre for Arab-West Understanding (CAWU) was founded by leading representatives of all churches and the Azhar as well as a number of influential scholars and media representatives 16 and became the vehicle of student internships, Egyptian and non-Egyptian, Muslim, Christian, secular or whatever religion students adhered to. Between 2008 and 2022, CAWU hosted 427 student interns, who contributed in various ways, for periods ranging from one to twelve months, to interreligious dialogue that was reflected in numerous reports in the Arab-West Report database that my successor Dr. Matthew Anderson in 2022 renamed Dialogue Across Borders; Emerging Perspective on Intercultural and Interreligious relations. CAWU's contribution has been unique in that it has maintained good relations with all Egyptian religious institutions while remaining independent of each. Until 2011 CAWU was probably the only Egyptian organisation with such a wide diversity of leading religious representatives. This changed with the formation of the Bayt al-Ayla (House of the Family) after a terrible bomb attack on worshippers of the Two Saints Church in Alexandria on 1 January 2011 that claimed the lives of 23 people and injured 97 people. Each of the churches and al-Azhar that participate in Bayt al-Ayla has its own dialogue activities, either selffunded or through own fundraising. Representatives represent their religious institution and are bound by the beliefs and policies of their institutions. That makes Bayt al-Ayla different from CAWU. Bayt al-Ayla has grown out to be a major and influential centre for interreligious dialogue in Egypt. Sadly, Bay al-Ayla is not well known outside Egypt. Egypt experienced great instability in the years 2011-2014 when Islamists were striving for power and later pushed into the margins. This period made them visible and accessible which gave us unique opportunities to interview also radical Jihadi Salafis and in 2014 we even had the spokesperson of Bin-Laden's al-Qaida visit our office and meet with our students. He wanted to talk, and I had prepared our students: ask 'why' questions but do not engage in argumentations about what in his statements is true or not. These radical Islamists presented Islam as the victim of Western powers. These meetings were lessons to us but of course we should not expect change in one meeting but every opportunity to meet people radically different from us should be taken. In 2020 Egyptian student intern Nour Saad, a graduate of the 'Deutsche Evangelische Oberschule' (DEO, German Evangelical High School) and student in Germany, interned at CAWU resulting in a paper of religious education at the DEO during which students in the last two school years follow cooperative religious education, whereby Christian students learn to understand the religious language of Muslim students and vice versa. When this initiative started Egyptian educational authorities responded with hesitation. In 2020 the Ministry of Education announced the introduction of subject of ethics and principles in Egyptian schools. This is clear proof, Nour Saad concludes, that progress in the field of interreligious education in Egypt is made which gives hope for the future (Saad 2020). --- Conclusions The research question we sought to answer with this paper concerns how we can contribute to interreligious dialogue by seeing the world from different points of view. At the same time, the paper tried to explain how this has influenced my faith in the context of the differences between religious orthodoxy and religious liberalism, intertwined with political influences in Dutch, Israeli and Egyptian cultures, deeply influenced by Abrahamic beliefs. Since World War II, American Evangelical influences aimed to strengthen Orthodox Christianity in the Netherlands and Egypt, as well as the State of Israel, believing that this was "God's will," often merging with Islamophobic prejudices. The paper argues that interreligious dialogue should not only concern members of different religions, but also orthodox and religious liberalism. The paper concludes that deeply held beliefs about one's own truth are linked to an absence of awareness of the broader historical context, the positions of the parties involved and their beliefs, understanding that these are not static, but dynamic and constantly changing over time. Both literature and personal narratives show a strong intertwining of religion and politics through ideologically driven institutions and media that aim to promote the interests of their own social bubble with associated stories and myths. The conclusion is that interreligious dialogue should strive to separate myth from factual truth, which is far from easy because of the various interests involved. Evidence in the literature and personal narratives also show people's personal social bubbles can expand through personal friendships across religious borders, in which personal faith can be questioned. The personal narrative adds the importance of having one or more long-term personal mentors in interreligious dialogue, providing guidance, connections, and encouragements. A pluralist attitude can contribute to promoting the common good that, in turn, needs interreligious dialogue to build bridges of understanding and create social and political solidarity that is needed to address world-encompassing issues that keep our earth inhabitable for our children and grandchildren. There is also a need to offer students opportunities to expand their understanding of different religious beliefs with tutors who can introduce them to widely different believers living in circumstances that contrast with their own experiences. The student interns the author has worked with were given the opportunity to actively engage in activities and share their experiences with others through contributions to the Arab-West Report/Dialogue Across Borders database. Further research could be conducted on separating myth from factual truth in reporting about interreligious relations, the interaction between religion and politics, and other authentic dialogue experiences. How can a better understanding of the relationship between religion and politics be communicated to committed orthodox Jews and Muslims and temper the religious angle in the political conflict between Israel and Palestinians? How often do serious approaches to interreligious dialogue lead to a more liberal understanding of faith? What other factors may play a role in such an outcome? Why do some people retain their original beliefs more or less? --- Data Availability Statement: All data are publicly accessible. Email correspondence referenced in this paper is stored in the database of Dialogue Across Borders. --- Conflicts of Interest: The author declares no conflict of interest.

This paper argues that interreligious dialogue through study and friendships across the religious divide makes participants less susceptible to religious and cultural misinformation that is often used to maintain social bubbles, in which members draw clear boundaries between "us" and "them". Differences between social groups can culminate in a struggle between "good" and "evil" that can escalate into tension and violence. Preventing tensions and conflicts requires respect for differences, willingness to engage in dialogue, and a sound understanding of what religion is and the historical processes that have determined its development, distinguishing between empirical facts and images to which believers adhere. Because the author is a Dutch sociologist turned journalist from a conservative Christian family involved in interreligious dialogue in the Netherlands, Israel, and Egypt, the literature review presents contemporary religious developments in all three countries. The literature review is flanked by the author's personal narrative on the events that changed his views on truth and spirituality, making him more aware of the commonalities between peoples of different beliefs and leading him to a lifelong commitment to interreligious and intercultural dialogue.

Introduction The Sustainable Development Goals were introduced by the United Nations in 2015 with the objective of eradicating poverty and reducing inequality by 2030. In China, a significant developmental disparity exists between urban and rural areas. The Report of the 20th National Congress of the Communist Party of China (CPC) identified the advancement of balanced regional development and urban-rural integration as a crucial step toward facilitating high-quality growth. Although traditional economic models have favored urban areas over rural regions owing to their abundance of resources and higher productivity levels [1], the digital age has presented opportunities for rural communities to leverage technology and drive innovation, transformation, and growth within the digital economy [2]. Examining the impact of Internet development on urban-rural consumption inequality can shed light on the role and potential of the Internet in reducing these economic disparities and achieving sustainable development. Consumption inequality closely mirrors income inequality, often to a greater extent than indicated by overall reported expenditures [3,4]. Economists typically focus on individuals' utility function, which pertains to consumption and leisure rather than income [5]. The consumption gap provides a distinct indication of welfare disparities among socioeconomic groups compared with the income gap [6]. It reflects the imbalanced distribution of consumption resources, capabilities, and opportunities, influenced by individual differences in abilities as well as disparities in resources and opportunities [7]. Empirical evidence based on data from the Urban Household Survey (UHS) suggests that consumption inequality in urban China has increased by 67% during the sample period, surpassing the original figure of 36% reported by raw data. The disparity in consumption was more pronounced in the central and western regions, which played a pivotal role in driving up consumption inequality [8]. Expenditure inequality exhibits a greater magnitude in China compared with India, whereas income inequality is less pronounced. These variations can be attributed to differences in population demographics, with China being more urbanized and having smaller household sizes, as well as divergences in conditional income distributions based on the achieved educational level of the household head [9]. Information and communication technologies (ICTs), particularly the Internet, have been considered essential in facilitating market access, reducing transaction costs, and augmenting income for a significant proportion of individuals residing in developing nations since the beginning of the century [10]. Internet accessibility has a positive impact on poverty reduction, with greater benefits seen in the rural sector for reducing extreme income and multidimensional poverty compared with urban areas [11]. Digital inclusive finance, based on the Internet, can effectively narrow the per capita disposable income gap between urban and rural areas [12]. Although the Internet presents a potential solution for mitigating health disparities, ameliorating income inequality, promoting healthier lifestyles, and mitigating depression, the existence of a "digital divide" among rural residents, elderly individuals, and low-income populations highlights the urgent need for redress [13]. The digital divide can be observed across multiple levels, including inter-country, inter-regional, and socio-demographic (such as race, age, income, education, etc.) groups [14][15][16][17]. Researchers have shifted their focus from the first-level digital divide of Internet access to the second-level digital divide, which refers to the "soft" gap caused by differences in communication literacy and levels of Internet use [18]. In other words, uniform availability and proficiency in ICTs are not evenly distributed across different consumer segments [19]. The Internet has facilitated the digital transformation of the economy and has had a significant impact on social development. For example, the digital economy can effectively drive household consumption, with a more pronounced impact on urban residents than rural residents [20]. Digital economic development has also significantly contributed to enhancing the economic structure and material well-being of the elderly population [21]. Certain studies suggest that digital finance has the potential to mitigate consumption inequality by boosting household trickle-down consumption, particularly among low-income groups. Moreover, the level of digital financial development within a county is positively correlated with the amount of trickle-down consumption in Chinese households [22,23]. Recent research has focused on the inverted-U-shaped relationship between the development of the digital economy and the urban-rural consumption gap [24]. However, contrasting findings have been reported in other studies. On the basis of the data from the China Family Panel Studies (CFPS) covering 155 counties between 2010 and 2016, Internet penetration may cause an increase in consumption inequality. Additionally, higher education and a certain threshold of Internet penetration can mitigate the negative effects of the Internet [25]. Previous research has conducted comprehensive investigations into the correlation between Internet-related content and consumption, as well as its inequality. However, most studies focus only on the inequality of food or energy consumption while failing to comprehensively analyze the causes and shifts in the urban-rural consumption gap [26][27][28]. This leaves room for debate. First, the impact of Internet-related content on consumption inequality remains a contentious issue. Second, most studies fail to account for nonlinear relationships. Third, many empirical studies use provincial panels, leading to imprecise findings. Therefore, this study aims to explore the impact of Internet development on urban-rural consumption inequality, as well as the potential influencing mechanisms. The remainder of the paper is structured as follows. First, drawing on a comprehensive literature review, we propose four research hypotheses and the corresponding theoretical framework to examine the impact of Internet development on urban-rural consumption inequality. Second, we employ panel data of prefecture-level cities or above from 2016 to 2019 to empirically examine the aforementioned hypotheses as well as conduct robustness tests and heterogeneity analyses. Third, we summarize and analyze the findings and providing corresponding recommendations. --- Theoretical Analysis and Research Hypothesis The development and application of the Internet have strengthened the interconnectedness between urban and rural areas, resulting in improved factor allocation, upgraded industrial structure, and impacted income distribution. The widespread use of the Internet has the potential to greatly enhance the consumer structure of individuals [29,30]. It is expected that the Internet will serve as a significant impetus in dismantling the urban-rural dual structure and unleashing consumption potential for both urban and rural residents. However, the existence of a "digital divide" among rural residents, elderly individuals, and low-income populations has resulted in new disparities in opportunities and impeded equitable access to the advantages of digital resources [31]. This may potentially exacerbate consumption inequality between urban and rural areas. Owing to the objective fact of uneven development between urban and rural areas and the difference in the ability of urban and rural residents to use the Internet, the above "digital dividend" and "digital divide" may have different manifestations in different stages of development. Therefore, we posit Hypothesis 1: Hypothesis 1. The impact of Internet development on urban-rural consumption inequality exhibits a nonlinear relationship. China faces the objective reality of imbalanced regional economic development and the urban-rural dual structure [31]. These factors contribute to a significant digital divide between the eastern, middle, and western regions of China as well as between cities and urban and rural areas. Urbanization, as a crucial driver for China's leapfrog development, is closely linked to the distribution of income between urban and rural areas and consumption inequality. Urban areas, as important spatial carriers for economic activities, also provide essential infrastructure and talent support for the growth of the Internet. In general, a higher level of urbanization corresponds to a smaller digital divide, indicating that the level of urbanization may impact the relationship between Internet access and consumption inequality in urban-rural areas [32]. Therefore, we posit Hypothesis 2: Hypothesis 2. Urbanization has a threshold effect on the impact of Internet development on urban-rural consumption inequality. A significant urban-rural income disparity will inevitably result in a substantial consumption gap between urban and rural residents [3,4]. The application and development of the Internet deeply affect the income level and distribution of urban and rural residents [33]. As a universal informational medium, the Internet narrows the urban-rural divide by facilitating the exchange and sharing of information, enhancing the mobility of labor resources, and improving resource allocation. This significantly improves the income level of rural residents. The Internet, as a cost-effective and efficient method of information acquisition, reduces the costs associated with information searching, thus enhancing job matching efficiency, promoting employment opportunities and entrepreneurship, facilitating industrial upgrading, and diversifying income sources for residents. The rapid development of the Internet not only provides employment opportunities for farmers and improves their income level, but also accelerates the accumulation and optimization of their human capital [34], ultimately impacting the income gap between urban and rural areas. Based on Keynes' absolute income hypothesis, consumption is determined by income. The income gap between urban and rural residents has a significant positive effect on the consumption gap. Therefore, we posit Hypothesis 3: Hypothesis 3. Internet development impacts urban-rural consumption inequality through its influence on urban-rural income inequality. The industrial structure has a significant impact on urban-rural consumption inequality [35,36]. With the advent of the Internet era, it has driven the modernization and development of the service industry, manufacturing industry and agriculture with information technology, gradually linking all aspects of the national economy. The integration of the Internet and traditional industries is a double-edged sword for China's economy. In the case of inadequate innovation, the rapid development of the service industry over the manufacturing industry may lead to a premature industrial structure, which will have a negative impact on sustained economic growth [37]. This is especially evident when workers move from high-productivity manufacturing departments to low-productivity service industries such as food delivery. Premature industrial structure in the process of industrial evolution means that although the industrial structure is close to that of developed countries, the contradiction between supply and demand or sluggish demand and insufficient effective supply cannot be effectively resolved due to the lack of per capita income and national innovation capacity. Premature industrial structures constrain the development of the manufacturing industry, trigger a retreat in the industrial sector, result in sluggish national economic growth, and increase the risk of falling into the "middleincome trap" [38], further affecting the consumption sector and its urban-rural inequality. Therefore, we posit Hypothesis 4: Hypothesis 4. Internet development impacts urban-rural consumption inequality through its influence on the premature industrial structure. Figure 1 presents the mechanism diagram, briefly illustrating the main ideas of Hypotheses 1 to 4. A nonlinear relationship and a threshold effect between Internet development and urban-rural consumption inequality can be concluded. The influencing mechanism is that the Internet development affects urban-rural consumption inequality by influencing urban-rural income inequality and premature industrial structure. their human capital [34], ultimately impacting the income gap between urban and rural areas. Based on Keynes' absolute income hypothesis, consumption is determined by income. The income gap between urban and rural residents has a significant positive effect on the consumption gap. Therefore, we posit Hypothesis 3: --- Hypothesis 3. Internet development impacts urban-rural consumption inequality through its influence on urban-rural income inequality. The industrial structure has a significant impact on urban-rural consumption inequality [35,36]. With the advent of the Internet era, it has driven the modernization and development of the service industry, manufacturing industry and agriculture with information technology, gradually linking all aspects of the national economy. The integration of the Internet and traditional industries is a double-edged sword for China's economy. In the case of inadequate innovation, the rapid development of the service industry over the manufacturing industry may lead to a premature industrial structure, which will have a negative impact on sustained economic growth [37]. This is especially evident when workers move from high-productivity manufacturing departments to low-productivity service industries such as food delivery. Premature industrial structure in the process of industrial evolution means that although the industrial structure is close to that of developed countries, the contradiction between supply and demand or sluggish demand and insufficient effective supply cannot be effectively resolved due to the lack of per capita income and national innovation capacity. Premature industrial structures constrain the development of the manufacturing industry, trigger a retreat in the industrial sector, result in sluggish national economic growth, and increase the risk of falling into the "middle-income trap" [38], further affecting the consumption sector and its urban-rural inequality. Therefore, we posit Hypothesis 4: --- Hypothesis 4. Internet development impacts urban-rural consumption inequality through its in- fluence on the premature industrial structure. --- Materials and Methods --- Variables Selection The variables in this study mainly include explained variables, core explanatory variables, a threshold variable, mechanism variables, and control variables. The details are as follows: --- Explained Variable Urban-rural consumption inequality can be measured using various methods in academic research [12]. The first method is absolute consumption inequality, which subtracts rural residents' consumption from urban residents' consumption. However, the relative degree of consumption inequality is challenging to determine due to the significant consumption disparities between cities. The second approach involves calculating the Gini coefficient based on the Lorenz curve. Although this indicates overall consumption inequality, the contribution of intra-group and inter-group gaps is difficult to determine. The third method is relative consumption inequality, which uses the ratio of urban to rural residents' consumption. However, this cannot accurately reflect the impact resulting from changes in the proportion of urban and rural populations. The fourth method is the Theil index, which has the significant advantage of decomposability, allowing the urban-rural gap to be separated from the overall gap while maintaining consistency. The Theil index can also reflect changes in urban and rural consumption polarization while considering demographic factors. Higher values indicate higher levels of inequality. In this paper, the Theil index is used to measure the total urban-rural consumption inequality, combining existing popular practices. The formula for the Theil index is as follows: theil it = C u,it C it ln( C u,it C it / P u,it P it ) + C r,it C it ln( C r,it C it / P r,it P it )(1) C u,it, C r,it, respectively, represent the urban and rural consumption expenditure of year t in city i. P u,it, P u,it, respectively, represent the urban and rural permanent population of year t in city i. C it, P it, respectively, represent the total consumption expenditure and total population in both urban and rural areas of year t in city i. --- Core Explanatory Variable The core explanatory variable in this study is the level of Internet development. The Tencent Research Institute's China Internet Plus Index is used as a proxy variable to measure Internet development. To account for measurement differences, the variable is logarithmically transformed. --- Threshold Variable We employ the level of urbanization as a threshold variable, which is measured by the proportion of urban permanent residents in the total population of the region. --- Mechanism Variables Referring to the research of Zou et al. [6] and Tian et al. [39], we select the urban-rural income inequality and the industrial structure upgrading as the mechanism variables. The urban-rural income inequality is also expressed by the Theil index. The industrial structure precocity is represented by the ratio of value added by the tertiary industry to that of the secondary industry minus 1. --- Control Variables To mitigate the endogeneity problem arising from missing variables, this study incorporates significant regional economic characteristic variables that impact urban-rural consumption inequality as control variables. Based on previous research [13,25] and considering the theoretical impact of control variables on dependent variables, the following control variables are selected: economic development level (measured by GDP per capita, logarithmically processed), industrial structure (expressed as the proportion of workers in the tertiary industry), fiscal expenditure (expressed as the proportion of general fiscal expenditure budget to GDP), educational expenditure (expressed as the proportion of educational expenditure to GDP), level of economic openness (expressed as foreign-invested enterprises' industrial output as a percentage of GDP), and unemployment rate (expressed as the proportion of urban registered unemployed people to the total population). --- Data Source and Processing Data for the core explanatory variables are obtained from the Tencent Research Institute's "Internet Plus" Index Report for China, which provides a comprehensive reflection of the Internet development status of cities in several dimensions. Data for urban-rural consumption inequality, disposable income inequality, industrial structure, and control variables are collected from the China Statistical Yearbook and EPS data platform for cities at the prefectural level or above. Panel data from 2016 to 2019 are selected and processed as the sample for this research. Samples with missing main variables are removed, and some missing values are filled in. The data are then combined into balanced panel data, resulting in 1323 observations. Table 1 provides the descriptive statistical results for the main variables. During the sample period, the minimum, maximum, and standard deviation of urban-rural consumption inequality (measured by the Theil index) for each city are 0.001, 0.319, and 0.035, respectively, indicating certain differences in the urban-rural consumption gap among cities. The level of Internet development varies from 0.048 to 3.604, highlighting significant differences in the level of Internet development among cities in China. The multicollinearity test results show that the variance inflation factor (VIF) values of all variables are less than 10, indicating no multicollinearity among the variables. In this study, the Hausman test first significantly rejects the original hypothesis, indicating that the fixed effects model should be selected. To assess the joint significance of time dummy variables, we incorporated them into the individual fixed effects model and conducted an F statistic test. The results indicate the necessity of incorporating time fixed effects. Therefore, we employ a panel two-way fixed effect econometric model to examine the impact of Internet development on urban-rural consumption inequality. To investigate the potential nonlinear relationship, we introduce the quadratic term of Internet development into the model. Specifically, we construct the following panel model: theil it = <unk> 0 + <unk> 1 net it + <unk> 2 net 2 it + <unk>Z it + <unk> t + u i + <unk> it(2) In model (2), i represents cities at or above the prefecture level, whereas t denotes the year. The variable theil it refers to the urban-rural consumption inequality; net it is the Internet development index; net 2 it represents the squared term of the Internet development index; Z it stands for a series of control variables; <unk> t, u i, and <unk> it reflect the year fixed effects, the city fixed effects, and the random disturbance term, respectively. --- Threshold Regression To further investigate the potential threshold effect in the nonlinear relationship between the Internet development and the urban-rural consumption inequality, we construct a dynamic panel single-threshold model. Based on our theoretical analysis in the previous section, we utilize the level of urbanization as a threshold variable in the following model: theil it = <unk> 0 + <unk> 1 net it <unk> I(urb <unk> <unk>) + <unk> 2 net it <unk> I(urb <unk>) + <unk>Z it + <unk> t + u i + <unk> it (3) In model (3), urb represents the threshold variable; <unk> represents the value at which to test the threshold; and I(•) is an indicator function for the threshold model that equals 1 if true in parentheses and 0 otherwise. --- Results --- Benchmark Regression Model Estimation The regression estimation was performed on the benchmark regression model (2), and the results are presented in Table 2. To ensure the robustness of the findings, we examined the regression results by transitioning from linear mixed OLS regression to nonlinear mixed OLS regression, two-way fixed effect and two-way fixed effect with control variables added. Columns (1)-( 4) display the regression results for each model variation. The consistent and significant negative effect of Internet development on urbanrural consumption inequality is observed at the 5% significance level, but its squared term consistently and significantly indicates a positive effect. We give precedence to the findings presented in column (4). In the context of low Internet development, a linear relationship prevails, wherein each unit increase in the level of Internet development corresponds to a 0.5% decrease in the urban-rural consumption inequality index. Conversely, in high Internet development scenarios, a nonlinear relationship emerges, where each unit increase leads to a 0.2% increase in the urban-rural consumption inequality index. This finding confirms the existence of a U-shaped relationship between Internet development and urbanrural consumption inequality, thus supporting Hypothesis 1. These findings align with the research of Tian et al. [39] and Jiang et al. [40], who previously established a U-shaped relationship between Internet development and both the urban-rural gap and premature industrial structure. The digital divide and digital dividends resulting from Internet development vary across different stages of its evolution, highlighting the importance of investigating the potential nonlinear relationship between Internet development and urban-rural consumption inequality. --- Threshold Regression Model Estimation Initially, we conduct a regression analysis using the three-threshold model, and the results indicate that only the p-value associated with the single threshold is less than 0.1, suggesting the suitability of the single threshold model for this study. In Table 3, we analyze the impact of Internet development on urban-rural consumption inequality by incorporating the level of urbanization as a threshold variable. The results indicate a threshold effect of urbanization on the impact of Internet development on urban-rural consumption inequality, providing support for Hypothesis 2. Additionally, our regression analysis reveals that Internet development has a significant impact on increasing urbanrural consumption inequality when the level of urbanization is below 0.3474. However, this impact becomes insignificant once the level of urbanization exceeds 0.3474. These findings suggest that a low level of urbanization is not conducive to the Internet's role in bridging the consumption gap between urban and rural areas. To validate the threshold results, we perform a likelihood ratio test (LR test) on the outcomes obtained from the single threshold model, as illustrated in Figure 2. The results demonstrate that the LR statistical graph of the single threshold intersects with the horizontal line, indicating the passing of the significance test and ensuring the authenticity of the threshold result. becomes insignificant once the level of urbanization exceeds 0.3474. These findings suggest that a low level of urbanization is not conducive to the Internet's role in bridging the consumption gap between urban and rural areas. To validate the threshold results, we perform a likelihood ratio test (LR test) on the outcomes obtained from the single threshold model, as illustrated in Figure 2. The results demonstrate that the LR statistical graph of the single threshold intersects with the horizontal line, indicating the passing of the significance test and ensuring the authenticity of the threshold result. Municipalities directly under the central government possess comparative advantages in political, economic, transportation, and technological resources [38], which results in well-developed Internet infrastructure. This simultaneous change in the Internet development index and urban-rural consumption inequality in these municipalities may --- Robustness Analysis 4.3.1. Change of Samples Municipalities directly under the central government possess comparative advantages in political, economic, transportation, and technological resources [38], which results in welldeveloped Internet infrastructure. This simultaneous change in the Internet development index and urban-rural consumption inequality in these municipalities may introduce a self-selection bias in estimation results. In the benchmark regression, we control for citylevel fixed effects to mitigate this issue. Furthermore, to enhance the robustness of our analysis, we exclude samples of municipalities directly under the central government. The regression results presented in column (1) of Table 4 are consistent with the benchmark regression results, confirming their robustness. --- Endogenous Test To address endogeneity, we carefully select appropriate instrumental variables that can effectively control for potential confounding effects. The infrastructure of local post offices affects subsequent stages of Internet development, as it serves as a continuation of traditional communication technology. Its influence on economic development gradually diminishes with decreased frequency of use, ensuring exclusivity. Following methods used by Zhao et al. [41] and Nunn and Qian [42], we construct an interaction term using the number of Internet users in China from the previous year and the number of Post Offices Per Billion People in each city in 1984 as instrumental variables for measuring Internet development during that year. In examining the U-shaped relationship using the instrumental variable approach, we include a squared term of the instrumental variable. The 2SLS estimation is manually conducted in this study, which may increase the variance of the estimation coefficients in the second stage; nevertheless, the results remain unbiased estimators [43]. The regression results are shown in columns (2)-( 4) of Table 4. The variables post and post 2 represent the instrumental variable and its squared term, respectively. From the regression results of the second stage, we observe that the U-shaped effect of Internet development on urban-rural consumption inequality remains significant even after considering endogeneity. The first-stage results demonstrate that the instrumental variables exhibit a high correlation with the core explanatory variable, as indicated by their highly significant coefficients. The overall F statistic of the model rejects the null hypothesis, indicating the absence of a weak instrumental variable problem. In general, the validity of the instrumental variables is verified. --- The Empirical Tests of Influence Mechanism 4.4.1. Urban-Rural Income Inequality This study calculates the Theil index of urban-rural income inequality and regresses it with the level of Internet development as the explained variable. The control variables are consistent with the benchmark regression. The regression results are presented in columns ( 1)-(2) of Table 5. The coefficient of the core explanatory variable exhibits a negative but insignificant effect, whereas the quadratic term displays a positive and significant impact. This indicates that the impact of Internet development on urban-rural income inequality is not nonlinear. Therefore, the present study employs a linear regression model. Column (2) reveals that the impact of Internet development on urban-rural income inequality is significantly positive, which, in turn, affects urban-rural consumption inequality through the former [3]. Hence, Hypothesis 3 is confirmed. --- Premature Industrial Structure Referring to the research of Tian et al. [39], it is evident that a U-shaped relationship exists between Internet development and the precocity of the industrial structure. Therefore, this study continues to use nonlinear models to verify the relationship between the two. The regression results presented in column (3) of Table 5 reveal a U-shaped relationship between Internet development and premature industrial structure, providing support for Hypothesis 4, and reinforcing the causal relationship posited in Hypothesis 1. The potential explanation for these findings is that in contexts of low Internet development, the utilization of this technology can enhance labor productivity and manufacturing efficiency within enterprises (industries). Concurrently, the Internet has expedited labor market mobility and bolstered employment rates within the service industry [44][45][46][47][48][49], thereby promoting the upgrading of the industrial structure and reducing consumption inequality. However, a high level of Internet development may lead to an excessive transfer of production factors from primary and secondary industries to the tertiary industry. When the national capacity for innovation and overall labor productivity within the tertiary industry are insufficient to sustain high-quality economic growth over time, it can result in a premature industrial structure and aggravate urban-rural consumption inequality. --- Heterogeneity Analysis The spatial distribution of Internet development in China exhibits clear agglomeration characteristics, prompting this study to investigate the heterogeneity of its impact on urbanrural consumption inequality across different city clusters. Urban agglomerations, as the most dynamic and competitive core areas in economic development patterns, typically exhibit compact spatial organization and close economic links [50]. Owing to significant regional heterogeneity in industrial structure and development stage, the impact of Internet development on urban-rural consumption inequality may vary greatly. With consideration of the development planning and level of urban agglomerations in China, this study primarily examines the heterogeneity in five major agglomerations: Beijing-Tianjin-Hebei (BTH), Yangtze River Delta (YD), the Pearl River Delta (PRD), Chengdu-Chongqing (CC) and the middle reaches of Yangtze River (MY). Considering the consistency in sample size and geographical location of city clusters, this study classifies the three major urban agglomerations (BTH, YD, and PRD) into one group, while dividing CC and MY into another group. All cities outside of these aforementioned city clusters are classified into a third group for regression analysis. The grouped regression results are shown in columns ( 4)-( 6) of Table 5. A significant difference is noted in the results between city clusters and other cities. Specifically, in other cities, the impact of Internet development on urban-rural consumption inequality exhibits a significant U-shaped relationship, consistent with the regression results of the full sample. For the cities of BTH, YD and PRD, Internet development significantly exacerbates the urban-rural consumption inequality. However, for the cities of CC and MY, it significantly alleviates such inequality. The reason for this disparity may lie in the fact that BTH, YD, and MY, as China's three world-class agglomerations, boast a relatively high level of economic and Internet development. However, they lack sufficient support for innovation and productivity, resulting in significant urban-rural income inequality and a premature industrial structure, which ultimately exacerbates consumption inequality. On the other hand, for the agglomerations in the central region, namely CC and MY, they have not yet reached the standard to lead to premature industrial structure. Instead, they promote industrial upgrading and reduce urban-rural consumption inequality. --- Discussion China's internet penetration rate reached nearly 50% in 2014, marking the advent of the "Internet+" era and presenting a unique opportunity for development. However, it is crucial to remain cognizant of the double-edged sword effect that comes with internet development. Internet development can directly facilitate consumption upgrading and market renewal. Simultaneously, by improving information exchange and resource allocation, it can promote industrial upgrading, economic growth, employment increase, and indirectly provide stable support for expanding domestic demand. However, the digital divide between urban and rural residents has a significant impact on urban-rural consumption inequality caused by Internet development. Building upon the relevant research conducted by Tian (2021) and Luo (2021), we systematically examine the nonlinear relationship and influencing mechanism between Internet development and urban-rural consumption inequality. The research conclusions are as follows: First, a U-shaped relationship exists between Internet development and urban-rural consumption inequality. That is, with Internet development, the urban-rural consumption inequality index will first decline and then rise. The main reason is that Internet development that is not matched with technological breakthrough and product innovation will lead to a premature industrial structure and further affect economic development and urban-rural consumption inequality. In the whole country and other cities except for the five major urban agglomerations, the U-shaped relationship between Internet development and urban-rural consumption inequality is statistically consistent and stable, indicating that Internet development is a double-edged sword. Second, the level of urbanization exhibits a threshold effect on the relationship between Internet development and urban-rural consumption inequality. When the level of urbanization is below 0.3474, Internet development will exacerbate urban-rural consumption inequality. Finally, Internet development will affect urban-rural consumption inequality by influencing urban-rural income inequality and premature industrial structure. --- Practical Implications Based on the above research conclusions and the previous theoretical analysis, this paper proposes the following policy implications: First, we must fully leverage the positive impact of the Internet on urban-rural consumption inequality. The Internet has penetrated into all links of the intra-product division of labor and has different degrees of impact on employment in the labor market and the labor productivity of the production link. We should fully exploit the role of the Internet in resource reallocation, deeply explore and continuously unleash the dividends of IT, digitalization and networking development, and maximize the scale effect and network effect of Internet development. For example, we can expand internet services by improving their application content, enhance societal digital capabilities, reinforce governmental efforts toward digital transformation and promote data-driven governance. Second, a precise analysis of regional disparities must be conducted, taking into full account the U-shaped impact of Internet development on urban-rural consumption inequality. For BTH, YD and other economically developed regions, the primary focus should be on bolstering their internet development advantages by augmenting investments in technological innovation and enhancing production efficiency within the service industries. For the cities with average or poor development in central and western China, they should promptly address the deficiencies in their information infrastructure construction, leverage the positive impact of Internet development, and establish an innovative model for urban-rural interaction development, both inter-regionally and intra-regionally. This can effectively mitigate resource allocation disparities across different areas and address the issue of unbalanced regional and urban-rural development. Third, as we increase the scale and intensity of our investments in the Internet, regional disparities in urbanization development must be considered. All regions should adhere to the objective law of coordinated economic development, conduct policy research on integrating the Internet and urbanization based on local conditions, and establish and improve relevant guarantee mechanisms. Only by surpassing the threshold of urbanization can we fully leverage the constraining effect of Internet development on urban-rural consumption inequality. Fourth, we should facilitate the effective integration of the Internet with industry, particularly in manufacturing, to compensate for the dearth of technological breakthroughs and product innovation. We must harness the innovative potential of the Internet to drive evolution toward a "Kuznets" industrial structure within both the manufacturing and service sectors, thereby achieving sustained growth in macroeconomic conditions and domestic demand. Fifth, the digital divide among vulnerable groups must be addressed and digital dividends should be created for them. Enhancing the digital skills of marginalized populations such as farmers and elderly individuals is crucial in bridging this gap. We should reinforce effective linkages between poverty alleviation and rural revitalization policies to narrow the digital divide across all regions during the process of Internet development. Fiscal and urbanization policies must be coordinated to promote equitable access to digital dividends and vigorously advocate for "equal internet speed" in both rural and urban areas. In addition, the equalization of basic public services should be promoted. We should improve educational resource allocation and provide training programs to enhance digital literacy, thereby enabling individuals to increase their income levels and fully realize their consumption potential. --- Limitations and Future Research There are several limitations to this study. First, the sample scope is limited. Due to the lack of some indicators, the selection of cities within China may not be inclusive, potentially leading to biased results. Future research can consider expanding the sample size and incorporating a more diverse range of cities to enhance the generalizability of the findings. Second, the data in this study only begin from 2016 due to the availability and accuracy of Internet development index data. As such, this study fails to explore the relationship between Internet development and urban-rural consumption inequality before then. Future research can consider incorporating earlier data to provide a more comprehensive understanding of the long-term trends and dynamics. Third, although we find that the level of urbanization exhibits a threshold effect on the relationship between Internet development and urban-rural consumption inequality, we do not examine whether other factors also influence this relationship. Future research can explore the interaction effects between Internet development and various contextual factors to gain a deeper understanding of the complex dynamics at play. In future research, a multidimensional index system can be established to comprehensively evaluate the development status and trends of the Internet in China. Additionally, other factors that impact the relationship between Internet development and urban-rural consumption inequality can be further investigated to promote their mutually beneficial growth. --- Data Availability Statement: Data resources are clear in Section 3.2 of this article. No new data were created or analyzed in this study. Data sharing is not applicable to this article due to privacy. --- Author Contributions: Conceptualization, J.Z.; formal analysis, Z.L. and H.W.; writing-original draft, Z.L. and J.Z.; writing-review and editing, Z.L. and H.W. All authors have read and agreed to the published version of the manuscript. Funding: This research was funded by Hunan Provincial Innovation Foundation for Postgraduate (Grant Number: CX20220629). --- Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. --- Conflicts of Interest: The authors declared no potential conflict of interest with respect to the research

The impact of the digital dividends from Internet development on urban and rural residents is influenced by the existing urban-rural dual structure, resulting in heterogeneous and time-varying impacts on urban-rural consumption inequality. This study aims to investigate the nonlinear effect and mechanism of the Internet development on urban-rural consumption inequality in China. Using panel data from 263 prefecture-level cities between 2016 and 2019, we employ a two-way fixed effect model and a threshold model to examine this relationship. The findings of our study are as follows: (a) Internet development exhibits a U-shaped relationship with urban-rural consumption inequality. This U-shaped relationship is statistically consistent and stable in the whole country and in cities outside the five major urban agglomerations. (b) The level of urbanization acts as a threshold for the relationship between Internet development and urban-rural consumption inequality. (c) The influence of Internet development on urban-rural consumption inequality operates through its impact on income inequality and premature industrial structure. To effectively harness the positive impact of Internet development in reducing urban-rural consumption inequality, several key aspects deserve attention: acknowledging regional disparities and leveraging the Internet's positive impact on urbanrural consumption inequality, considering the joint effects of Internet and urbanization developments, addressing digital divides among vulnerable groups, and promoting effective integration between the Internet and industry, particularly in manufacturing.

factors to gain a deeper understanding of the complex dynamics at play. In future research, a multidimensional index system can be established to comprehensively evaluate the development status and trends of the Internet in China. Additionally, other factors that impact the relationship between Internet development and urban-rural consumption inequality can be further investigated to promote their mutually beneficial growth. --- Data Availability Statement: Data resources are clear in Section 3.2 of this article. No new data were created or analyzed in this study. Data sharing is not applicable to this article due to privacy. --- Author Contributions: Conceptualization, J.Z.; formal analysis, Z.L. and H.W.; writing-original draft, Z.L. and J.Z.; writing-review and editing, Z.L. and H.W. All authors have read and agreed to the published version of the manuscript. Funding: This research was funded by Hunan Provincial Innovation Foundation for Postgraduate (Grant Number: CX20220629). --- Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. --- Conflicts of Interest: The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article.

The impact of the digital dividends from Internet development on urban and rural residents is influenced by the existing urban-rural dual structure, resulting in heterogeneous and time-varying impacts on urban-rural consumption inequality. This study aims to investigate the nonlinear effect and mechanism of the Internet development on urban-rural consumption inequality in China. Using panel data from 263 prefecture-level cities between 2016 and 2019, we employ a two-way fixed effect model and a threshold model to examine this relationship. The findings of our study are as follows: (a) Internet development exhibits a U-shaped relationship with urban-rural consumption inequality. This U-shaped relationship is statistically consistent and stable in the whole country and in cities outside the five major urban agglomerations. (b) The level of urbanization acts as a threshold for the relationship between Internet development and urban-rural consumption inequality. (c) The influence of Internet development on urban-rural consumption inequality operates through its impact on income inequality and premature industrial structure. To effectively harness the positive impact of Internet development in reducing urban-rural consumption inequality, several key aspects deserve attention: acknowledging regional disparities and leveraging the Internet's positive impact on urbanrural consumption inequality, considering the joint effects of Internet and urbanization developments, addressing digital divides among vulnerable groups, and promoting effective integration between the Internet and industry, particularly in manufacturing.

Introduction Since 2016, nineteen companies across multiple industries, including Google, Uber, and Tesla, have been involved in developing self-driving cars, aiming at commercializing self-driving cars for the road by 2021 [1]. The U.S. government has supported the movement of introducing self-driving cars by diminishing the related regulations [2]. In Europe, the U.K. government also announced their strong support for self-driving cars [3]. In Asia, the South Korean government allowed companies such as Samsung and Hyundai to test self-driving cars on public roads [4]. Altogether, clear evidence suggests that self-driving cars are becoming a worldwide trend due to immense potential benefits. Although commercial autonomous cars are likely to be safe and reliable, potential adopters will still experience a high level of uncertainty about the safety, reliability, and control of these vehicles [5,6]. Uncertainty is a major hindrance to technological adoption [7] because if people are uncertain about how the vehicle will behave, they will be reluctant to relinquish control to the autonomous system. Such uncertainty can be reduced through vehicle design approaches that help users trust and thus adopt the technology [8,9]. The present paper builds on the notion that people respond to computational technologies following the social rules that govern normal human interaction [10]. Specifically, we focus on the potential for an autonomous vehicle voice agent (AVVA) to display social characteristics that affect the experience of the autonomous vehicle passenger (AVP) and thus willingness to adopt autonomous vehicles. This paper utilizes the technology acceptance model (TAM) as a theoretical framework to examine how an AVVA's style (informative vs. sociable) and gender influence the perceived ease of use (PEU) and usefulness (PU) of the autonomous vehicle itself, thereby influencing intention of adoption. --- Literature Review --- Technology Acceptance Model to Adoption of Intelligent Technology Davis [11] adopted the Theory of Reasoned Action (TRA) to explain how people accept technologies (Figure 1). TRA suggests causal relationships between beliefs, attitudes, and intentions. Based on this notion, Davis [11] reasoned that perceived beliefs toward technologies influence intentions to adopt technologies. Since Davis [11] proposed the technology acceptance model (TAM), the model has been tested and supported by a large number of empirical studies. The core concepts of the model include PEU and PU. TAM predicts that people are more likely to adopt a technology when it is perceived as easy to use and useful. Also, PEU has been found to influence PU [11]. Scholars have extended the model by adding other contextual variables, including social influence and environmental influence [12,13]. The TAM is a useful theoretical framework for investigating the determinants of internal beliefs of use. Although substantive academic works have focused on adoption of Computer-Mediated Communication (CMC) technologies such as email, telecom, internet, and e-commerce [14], scholars have expanded the TAM to the context of human-computer interaction. For instance, Heerink et al. used the TAM to explain the adoption of a healthcare robot for the elderly [15]. The TAM framework has also been used to investigate the mechanism of technology acceptance. However, as we enter the fourth industrial revolution, researchers are striving to better understand the psychological processes that influence adoption of intelligent technologies that interact autonomously with humans, such as autonomous vehicles. Choi and Ji [16] investigated adoption of autonomous vehicles and, as the TAM predicted, found that PEU and PU lead to adoption. In particular, the results showed that PU was a stronger predictor than other variables. The current study intended to replicate these previous findings based on TAM as a foundational step for the present research. Building on a conventional understanding of TAM, we hypothesize the following: Hypothesis 1 (H1). The PEU of an autonomous car will positively influence the PU of the autonomous car. Hypothesis 2 (H2a,b). Intention of adopting an autonomous car will be influenced by (a) the PEU and (b) the PU of an autonomous car. --- Intelligent Technology as Social Actors Mobile technologies are becoming increasingly intelligent. Voice assistant systems such as Siri, Alexa, and Google Home, can set schedules, read articles, and entertain people by telling jokes. Although these intelligent technologies can only mimic human communications based on pre-existing algorithms, these mimicked behaviors are enough to elicit social presence, defined as the degree of perceiving an object as a social other [17]. The question of how people interact with technologies is becoming increasingly significant as people have more chances to encounter intelligent entities that are not human. Early research on this topic concluded that humans interact with technologies the same ways as they interact with other humans [18]. In other words, people treat computers as social actors (CASA). Research examining human interaction with technologies have supported the idea of CASA and found that people perceive human features such as gender and personality in technologies [19][20][21]. People also naturally apply various social rules, such as social identification [20], similarity-attraction [9,19], and gender stereotypes [20,22], when interacting with technologies. According to the CASA paradigm, social science theories can be extended into the context of human-technology interaction in order to better design assistant technologies. In the current study, we consider a dual-process model to frame the types of information that an AVVA can communicate in order to influence drivers' perceptions. Dual-process models generally describe differences between intuitive and reasoning-based cognitive processes [23]. That is, an AVVA can be designed to appeal to intuitive cognitive processes by being sociable or to reasoning-based cognitive processes by providing task-related information. Returning to autonomous vehicles and the TAM, we expect that an AVVA would lead to different perceptions depending on whether it is informative or social. These attributes of an AVVA should influence perceptions of the autonomous vehicle. Although the AVVA is only one piece of the larger assemblage of the autonomous vehicle, it potentially serves as the primary information interface between the user and the technology. Thus, we expect that TAM factors for an AVVA are applicable to the entire technology. More specifically, we expect that the extent to which an AVVA is informative and/or sociable will influence TAM factors (PEU and PU) as related to the autonomous vehicle and thus willingness to adopt autonomous vehicles in general. People tend to heuristically ascribe social identities to technologies when the technology displays social cues such as sociability and friendliness [10]. Further, such sociability cues can contribute to PEU. Anxiety toward robots has been found to negatively relate to ease of use [24]. Just as people can reduce other's anxiety by acting friendly and sociably toward those others, the anthropomorphic cues of sociability and friendliness may reduce anxiety towards the technology and subsequently increase PEU. Thus, we predict the following with respect to an AVVA's sociability characteristics and PEU. --- Hypothesis 3 (H3). A sociable AVVA will induce more autonomous vehicle PEU than an informative AVVA. On the other hand, an AVVA can appear more intelligent by providing dynamic updates of the driving environment, which should contribute to the AVP's situational awareness and thus sense of control [25]. Belief in system transparency, the degree of prediction of the technology's operation, is associated with PU and adoption intention [16]. If a technology provides information that people can use to predict surroundings or behavior of technology, they perceive it to be more useful. Hence, we expect that an AVVA that informs the AVP with dynamic situational updates will be perceived as more useful. --- Hypothesis 4 (H4 ). An informative AVVA will induce more autonomous vehicle PU than a sociable AVVA. The effects of AVVA gender is also a topic of interest. Agent gender plays an important role in people's responses to such technologies [26,27]. Reactions to an agent's communication style are influenced by gender stereotypes developed through interactions with humans. Multiple studies have identified gender differences in communication style (e.g., [28,29]). For instance, scholars have found that communication from men tends to be more task-oriented (i.e., informative) while women tend to adopt more socially-oriented (i.e., sociable) communication styles [30][31][32]. Given these patterns, gender stereotyping occurs in interactions with technologies. Nass and colleagues found that both male and female participants perceived that evaluation from a male-voiced computer is more valid than evaluation from a female-voiced computer due to the gender stereotype that men are more dominant and influential [22]. Studies have found that people tend to apply the same gender stereotypes to synthetic, computer-generated voices as they do human voices and this affects how people make decisions while interacting with technology [20,33,34]. Notably, studies have found a stereotype-driven matching effect: Male voices are perceived as more authoritative in general, but female voices are trusted and preferred more in contexts that are stereotypically feminine, such as love and relationships [22,35]. Returning to the context of AVVAs and autonomous vehicles and building on this previous literature, the match between an AVVA's communication style and gender will influence perceptions of the autonomous vehicle. Connecting this to TAM, we predict that AVVA gender moderates the effect of communication styles on PEU and usefulness such that a social female AVVA and informative male AVVA will be preferred over AVVAs that reflect a gender/style mismatch. --- Hypothesis 5 (H5 ). An informative male AVVA and a social female AVVA will be perceived as easier to use than an informative female AVVA and a social male AVVA. --- Hypothesis 6 (H6 ). An informative male AVVA and a social female AVVA will be perceived as more useful than an informative female AVVA and a social male AVVA. Further, given that TAM scholars have found that PEU and PU play roles of mediators [36], we test for the same relationship in the current context. We hypothesize that both variables will mediate the influence of AVVA style and gender on intention of adoption. Hypothesis 7 (H7). PEU and PU will mediate the influence of AVVA style and AVVA gender on intention of adopting an autonomous car. In addition, given that, in general, PEU and PU have a strong association with each other [36,37], certain features of a technology increasing PEU may increase PU indirectly. Thus, we hypothesize PEU will mediate the influence of AVVA style and AVVA gender (as a moderator) on PU. H5: An informative male AVVA and a social female AVVA will be perceived as easier to use than an informative female AVVA and a social male AVVA. H6: An informative male AVVA and a social female AVVA will be perceived as more useful than an informative female AVVA and a social male AVVA. Further, given that TAM scholars have found that PEU and PU play roles of mediators [36], we test for the same relationship in the current context. We hypothesize that both variables will mediate the influence of AVVA style and gender on intention of adoption. H7: PEU and PU will mediate the influence of AVVA style and AVVA gender on intention of adopting an autonomous car. In addition, given that, in general, PEU and PU have a strong association with each other [36,37], certain features of a technology increasing PEU may increase PU indirectly. Thus, we hypothesize PEU will mediate the influence of AVVA style and AVVA gender (as a moderator) on PU. H8a,b: PEU will mediate a) the influence of AVVA style and b) the influence of AVVA gender (as a moderator) on PU. --- Methods --- Experiment Design and Procedure An online experiment survey was distributed to undergraduate students at an American university (N = 158; 43 men, 114 women, 1 unreported; mean age = 21.51; SD = 6.86). Participants were randomly assigned to one of the four conditions, 2 (AVVA style-informative or social) by 2 (AVVA gender-male or female). Two participants skipped one item each from a measure of PU and PEU. For these two participants, the missing response was replaced with the mean for their other responses so they would not be excluded from the analysis. This approach did not change the mean value of the respective metric for each individual participant. Participants were given a small amount of course extra credit for their participation. They watched a driving simulation and listened to one of the assigned AVVA voices. Participants were given the following instruction before watching the video of the autonomous car simulation: "Please view the following video in FULL SCREEN MODE with your volume ON. Imagine that you are sitting in the vehicle itself during this experience. Please watch the full video clip (<unk> 5 min), then exit full screen mode and complete the questions about the experience." The simulation lasted 5 min and 20 s. After the simulation, participants were asked to complete a set of survey questions. Note that item order within the questionnaire was randomized within blocks of questions to reduce potential ordering effects. --- Experiment Treatments --- Methods --- Experiment Design and Procedure An online experiment survey was distributed to undergraduate students at an American university (N = 158; 43 men, 114 women, 1 unreported; mean age = 21.51; SD = 6.86). Participants were randomly assigned to one of the four conditions, 2 (AVVA style-informative or social) by 2 (AVVA gender-male or female). Two participants skipped one item each from a measure of PU and PEU. For these two participants, the missing response was replaced with the mean for their other responses so they would not be excluded from the analysis. This approach did not change the mean value of the respective metric for each individual participant. Participants were given a small amount of course extra credit for their participation. They watched a driving simulation and listened to one of the assigned AVVA voices. Participants were given the following instruction before watching the video of the autonomous car simulation: "Please view the following video in FULL SCREEN MODE with your volume ON. Imagine that you are sitting in the vehicle itself during this experience. Please watch the full video clip (<unk>5 min), then exit full screen mode and complete the questions about the experience." The simulation lasted 5 min and 20 s. After the simulation, participants were asked to complete a set of survey questions. Note that item order within the questionnaire was randomized within blocks of questions to reduce potential ordering effects. --- Experiment Treatments The virtual agent's voice was generated by Amazon Polly which is a web-based service that turns text into a voice [38]. A female voice named Joanna and a male voice named Matthew were used. The generated voice files were edited on Audacity to synchronize the recorded scene and the voice [39]. For the social AVVA, messages were constructed to focus on relational aspects of communication by disclosing personal information, making jokes, and referring to users' potential concerns [40]. For the informative AVVA, the script was designed to focus on providing information about the autonomous car's actions as well as the surrounding environment, such as the weather, speed limit, and traffic signals [40]. The scripts for both agents are available in Appendix A. City Car Driving software was used to generate the driving simulation (see Figure 2). This software is commercially available and allows users to practice basic driving skills in a realistic city environment [41]. To generate an autonomous car experience, a driving simulation scene was recorded while a researcher drove the car. This recording, along with verbal prompts provided by an AVVA, were played back during the study. Multimodal Technol. Interact. 2019, 3, x FOR PEER REVIEW 5 of 12 voice [39]. For the social AVVA, messages were constructed to focus on relational aspects of communication by disclosing personal information, making jokes, and referring to users' potential concerns [40]. For the informative AVVA, the script was designed to focus on providing information about the autonomous car's actions as well as the surrounding environment, such as the weather, speed limit, and traffic signals [40]. The scripts for both agents are available in Appendix A. City Car Driving software was used to generate the driving simulation (see Figure 2). This software is commercially available and allows users to practice basic driving skills in a realistic city environment [41]. To generate an autonomous car experience, a driving simulation scene was recorded while a researcher drove the car. This recording, along with verbal prompts provided by an AVVA, were played back during the study. --- Measurements --- Manipulation Check Perception of the AVVA as informative ("The virtual agent focused on providing me with driving-related information," and "The virtual agent primarily talked to me about driving-related information,") and sociable ("The virtual agent was interested in socializing with me," and "The virtual agent was sociable,") were used to check the manipulations as well as in the analyses. Composites were created from means for the informative measure (Cronbach's alpha =.87) and social measure (Cronbach's alpha =.86). --- Perceived Ease of Use PEU was derived from a previous study [11]: "It would be easy to learn how to operate an autonomous car," "I would find it easy to get an autonomous car to do what I want it to do," "Interacting with an autonomous car would not require a lot of my mental effort," and "I would find it easy to use an autonomous car" (Cronbach's alpha =.84). --- Perceived Usefulness PU was derived from a previous study [11]: "Using an autonomous car would increase my productivity," "Using an autonomous car would increase my driving performance," "Using an autonomous car would enhance my effectiveness on the driving task," and "Using an autonomous car would be useful for driving" (Cronbach's alpha =.87). --- Measurements --- Manipulation Check Perception of the AVVA as informative ("The virtual agent focused on providing me with driving-related information," and "The virtual agent primarily talked to me about driving-related information,") and sociable ("The virtual agent was interested in socializing with me," and "The virtual agent was sociable,") were used to check the manipulations as well as in the analyses. Composites were created from means for the informative measure (Cronbach's alpha = 0.87) and social measure (Cronbach's alpha = 0.86). --- Perceived Ease of Use PEU was derived from a previous study [11]: "It would be easy to learn how to operate an autonomous car," "I would find it easy to get an autonomous car to do what I want it to do," "Interacting with an autonomous car would not require a lot of my mental effort," and "I would find it easy to use an autonomous car" (Cronbach's alpha = 0.84). --- Perceived Usefulness PU was derived from a previous study [11]: "Using an autonomous car would increase my productivity," "Using an autonomous car would increase my driving performance," "Using an autonomous car would enhance my effectiveness on the driving task," and "Using an autonomous car would be useful for driving" (Cronbach's alpha = 0.87). --- Intention of Adoption Intention for future use was measured with a composite measure derived from a previous study [16]: "I intend to use an autonomous car in the future," "I expect that I would use an autonomous car in the future," and "I plan to use an autonomous car in the future" (Cronbach's alpha = 0.96). A 5-point Likert scale were used for all measurements. --- Results Two manipulation checks were conducted. AVVA style was found to significantly influence the perception of the AVVA as informative, F (1, 156) = 55.98, p <unk> 0.001, partial eta-squared = 0.33, with informative perception being higher in the informative AVVA condition (M = 4.02, SD = 0.86) than the sociable AVVA condition (M = 2.83, SD = 0.84). Also, perception of the AVVA as social also differed by style, F (1, 156) = 61.65, p <unk> 0.001, partial eta-squared = 0.28, with social perception being higher in the sociable AVVA condition (M = 3.17, SD = 0.83) than the informative AVVA condition (M = 1.99, SD = 1.06). Neither AVVA gender nor the interaction between AVVA style and gender significantly influenced these manipulation check measures. These results suggest the manipulations were successful. The hypotheses were tested through structural equation modeling using AMOS (v. 20). To test the interaction effects of AVVA's style and gender, we used the contrast coefficient approach. We coded matched conditions (i.e., information = 1 * male = 1 and social = -1 * female = -1) as 1 and mismatched conditions (information = 1 * female = -1 and social = -1 *male = 1) as -1. We checked the fit of the model. For cross sectional research, it is suggested to report the Root Mean Square Error of Approximation (RMSEA), Tucker-Lewis Index (TLI), and Comparative Fit Index (CFI) [42]. Regarding the criteria of model fits, RMSEA of 0.01, 0.05, and 0.08 indicates excellent, good, and mediocre fit, respectively [43]. For TLI and CFI, fit values above 0.95 indicate an excellent model fit [44]. The study results showed that the suggested model has an excellent or good fit, <unk>2 = 107.21, df = 71, p = 0.004, RMSEA = 0.057, TLI = 0.967, CFI = 0.975. Supporting H1-the PEU of an autonomous car will positively influence the PU of the autonomous car-PEU significantly influenced PU, <unk> = 0.88, SE = 0.08, p <unk> 0.001. Participants who perceived autonomous cars as easy to use were more likely to perceive autonomous cars as useful. Supporting H2a and H2b-intention of adopting an autonomous car will be influenced by (a) PEU and (b) PU of the vehicle's AVVA-PEU significantly influenced intention of adoption, <unk> = 0.37, SE = 0.17, p = 0.014, along with PU, <unk> = 0.51, SE = 0.18, p <unk> 0.001. Participants expressed higher autonomous car adoption intent when they perceived more autonomous car ease of use and usefulness. Providing no support for H3 (a socializing AVVA will induce more PEU than an informative AVVA), the results showed that AVVA style did not influence perceived autonomous car ease of use, <unk> <unk> 0.003, SE = 0.09, p = 0.97. There was no evidence supporting H4 (an informative AVVA will induce more PU than a socializing AVVA). AVVA style was not found to influence perceived autonomous car usefulness, <unk> = -0.016, SE = 0.05, p = 0.78. Supporting H5-AVVA gender will moderate the influence of AVVA style on PEU-AVVA gender moderated the influence of AVVA style on perceived autonomous car ease of use such that an informative male AVVA and a sociable female AVVA was perceived as easier to use than an informative female AVVA and a sociable male AVVA, <unk> = 0.17, SE = 0.09, p <unk> 0.05. Providing no support for H6-AVVA gender will moderate the influence of AVVA style on PU-no moderation effect was found, <unk> = -0.03, SE = 0.06, p = 0.61 (See Figure 3 for the graphical representation of the results). Providing no support for H7a and H7b-PEU and PU will mediate (a) the influence of AVVA style and (b) AVVA gender (moderating effect) on the intention of adopting an autonomous car-PEU and PU did not mediate the influence of AVVA style, <unk> = -0.006, CI = [-0.15, 0.13], nor the AVVA gender moderating effect on autonomous car adoption intention, <unk> = 0.13, CI = [-0.02, 0.27]. Regarding H8a and H8b-PEU will mediate (a) the influence of AVVA style and (b) AVVA gender (moderating effect) on PU-PEU was not found to mediate the influence of AVVA style on PU, <unk> = 0.003, CI = [-0.14, 0.16]. However, PEU mediated the influence of the AVVA gender moderating effect on PU, <unk> = 0.15, CI = [0.003, 0.30]. The moderating effect between AVVA's style and gender indirectly influenced PU through PEU. In other words, the finding that stereotypically matched conditions (informative male or sociable female AVVA) led to greater PU than mismatched conditions (sociable male or informative female AVVA) was mediated by PEU. Multimodal Technol. Interact. 2019, 3, x FOR PEER REVIEW 7 of 12 and gender indirectly influenced PU through PEU. In other words, the finding that stereotypically matched conditions (informative male or sociable female AVVA) led to greater PU than mismatched conditions (sociable male or informative female AVVA) was mediated by PEU. --- Discussion This research explored how autonomous vehicle voice agent (AVVA) design influences autonomous vehicle passenger (AVP) intention to adopt autonomous vehicles. Results suggest that AVVA design influences perceptions of the autonomous vehicle, as reflected by the core factors of the technology acceptance model, perceived ease of use (PEU) and perceived usefulness (PU), both of which strongly predicted autonomous vehicle adoption intention. No evidence was found for the predicted main effects of AVVA style (informative versus sociable) on PEU or PU. However, results indicated that AVVA gender moderated the relationship between AVVA informativeness and sociability on PEU (directly) and PU (indirectly, through PEU) in ways that were consistent with gender stereotypes. These results offer new insights into the role of stereotype consistency in the technology acceptance model as well as the importance of considering agent style and gender in the design of voice agents. Participants perceived an autonomous vehicle as easier to use and more useful when there was stereotypical consistency between the AVVA style and gender. Namely, consistent conditions (informative male AVVA and social female AVVA) fostered greater PEU and PU than inconsistent conditions (social male AVVA and informative female AVVA). This is consistent with previous studies which have found that gender stereotypes guide the ways that people respond to virtual agents [20,33,34], such as the perception that male-voiced computers are generally more dominant and influential, but female-voiced computers are trusted and preferred more when discussing stereotypically feminine topics, such as love and relationships [22,35]. The present research makes a contribution beyond these previous studies by illustrating that stereotypical consistency in a voice agent influences not only the perception of the voice itself, but also the PEU and PU of the technology that the voice agent represents. Given the strong influence of PEU and PU on adoption intention, this research suggests that stereotypical consistency is an important consideration when examining technology adoption, especially in the context of autonomous technologies represented by voice agents. This finding is consistent with the notion that more intuitive interfaces increase PEU [45]. The CASA (computer as social actor) paradigm suggests that people mindlessly apply various social interaction rules, such as gender stereotypes, to human-computer interaction [19][20][21]. In other --- Discussion This research explored how autonomous vehicle voice agent (AVVA) design influences autonomous vehicle passenger (AVP) intention to adopt autonomous vehicles. Results suggest that AVVA design influences perceptions of the autonomous vehicle, as reflected by the core factors of the technology acceptance model, perceived ease of use (PEU) and perceived usefulness (PU), both of which strongly predicted autonomous vehicle adoption intention. No evidence was found for the predicted main effects of AVVA style (informative versus sociable) on PEU or PU. However, results indicated that AVVA gender moderated the relationship between AVVA informativeness and sociability on PEU (directly) and PU (indirectly, through PEU) in ways that were consistent with gender stereotypes. These results offer new insights into the role of stereotype consistency in the technology acceptance model as well as the importance of considering agent style and gender in the design of voice agents. Participants perceived an autonomous vehicle as easier to use and more useful when there was stereotypical consistency between the AVVA style and gender. Namely, consistent conditions (informative male AVVA and social female AVVA) fostered greater PEU and PU than inconsistent conditions (social male AVVA and informative female AVVA). This is consistent with previous studies which have found that gender stereotypes guide the ways that people respond to virtual agents [20,33,34], such as the perception that male-voiced computers are generally more dominant and influential, but female-voiced computers are trusted and preferred more when discussing stereotypically feminine topics, such as love and relationships [22,35]. The present research makes a contribution beyond these previous studies by illustrating that stereotypical consistency in a voice agent influences not only the perception of the voice itself, but also the PEU and PU of the technology that the voice agent represents. Given the strong influence of PEU and PU on adoption intention, this research suggests that stereotypical consistency is an important consideration when examining technology adoption, especially in the context of autonomous technologies represented by voice agents. This finding is consistent with the notion that more intuitive interfaces increase PEU [45]. The CASA (computer as social actor) paradigm suggests that people mindlessly apply various social interaction rules, such as gender stereotypes, to human-computer interaction [19][20][21]. In other words, interfaces that utilize stereotypes facilitate mindless responses that foster more heuristic-based interactions which ease cognitive efforts that individuals would otherwise spend to understand the interface. Increasing PEU helps people identify the usefulness of the technology and ultimately increase the intention to adopt, particularly in the early stages of the adoption process [46]. Through social interaction, people develop schemas that can help them more easily interact with and understand their surroundings. The study results imply that designing a voice agent to be more congruent with social role expectations may help people use the technology more easily, which leads to a greater perception that the technology is useful, ultimately leading to greater adoption intention. However, we do not mean to suggest that designers should replicate and thus reinforce gender or any other social-role stereotypes. In fact, designers have the power to shape the social norms that guide expectations regarding social roles. Just as perceptions of social norms are influenced by depictions of archetypal individuals and groups in popular media, such as television (e.g., [47]) or video games (e.g., [48]), interactions with voice agents have the potential to influence status quo perceptions outside of media use. In other words, complementing the idea that our understandings of human-human interaction guide our interactions with technology [18], our interactions with social technologies also affect our understandings of human-human interactions. Thus, designers' choices of whether to rely on or move beyond stereotypes in their autonomous agent interfaces have real potential outcomes for social interaction in our society. Stereotyping, or the reliance on limited information to make broad generalizations about individuals and groups, is harmful to groups and individuals. Although humans are cognitive misers who prefer to use heuristics to minimize effort during decision making, people are also aversive toward biased thinking and would prefer to act in ways that reflect cognitive complexity [49]. Thus, designers have an incentive to counteract or disconfirm stereotypes in their designs, at least to some extent. In the present context, this could mean offering autonomous agents who are equally informative and sociable, regardless of gender. Furthermore, the present research did not compare degrees of informativeness or sociability. Future research should attempt to identify the extent to which a sociable female voice agent can reflect informative functionality before suffering reductions in PEU and PU. Limitations of this research include the sample, the fidelity of the simulation technology utilized, and the flexibility of the AVVA technology utilized. First, this study was conducted with a college student sample. This population is potentially not representative of the autonomous vehicle adopter target market (e.g., because they have lower incomes). Future research should use older samples who have a higher likelihood of using such vehicles. Second, this study was conducted as an online study on the participants' own devices. Because of the constraint, the modality may not have felt realistic enough for participants to respond in ways that were externally valid. Thus, future research on this topic should be conducted in more immersive simulators. Finally, the method of providing the AVVA-a pre-recorded driving scenario and set of verbal instructions-only offered a single driving route and scenario. While this scenario was designed to represent a typical driving experience in a low-traffic city, a chance exists that this specific scenario influenced participants in ways that would not generalize to other scenarios. Thus, future research should be conducted in other driving contexts. These limitations notwithstanding, the present research provides an exploratory examination that yields unique insights about the aspects of AVVA design that influence autonomous vehicle research. Future research can build on these findings to develop more targeted, externally valid examinations of the relationships explored here. I hope you will enjoy this autonomous driving experience. Currently, the weather is 65 degrees Fahrenheit and sunny. I am excited to drive with you in this perfect weather. We have arrived at our destination. We have traveled 3 miles with 35 miles per gallon fuel efficiency. Thank you. We have arrived at our destination. Thank you for using this autonomous vehicle today. I hope you enjoyed the ride and that I will see you again soon --- Author Contributions: Conceptualization, S.L. and R.R.; methodology, S.L., T.P. and R.R.; software, S.L. and T.P.; formal analysis, S.L. and R.R.; resources, T.P. and R.R.; writing-original draft preparation, S.L.; writing-review and editing, S.L., T.P., and R.R.; supervision, S.L. --- Conflicts of Interest: The authors declare no conflict of interest. --- Appendix A

The present research explores how autonomous vehicle voice agent (AVVA) design influences autonomous vehicle passenger (AVP) intentions to adopt autonomous vehicles. An online experiment (N = 158) examined the role of gender stereotypes in response to an AVVA with respect to the technology acceptance model. The findings indicate that characteristics of the AVVA that are more consistent with the stereotypical expectation of the social role (informative male AVVA and social female AVVA) foster greater perceived ease of use (PEU) and perceived usefulness (PU) than inconsistent conditions (social male AVVA and informative female AVVA). The study offers theoretical implications regarding the technology acceptance model in the context of autonomous technologies as well as practical implications for the design of autonomous vehicle voice agents.

INTRODUCTION In recent years, obesity has become a major health issue in the US and worldwide. The World Health Organization estimated that, as of 2007, 74.1% of Americans over 15 years old were overweight, and the US ranked ninth in the world in terms of obesity [1]. The growth of obesity is also remarkable: 19.4% in 1997, 24.5% in 2004, and 26.6% in 2007 [2]. Mental disorders may be an important issue related to obesity. Approximately 25% of all adults in the US (approximately 57.7 million Americans) have been reported to experience some mental health disorder each year [3]. Psychologists have found that obesity is considered a "stigma" because it is con-pISSN 1975-8375 eISSN 2233-4521 ceptualized as a form of physical deviance [4]. According to Goffman [5], obese individuals are even viewed as "not quite human" and subject to discrimination or avoidance. Richardson et al. [6] conducted several experiments to rank preferences for 6 images of individuals (those with no physical handicap or some physical handicap and 10-year-old or 11-year-old obese children). They found consistent preferences for no handicap over some handicap. Remarkably, the least preferred image was always that of obese children [7,8]. The stigma attached to obesity may generate considerable stress, which can lead to mental health disorders. Although the precise mechanism that causes depression remains unclear, textbook causes known thus far include social isolation, abuse, certain medications such as cholesterol-reducing drugs, the death or loss of a significant other, genetic factors, serious illness, and substance abuse [9]. Therefore, social isolation due to the stigma attached to obesity might trigger depression. If obesity increases the likelihood of a mental disorder, then the true cost of obesity may be higher than has been estimated thus far. Several studies have examined the relationship between --- Can Obesity Cause Depression? obesity and depression [10][11][12], but no study has analyzed their causal relationship. The first issue to consider is bias due to omitted variables. As Faith et al. [11] and Comings et al. [13] report, the common gene ObD7s1875 may make people obese and depressed simultaneously, and omitting this gene may be another source of upward bias for the ordinary least squares estimator. Unobserved individual characteristics may be another relevant factor. If an individual shows a high discount rate (i.e., emphasizes the present), then he or she may overeat and engage in other unhealthy behaviors, such as smoking or avoiding exercise. Another source of endogeneity is reverse causality, according to which depressed individuals may overeat or undereat [14], which may generate an upward or downward bias. This paper attempted to characterize the causal relationship between obesity and depression by using a pseudo-panel approach. In particular, we dealt with endogeneity introduced by omitting unobservable factors such as the ObD7s1875 gene and other time-invariant unobservable individual characteristics. --- METHODS We used the Behavioral Risk Factor Surveillance System (BRFSS), which is an annual cross-sectional survey of the adult population (18 years of age or over). The BRFSS is a nationally representative sample based on a phone survey using both landlines and cell phones, and was established in 1984, covering 15 states. It has one of the largest numbers of observations with state identifiers, making it the best dataset available for this paper. We used the BRFSS data from the 1997-2008 period, during which the survey used consistent measures of depression variables. Depression, a measure of mental disorder, was calculated as the number of days that the respondent felt not good during the last 30 days due to stress, depression, or problems with emotions. For instance, a score of 3.37 means that a respondent had 3 days that they did not feel good in a month. We also defined depression as a binary variable, with a respondent considered to be depressed if he or she felt bad on more than half of the days of the month. Based on descriptive statistics, 7% of the BRFSS population was classified as depressed for the sample period (Table 1). The key independent variable was obesity, which was measured by the body mass index (BMI; weight in kilograms divided by the square of height in meters). We constructed pseudo-panel data for the analysis. Deaton [15] suggested the use of cohorts to estimate a fixed-effects model from repeated cross-sections. In his approach, individuals sharing some common characteristics are grouped into cohorts, after which the averages within these cohorts are treated as observations of a pseudo-panel [16,17]. Importantly, panel data allow researchers to account for unobservable individual heterogeneity, such as the ObD7s1875 gene or other time-invariant unobservable characteristics. Although our data set was not originally a panel data set, we were able to at least approximately account for individual heterogeneity that Participants were asked to identify for how many days during the past 30 days their mental health was not good. may have caused a spurious correlation between BMI and depression by grouping the individuals into homogenous units and constructing pseudo-panel data. Nonetheless, pseudopanel data are not genuine panel data. Importantly, if a group consists of very different individuals over different periods, then observations in each pseudo-panel would not share similar genes and unobservable characteristics, and the advantage of constructing the pseudo-panel would be limited. Therefore, it is important that the grouping is done so that each person is likely to remain in the same group over time. Thus, we constructed pseudo-panel data sets based on individuals' physical and socioeconomic backgrounds. It is possible that the constructed groups were still heterogeneous over time, so we considered multiple levels of pseudo-panel data in order to obtain as much information as possible. The simplest form is the representative agent for each state and time. Time is measured by year and month together. For example, January 1997 is a unit of time. For every group and period, we averaged the variables and formed a pseudo-panel data set. We constructed 4 more pseudo-panels by adding sex, marital status, race (ethnic group separately), and education level, one by one, starting from the simplest state and time pseudo-panel. That is, a group in the second pseudo-panel in a period was constructed by averaging values among individuals of the same gender living in the same state. In the third pseudo-panel, each group in the second pseudo-panel was further divided into subgroups by marital status. The last 2 panel data sets were constructed by adding race and education level successively to the grouping criteria in the previous criteria. The econometric model for the estimations is given as follows: Yit=<unk>0+<unk>1BMIit+<unk>2Xit+<unk>i+uit (1) where Yit is the measure of mental health outcomes for unit i in the pseudo-panel, calendar year and month are indicated by t, <unk>i refers to the unobserved group-specific effects, uit is the error term, and X includes sex, marital status, race (white, black, and other), Hispanic ethnicity, education (no high school diploma, high school diploma, some college, college diploma or higher), age, annual household income (in US dollar [USD]) (<unk>10 000, 10 000-15 000, 15 000-20 000, 20 000-25 000, 25 000-35 000, 35 000-50 000, 50 000-75 000, and <unk>75 000), and year and month dummies accounting for long-run trends and common seasonal variability. --- RESULTS We present the pseudo-panel regression results in Table 2. The Hausman test suggested that the group fixed effects were correlated with the explanatory variables. The first column of Table 2 shows the results for the simplest pseudo-panel data. Every 1-unit increase in the BMI increased depression by 0.159 days per month. Standard errors (in parentheses) are clustered by panel group. This method provides consistent standard errors if the errors are independent across groups, while arbitrary correlations are allowed within each cluster. The second column of Table 2 shows results for the pseudogroups of state, time, and sex. In this column, male and female are not in the same group any more. The sample size doubled but the magnitude of the coefficient decreased slightly. As we --- Can Obesity Cause Depression? considered marital status additionally, the coefficient of interest became 0.104, which means that a 1-unit increase in BMI led to 0.1 additional depressed days. Considering race, ethnicity, and education level improved the precision substantially, although the coefficient was robust for these criteria. The specification in column 5 means the following: a 1-unit increase of BMI would increase depression days by 0.093, which is 2.8% of the sample mean (3.37). This finding was statistically significant at a 99% confidence level. The magnitude of this estimate can be interpreted as follows. The average BMI increased by 1.64 from 25.8 to 27.5 kg/m 2 during this period, which was associated with 0.15252 (=0.093<unk> 1.64) more depression days per month. Since the depression days per month increased by 0.29, increases in BMI would explain 53% of the total variation in depression days per month based on our estimation. This is a remarkably large magnitude, but it should be interpreted with caution. In particular, considering that the pseudo-panel approach does not account for reverse causality, although it deals with omitted unobservable effects, we admit the possibility that this result describes correlation. It is nonetheless possible to draw more positive implications. If the depressed are more likely to overeat than to undereat, this effect would act as an upper bound. If both tendencies cancel out, the effect would be closer to the true causal effects. Further research is warranted regarding this issue. Table 3 presents the results from a robustness check. The first concern was specifying the functional form for the obesity measure. We tried a quadratic specification and found a Ushape. A BMI of 20.8 kg/m 2 showed the minimum risk for depression, and as shown in the third and fourth columns, we found that thin people showed a statistically significant negative relationship with depression. However, obese people presented a statistically significant increase in depression. In the bottom panel of Table 3, we show the results using a binary specification of the dependent variable (depression). We defined an individual to be depressed if he or she felt depressed for more than 16 days per month, and this variable was averaged for the individuals in each pseudo-panel group. Thus, the 'depressed' variable was the proportion of those who felt depressed for more than 16 days per month out of the population of the group. A 1-unit increase of BMI increased the probability of being depressed by 0.3 percentage points, which is 4.2% of the sample mean (7.0%). This was statistically significant. During this sample period (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008) the percentage of the depressed population increased from 6.3 to 7.4% in our data, as shown in Figure 1, which is a 1.1 percentage point increase. The BMI increase during the same period would explain 0.5 percentage points of the increase (=0.003<unk>1.64), --- DISCUSSION The prevalence of obesity has been rising for at least 5 decades [18], and mental illness is widespread. Scott et al. [19] conducted a cross-sectional survey across 13 countries and found a statistically significant association between obesity and depressive disorders. McElroy et al. [12] also found that mood disorders and obesity may be related to each other. However, neither of the above studies could clarify the direction or nature of the relationship observed due to endogeneity. We examined the effects of obesity on mental health using the BRFSS, which is a nationally representative survey. We attempted to account for endogeneity introduced by omitting important unobservable factors by using a pseudo-panel approach and found that the association was still statistically significant. There remains the issue of reverse causality. For example, a depressed individual may overeat or undereat. If the former, our estimates overstate the causal effects. Our pseudo-panel data do not resolve the reverse causality issue. Ideally, legitimate and relevant instrumental variables would provide a solution if they can be found. We leave this interesting topic for future research. Our finding has an important policy implication. Based on the Medical Expenditure Panel Survey, 36.2 million people in the US paid for mental health services, with expenditures totaling USD 57.5 billion in 2006 [20]. Currently the economic costs of obesity range from USD 147 billion to nearly USD 210 billion per year [21]. These estimated costs, however, do not include the adverse impacts of mental health conditions. If we take this into account, the cost of obesity would increase. Recently, countries such as Japan and Denmark have introduced a 'fat tax,'and some schools have removed vending machines. Evidence from this paper can be used to support these social movements. --- CONFLICT OF INTEREST The authors have no conflicts of interest associated with the material presented in this paper.

The US ranks ninth in obesity in the world, and approximately 7% of US adults experience major depressive disorder. Social isolation due to the stigma attached to obesity might trigger depression. Methods: This paper examined the impact of obesity on depression. To overcome the endogeneity problem, we constructed pseudopanel data using the Behavioral Risk Factor Surveillance System from 1997 to 2008.The results were robust, and body mass index (BMI) was found to have a positive effect on depression days and the percentage of depressed individuals in the population.We attempted to overcome the endogeneity problem by using a pseudo-panel approach and found that increases in the BMI increased depression days (or being depressed) to a statistically significant extent, with a large effect size.

Introduction A social network is a graph-based model where vertices model individuals and edges model the existence of relationships between individuals. The type of relationship modelled by a given social network varies and is a function of the application in question. However, three commonly modelled relationships are friendship, social influence and information/resource flow. Social network modelling has successfully been applied in many application domains. For example, De la Haye et al. (2010) and Ranciati et al. (2020) performed social network modelling of obesity-related behaviours and terrorist activities, respectively. A social network intervention is a process of intentionally altering a social network to help achieve some objective. Here altering a social network includes actions such as adding or deleting an edge in the social network. The objective in question may relate to accelerating behaviour change or improving organisational performance (Valente 2012(Valente, 2017)). Many studies have demonstrated the usefulness of social network interventions (Hunter et al. 2019). Wang et al. (2011) Finally, we are unfortunately too well aware of the interventions, of reducing face-to-face interactions, performed by many governments to reduce COVID-19 transmission (Centola 2020). Valente (2012) defined a set of models of social network interventions which involve making alterations to the social network by considering vertices, edges and individual communities. A community is defined as a subset of individuals who share a particular characteristic. For example, in the area of security one may be interested in modelling communities corresponding to individuals belonging to terrorist groups and national security agencies. In this work we propose a novel model of social network interventions which considers topological properties of relationships existing between communities. We refer to such relationships as topological relationships. Relationships existing between communities can exhibit many different properties. Broadly speaking, topological properties of such relationships include properties described by natural language descriptions such as contains, partial overlap or disjoint. The proposed model represents a generalisation of the original models proposed by Valente (2012). Specifically, the proposed model provides a higher-level abstraction which in many cases is more useful or suitable for solving problems involving social network interventions. To illustrate this point consider a social network which contains one community corresponding to terrorists and a second community corresponding to individuals with access to and skills in the use of weapons. Furthermore, let us say these communities are modelled by the social network displayed in Fig. 1(a) where individuals belonging to the former community lie in the blue coloured region, while individuals belonging to the latter community lie in the red coloured region. In this social network, the existence of an edge between two vertices indicates the flow of information between the individuals in question. Due to the fact that individual c belongs to both communities, the relationship between the communities may be described as partial overlap. Such a relationship may be considered a security threat because the community with access to and skills in the use of weapons may share this with the terrorist community. Modelling the topological relationship between these communities allows the detection of this threat. Furthermore, the ability to apply an intervention which considers the topological relationship allows the elimination of this threat. For example, if one could apply an intervention to the social network in Fig. 1(a) to remove the individual c, the social network would change to that in Fig. 1(b). That is, the relationship between the communities would change from partial overlap to disjoint and in turn the security threat would be eliminated. The operation of removing individual c could be performed by detaining the individual in question. By defining interventions in terms of topological relationships we abstract away details relating to individual vertices, edges and communities which are unnecessary for solving many problems. For example, when modelling the relationships of partial overlap or disjoint we can abstract away which vertices belong to which communities or how these vertices are connected by edges. Instead, we can model both relationships as a corresponding binary variable indicating the presence or absence of the relationship in question. The use of this higher-level abstraction can therefore in many cases make the process of reasoning about intervention less complex. Note that, an intervention defined in terms of topological relationships will ultimately be implemented in terms of interventions defined in terms of vertices, edges and individual communities. For example, performing the intervention in the above example which transforms the relationship from partial overlap to disjoint is ultimately implemented by removing the individual or vertex c. The model proposed in this work can take an intervention defined in terms of topological relationships and determine a corresponding implementation. The remainder of this paper is structured as follows. In Sect. 2 we review related works on social network communities, social network interventions and modelling topological relationships. In Sect. 3 we present the proposed model of social network interventions which considers topological relationships between communities. In Sect. 4 we demonstrate that the proposed model provides a useful abstraction for solving many real-world problems involving social network interventions. This is achieved by simulating interventions on a number of hypothetical and real social networks. Finally, in Sect. 5 we draw conclusions from this work and discuss possible directions for future research. --- Related works Social networks communities are a well-studied research topic. However, to date most research on this topic has focused on the problem of automatically detecting communities existing in a given social network. One of the most commonly used models for performing this task is the stochastic block model which can detect flat, hierarchical and overlapping communities (Peixoto 2019). In this work we assume the communities in question are known and do not require detection. We instead focus on the problem of modelling relationships existing between these communities. As such, the work presented in this paper is distinct from most existing research on this topic. Modelling relationships existing between geographical regions is a well-studied problem in the field of geographical information science (Corcoran et al. 2012). The most cited model for performing this task is the intersection model proposed by Clementini et al. (1993) which models topological properties of relationships. As discussed later, this model provides inspiration for the model proposed in this work. Modelling the topological properties of graphs or networks is a well-studied problem in the fields of complex systems and network science. Models for performing this task commonly consider statistical features such as the vertex degree distribution (Corcoran and Mooney 2013) or algebraic features relating to connected components and holes or cycles (Corcoran 2020). The authors are unaware of any previous works that have considered the problem of modelling topological relationships existing between social network communities. Valente (2012) defined four models of social network interventions. An individual intervention is a type of social network intervention where a set of individuals are identified and their characteristics are altered. This type of intervention is commonly implemented by selecting a set of individuals to act as influencers of other individuals in the social network. For example, Starkey et al. (2009) used this approach when implementing an intervention to reduce the practice of smoking. A segment or community intervention is a type of social network intervention where a set of individuals sharing a given characteristic are identified and their behaviours are altered. For example, Buller et al. (1999) used this type of intervention to increase fruit and vegetable intake among lower socioeconomic, multicultural labour and trades employees. An induction or relationship intervention is a type of social network intervention where a set of relationships existing between individuals are identified and the features of these relationships are altered. For example, Hoffman et al. (2013) used this type of intervention to perform peer education of HIV prevention. Finally, an alteration intervention is a type of social network intervention where individuals and relationships are added and deleted from the social network (Wilder et al. 2018). For example, Litt et al. (2007) used this type of intervention to help treat alcoholics by reducing their network support for drinking. A social network intervention which is defined with respect to an event, such as a terrorist attack or an election, is known as an event-based intervention. Such interventions can take place before, during or after the event in question. Innes et al. (2021) examined how event-based interventions can influence public understandings and definitions of terrorist attacks after they happen. The authors identified three corresponding models of social network interventions associated with the communication of misinformation and disinformation. They entitled these models spoofing, truthing and social proofing. Spoofing involves the use of trickery, deception or misdirection to misrepresent the identity of sources and/or the validity and reliability of information. Truthing involves the use of truth claims, including conspiratorial hidden truths, or presenting factual information to try and persuade. Finally, social proofing involves the use of feedback mechanisms to construct an aura (sometimes illusion) of social support to influence the behaviour of others. Dobreva et al. (2020) examined how event-based interventions which considered the dissemination of'soft facts' were used to influence the public before and after the UK Brexit referendum. The authors define soft facts as facts where the corresponding information provenance is uncertain and include rumours, conspiracy theories and propaganda. Based on the above review of related works, we believe that the proposed model of social network interventions represents a novel combination of research ideas from the domains of social network analysis, topology and geographical information science. --- Social network intervention model In this section we present the proposed model of social network interventions which considers topological relationships between communities. The proposed model provides a framework for both defining and determining an implementation of a social network intervention. In this context, defining an intervention means to state the desired state of the social network one wishes to achieve. On the other hand, determining the implementation of an intervention means to determine a sequence of steps which achieves this state. In the following three subsections we present in turn a model of social networks, a model of topological relationships and a model for both defining and determining the implementation of a social network intervention. --- Social network Let G denote the space of graphs, L denote a set of commu- nity types and C denote the space of mappings from L to G. We model a social network as a graph G = (V, E) <unk> G plus a mapping C <unk> C. V is a set of elements called vertices which model individuals and E is a set of pairs of vertices called edges which model relationships existing between pairs of individuals. Note that, the type of relationship modelled by a given social network is a function of the application in question, but commonly modelled relationships are friendship, social influence and information/resource flow. A vertex may belong to zero, one or more than one community. The map C is a mapping from community type to the corresponding vertexinduced subgraph of the community in question. Note that, we assume crisp as opposed to fuzzy community membership. This choice is motivated by the fact that most social network data have this property. To illustrate this model consider again the example social network illustrated in Fig. 1(a) which contains two communities represented by blue and red regions. Let the community types in question be 'blue' and'red,' respectively. Given this, the social network in question is modelled as: (1) V = <unk>a, b, c, d, e<unk> E = <unk>(a, b), (a, c), (b, c), (c, d), (d, e)<unk> L = <unk>'blue','red'<unk> C('blue') = (<unk>a, b, c<unk>, <unk>(a, b), (a, c), (b, c)<unk>) C('red') = (<unk>c, d, e<unk>, <unk>(c, d), (d, e)<unk>) The mappings C('blue') and C('red') corresponding to this model are illustrated in Fig. 2(a) and (b) respectively. The above model of social networks is general in nature and can be used to model many different types of real-world social networks. Later we demonstrate this by considering three real-world social networks and associated problems in the domains of health and security. --- Topological relationships Modelling topological relationships is a challenging problem. Given a social network, simply modelling topological properties of the corresponding graph cannot distinguish between different topological relationships. For example, consider the topological relationships of disjoint and containment illustrated in Fig. 3(a) and (b), respectively. Despite having different topological relationships, the graphs in question are identical and therefore have identical topological properties. To overcome this challenge we define a set of subgraphs which are a function of the relationship in question. Specifically, these subgraphs are defined using a set of mappings I, U and S which have the form G <unk> G <unk> G. We refer to these mappings as binary relations. For example, the binary relation I corresponds to the intersection of the communities in question. The use of binary relations is motivated by the intersection model proposed by Clementini et al. (1993) for modelling topological relationships between geographical regions. In this model relationships are modelled by defining a set of regions which are a function of the relationship in question. Given the above set of binary relations, we model the topological relationship in question by modelling topological properties of these relations. Specifically, we define a mapping T <unk> G <unk> Z which is applied to each binary relation where Z denotes the set of multisets of positive integers. In this context, an element of Z models the number and size of connected components contained in the binary relation in question. The use of multisets to model topological properties is motivated by persistent homology which is a model of topological properties from the field of applied topology (Edelsbrunner and Harer 2010). In the remainder of this section we describe in detail the above model of topological relationships and demonstrate that it can make useful distinctions between topological relationships. The specific binary relations one considers are determined by the application in question and in turn what topological properties one is attempting to model. In this work we consider the three binary relations I, U and S which we found to be sufficient for making useful distinctions between topological relationships. The binary relation I is defined in Eq. 2 where g <unk> g denotes the graph containing the inter- section of the vertex and edge sets corresponding to g and g ′. For example, the binary relation I(C('blue'), C('red')) between the communities illustrated in Fig. 1(a) and (b) is the graphs (<unk>a<unk>, <unk>) and (<unk>, <unk>), respectively. The binary relation U is defined in Eq. 3 where g <unk> g denotes the graph containing the union of the vertex and edge sets corresponding to g and g ′. For example, the binary relation U(C('blue'), C('red')) between the com- munities illustrated in Fig. 1(a) and (b) is the graphs (<unk>a, b, c, d, e<unk>, <unk>(a, b), (a, c), (b, c), (c, d), (d, e)<unk>) a n d (<unk>a, b, d, e<unk>, <unk>(a, b), (d, e)<unk>), respectively. The binary relation S is defined in Eq. 3 where gg denotes the graph containing vertex and edge sets corresponding to g less the vertex and edge sets, respectively, corresponding to g ′. Note that, subtracting a vertex causes all adjacent edges to also be subtracted. For example, the binary relation S(C('blue'), C('red')) between the com- munities illustrated in Fig. 1 (2) Given the three binary relations I, U and S, we model the topological relationship in question by modelling the topological properties of these relations. Specifically, the topological properties we model are the number of vertices in each connected component. This is achieved using the map T defined in Eq. 5 where Z denotes the set of multisets of positive integers and g c denotes the set of connected com- ponents contained in the graph g. I <unk> G <unk> G <unk> G g <unk> g <unk> g <unk> g (3) U <unk> G <unk> G <unk> G g <unk> g <unk> g <unk> g (4) S <unk> G <unk> G <unk> G g <unk> g <unk> g -g (a) (b) To illustrate the map T consider the social network displayed in Fig. 4 containing blue and red communities which exhibit the topological relationship of containment. The binary relation I of these communities is a graph containing three connected components of sizes two, one and one. Therefore, the map T of this binary relation is the multiset <unk>2, 1, 1<unk>. This inference is formally stated as follows: Composing the set of binary relations with the map T we define the set of maps T•I, T•U and T•S as follows: The maps T•I and T•U are symmetric, while the map (b, a). Therefore, given two communities a and b we model the topological relationship in question using the set of maps (b, a). To illustrate this model consider again the social network displayed in Fig. 4. In this example the topological relationship existing between the blue and red communities is modelled by: The map T models both the number and size of connected components. Modelling the size of connected components is necessary for solving many problems involving social network interventions. To illustrate this point consider a social network which contains one community corresponding to a terrorist group and a second community corresponding to undercover agents working for a government intelligence agency. Furthermore, let us say these communities are modelled by the social network illustrated in Fig. 5(a) where individuals belonging to the former community lie in the blue coloured region, while individuals belonging to the latter community lie in the red coloured region. The objective of the undercover agents is to secretly infiltrate the terrorist community in a manner which minimises the probability that the discovery of one agent by the terrorist community causes the discovery of the other. Achieving this goal may be posed as transforming the topological relationship in question as follows. First the connection between the agents is removed, so the agents become disjoint as illustrated in Fig. 5(b). That is, the size of each connected component in the agents community is one. Next, the agents become members of, or contained within, the terrorist community as illustrated in Fig. 5(c). This example illustrates that interventions with multiple objectives can be modelled using the proposed approach by either performing a series of individual interventions or defining a single desired topological relationship which models all objectives. T•S is not. That is, T•I(a, b) = T•I(b, a) while T•S(a, b) <unk> T•S T•I(a, b), T•U(a, b), T•S(a, b) and (5) T <unk> G <unk> Z g <unk> <unk>|V | <unk> (V, E ) <unk> g c <unk> (6) I(C('blue'), C('red')) = (<unk>a, b, e, d<unk>, <unk>(a, b)<unk>) T((<unk>a, b, e, d<unk>, <unk>(a, b)<unk>)) = <unk>2, 1, 1<unk> (7) T•I <unk> G <unk> G <unk> Z g <unk> g <unk> T(g <unk> g ) (8) T•U <unk> G <unk> G <unk> Z g <unk> g <unk> T(g <unk> g ) (9) T•S <unk> G <unk> G <unk> Z g <unk> g <unk> T(g -g ) T•S (10) Finally, one does not need to consider the full set of binary relations defined above to model many topological relationships. For example, consider the topological relationship corresponding to disjoint. This topological relationship can be modelled using only the binary relation I which corresponds to the intersection of the communities in question. Specifically, the topological relationship is disjoint if and only if T•I equals the empty set. That is, this is a necessary and sufficient condition. T•I(C('blue'), C('red')) = <unk>2, 1, 1<unk> T•U(C('blue'), C('red')) = <unk>3, 1, 1<unk> T•S(C('blue'), C('red')) = <unk> T•S(C('red'), C('blue')) = <unk>1<unk> --- Defining and implementing interventions In this section we describe how the proposed model of topological relationships can be used to define and determine the implementation of a social network intervention. Recall that, defining an intervention means to state the desired topological relationship one wishes the social network communities in question to have. On the other hand, determining the implementation of an intervention means to determine a sequence of operations which if applied achieves this topological relationship. For example, consider again the social network displayed in Fig. 1(a) where the desired topological relationship is disjoint communities. A sequence of operations which achieves this relationship is the removal of vertex a, and the result of applying this operation is displayed in Fig. 1(b). The remainder of this section is structured as follows. In Sect. 3.3.1 we define a set of operations which can be applied to a social network. In Sect. 3.3.2 we describe how an intervention can be formally defined in terms of a corresponding set of necessary and sufficient conditions. If these conditions are satisfied, this implies the intervention in question has been successfully implemented. Finally, in Sect. 3.3.3 we describe how the implementation of the intervention can be determined where this implementation is defined in terms of the above operations. The above conditions and implementation for a given intervention are both determined automatically. Hence, this allows the process of reasoning about interventions to be performed completely at the abstraction of topological relationships. --- Social network operations Recall that G denotes the space of graphs, L denotes a set of community types and C denotes the space of mappings from L to G. Furthermore, recall that we model a social network as an element of G plus an element of C. Let 2 L denote the power set of L (the set of all subsets of L). Given a social network G = (V, E) <unk> G and C <unk> L <unk> G <unk> C, we define the following set of operations: The operation V -removes a specified vertex from the graph G. Note that, removing a vertex results in all edges adjacent to the vertex also being removed. For example, applying the operation V -(c) to the social network dis- played in Fig. 1(a How each of the operations defined above is performed in reality and not in the abstract graph model will depend on the real-world application domain in question. For example, consider the operation of removing a vertex which corresponds to removing an individual from the social network. In some application domains this may be performed by detaining the individual, while in other application domains it may be performed by confiscating the individual's mobile communication device. Furthermore, the usefulness of each operation will also depend on the application domain in question. For example, removing a vertex which corresponds to removing an individual from the social network, possibly through detainment, may be very difficult or impossible to perform in a particular application domain. To model these characteristics of the problem, we define a set of feasible operations which are a subset of the operations defined above. These operations correspond to those which can be successfully performed and are specific to the application domain in question. Note that, the set of operations defined above are very similar to the set of intervention models originally proposed by Valente (2012). For example, an individual intervention (11) which alters the characteristics of individuals is similar to the operation C <unk>. Likewise, an alteration intervention which alters the structure of the social network is similar to the operations V -, E -and E +. V -<unk> V <unk> G E + <unk> V <unk> V <unk> G E -<unk> E <unk> G C <unk> <unk> V <unk> 2 L <unk> C (a) (b) --- Defining interventions A social network intervention can be formally defined in terms of a corresponding set of necessary and sufficient conditions. For example, consider again the social network in Fig. 1(a) where we wish to perform an intervention which transforms the topological relationship to disjoint communities. A necessary and sufficient condition for the topological relationship of disjoint is defined as follows which states that the intersection of the communities in question is empty: There exist many different topological relationships which may exist between social network communities. Table 1 lists some possible topological relationships plus corresponding necessary and sufficient conditions. The last row in this table provides the necessary and sufficient conditions corresponding to the topological relationship of touching. We describe a topological relationship as touching if no vertex is a member of both communities in question, but there exists one or more edges connecting the vertices of these communities. For example, the communities displayed in Fig. 3(a) have this topological relationship because the vertices c and d, which belong to the blue and red communities, respectively, are connected. For most topological relationships in the above table, it is self-evident why the corresponding conditions are necessary and sufficient. Therefore, here we only present a proof of the necessary and sufficient conditions for the topological (12) T•I(C('blue'), C('red')) = <unk> relationship of touching. This proof is provided in Theorem 1 where |.| denotes the multi-set cardinality function. --- Theorem 1 Necessary and sufficient conditions for the topological relationship of touch between communities A and B are T•I(A, B) = <unk> and |T•U(A, B)| <unk> |T(A)| + |T(B)|. Proof To prove the conditions are necessary and sufficient we prove that the topological relationship exists if and only if the conditions are satisfied. We first prove that, if the topological relationship exists, the conditions are satisfied. If the topological relationship is touch, then by definition communities are disjoint and the condition T•I(A, B) = <unk> is satisfied. Furthermore, if the communities are connected by edges, the number of connected components in the union will be less than the sum of the number of connected components in each community. Next we prove that if the conditions are satisfied, the topological relationship exists. If the conditions are satisfied, then the communities are disjoint. Furthermore, if the number of connected components in the union is less than the sum of the number of connected components in each community, then the communities are connected by edges. <unk> --- Implementing interventions In this section we consider the process of determining the implementation of a social network intervention. Recall that an implementation corresponds to a sequence of feasible operations which if applied achieves the necessary and sufficient conditions of the intervention in question. The algorithm used to determine an implementation will vary depending on the intervention in question and the set of feasible operations. In the remainder of this section we demonstrate the process of determining the implementation of a specific intervention. To demonstrate the process for determining the implementation of an intervention consider again the social network in Fig. 1(a) where we wish to perform an intervention which transforms the topological relationship to disjoint communities. By examining Table 1, we see that the necessary and sufficient conditions corresponding to the topological relationship of disjoint are T•I('blue','red') = <unk>. If we assume all operations in Eq. 11 are feasible, we can determine multiple different implementations for this intervention. One implementation can be determined using Algorithm 1. This algorithm first determines the graph corresponding to the intersection of both communities (line 2). It next applies the operation V -to all vertices in this graph (lines 2 to 5). •I(A, B) = <unk> A contained in B T•S(A, B) = <unk> B contained in A T•S(B, A) = <unk> A and B equal T•S(A, B) = <unk> T•S(B, A) = <unk> A and B partial overlap T•I(A, B) <unk> <unk> T•S(A, B) <unk> <unk> T•S(B, A) <unk> <unk> A and B touch T•I(A, B) = <unk> |T•U(A, B)| <unk> |T(A)| + |T(B)| Algorithm 1: Disjoint Communities Input: A social network G = (V, E) <unk> G, L = <unk>'blue','red'<unk> and C <unk> C. 1 begin 2 (V i, E i ) = I(C('blue'), C('red')) 3 for v <unk> V i do 4 V -(v) 5 end 6 end Applying Algorithm 1 to the social network in Fig. 1(a), returns an implementation which contains the single operation V -(c) which removes the vertex c from the social net- work. The result of applying this implementation is displayed in Fig. 1(b). In Theorem 2 we prove that this method for determining an implementation of the intervention in question generalises to all social networks. Theorem 2 Consider a social network where G = (V, E) <unk> G, L = <unk>'blue','red'<unk> and C <unk> C plus a set of feasible opera- tions containing V -. Algorithm 1 determines an implemen- tation of the intervention which transforms the topological relationship between the communities in question to disjoint. Proof The necessary and sufficient conditions for the intervention in question are T•I(C('blue'), C('red')) = <unk>. Algorithm 1 returns an implementation of the intervention which applies the operation V -to all vertices in the graph --- I(C('blue'), C('red')). Applying this implementation will result in I(C('blue'), C('red')) being an empty graph and in turn T•I(C('blue'), C('red' )) = <unk>. Hence the necessary and sufficient conditions are satisfied. <unk> An alternative implementation of the above intervention can be determined by applying the operation C <unk> (., <unk>'blue'<unk>) to all vertices in the graph T•I(C('blue'), C('red')). In the context of this example, this results in an implementation containing the single operation C <unk> (c, <unk>'blue'<unk>) which removes the vertex c from the red community. Given multiple implementations of an intervention, in many cases one may wish to select a single implementation to apply. The actual implementation selected will in many cases depend on the real-world application domain in question. One implementation may be less difficult or expensive to implement in the application domain. In that case it makes sense to select that implementation. For example, removing an edge which corresponds to removing a communication link in the application domain may be less difficult to implement than removing a vertex which corresponds to removing an individual in the application domain. Furthermore, one implementation may have a higher probability of being successful in a given application domain. Again, in that case it makes sense to select that implementation. Badham et al. (2021) performed an analysis of social network interventions involving the diffusion of behaviour change. The authors found that the success of such interventions is strongly affected by the connectivity structure of the network. Note that, the methods described above for defining and implementing interventions assume that while they are being performed, the social network in question does not undergo any changes other than those specified by the implementation. If this were to occur, the definition and implementation in question may need to be redetermined. Furthermore, if the social network underwent changes after the intervention was successfully performed, again the definition and implementation in question may need to be redetermined. --- Simulation of social network interventions In this section we demonstrate that the proposed model of social network interventions, which models topological relationships between communities, provides a useful abstraction for solving many real-world problems. In the following subsections we consider three specific social networks and associated problems in the domains of health and security. Two of these correspond to hypothetical social networks, while the third corresponds to a real-world social network. The interventions in question are performed in simulation which is a standard practice in the field of social network research (Badham et al. 2018). Using the above problems, we demonstrate that the proposed model makes the process of reasoning about intervention less complex than previous models which directly model vertices, edges and individual communities. For a given problem, the intervention in question is first defined in terms of a desired topological relationship. As described in Sect. 3, this definition maps to a set of necessary and sufficient conditions which in turn maps to an implementation corresponding to a sequence of feasible operations. Since both of these mappings are determined automatically, this allows the process of reasoning about interventions to be performed completely at the abstraction of topological relationships. --- Infiltrate a terrorist group In this section we describe a social network intervention in the security domain with respect to a hypothetical social network. Consider again the social network displayed in Fig. 5(a) where the blue community corresponds to a terrorist group and the red community corresponds to undercover agents working for a government. Recall that, the undercover agents wish to secretly infiltrate the terrorist community in a manner which minimises the probability that the discovery of one agent by the terrorist community causes the discovery of the other. In the context of this domain we assume the following three feasible operations. Firstly, we assume the operation E -, which removes a given edge, can be applied to an edge if and only if the adjacent vertices correspond to agents. This is a reasonable assumption given the intervention in question is being carried out by the agents. Secondly, we assume the operation C <unk>, which changes the community membership of a given vertex, can be applied to a vertex if and only if the vertex corresponds to an agent. This is a reasonable assumption given the agents are trained in the art of infiltrating terrorist groups. For example, performing the operation C <unk> (d, <unk>'blue','red'<unk>) would involve the agent d successfully hiding their membership of the agent community from members of the terrorist community. Finally, we assume the operation E +, which adds an edge between pairs of vertices, can be applied if and only if one of the vertices in question corresponds to an agent. Again, this is a reasonable assumption given the agents are trained in the art of infiltrating terrorist groups. Successfully infiltrating the terrorist community can be achieved by applying two interventions which we now describe. In the first intervention the desired topological relationship between the communities is disjoint agents who are not members of the terrorist group. Let <unk>1,..., 1<unk> denote a multiset containing only elements equal to 1. Necessary and sufficient conditions for this relationship are: The first condition states that each agent is not connected to any other agent, while the second condition states that the two communities are disjoint. If we assume the two communities initially have the topological relationship disjoint, an implementation of ( 13) T(C('red')) = <unk>1,..., 1<unk> T•I(C('blue'), C('red')

A social network intervention is a process of intentionally altering a social network to achieve an objective. The objective in question may concern accelerating behaviour change or improving organisational performance. In this work we propose a novel model of social network interventions which considers topological properties of relationships existing between communities. Broadly speaking, topological properties of such relationships include properties described by natural language descriptions such as contains, partial overlap and disjoint. The proposed model provides an abstraction which in many cases is useful for solving problems involving social network interventions. We demonstrate this by simulating interventions on a number of hypothetical and real social networks in the domains of health and security.

their membership of the agent community from members of the terrorist community. Finally, we assume the operation E +, which adds an edge between pairs of vertices, can be applied if and only if one of the vertices in question corresponds to an agent. Again, this is a reasonable assumption given the agents are trained in the art of infiltrating terrorist groups. Successfully infiltrating the terrorist community can be achieved by applying two interventions which we now describe. In the first intervention the desired topological relationship between the communities is disjoint agents who are not members of the terrorist group. Let <unk>1,..., 1<unk> denote a multiset containing only elements equal to 1. Necessary and sufficient conditions for this relationship are: The first condition states that each agent is not connected to any other agent, while the second condition states that the two communities are disjoint. If we assume the two communities initially have the topological relationship disjoint, an implementation of ( 13) T(C('red')) = <unk>1,..., 1<unk> T•I(C('blue'), C('red')) = <unk> this intervention can be determined using Algorithm 2. The first step in this implementation determines the red community corresponding to agents (line 2). Subsequently, each edge between vertices in this community is removed using the operation E -(lines 3 to 5). Algorithm 2: Infiltrate a Terrorist Group Input: A social network G = (V, E) <unk> G, L = <unk>'blue','red'<unk> and C <unk> C. 1 begin 2 (V r, E r ) = C('red') 3 for e <unk> E r do 4 E -(e) 5 end 6 end Applying the above algorithm to the social network displayed in Fig. 5(a) results in an implementation containing the single operation E -((e, d)) which removes the edge (e, d) from the social network. Figure 5(b) displays the result of applying this implementation. In Theorem 3 we prove that this method for determining an implementation of the intervention in question generalises to all social networks. Theorem 3 Consider a social network where G = (V, E) <unk> G, L = <unk>'blue','red'<unk> and C <unk> C plus a set of feasible opera- tions containing E -. If we assume that initially the communi- ties have the topological relationship disjoint, Algorithm 2 determines an intervention implementation which satisfies the necessary and sufficient conditions in Eq. 13. Proof Initially the communities have the topological relationship disjoint; therefore, the first condition in Eq. 13 is immediately satisfied. Applying the operation E -to all edges in the graph C('red') results in this graph having a set of connected components each of size one. Hence, the second condition in Eq. 13 is satisfied. <unk> In the second intervention the desired topological relationship between the communities is disjoint agents who are members of the terrorist group. Necessary and sufficient conditions for this relationship are the following: The first condition states that each agent is not connected to any other agent. The second condition states that the agent community is contained in the terrorist community. The final condition states that T•U(C('red'), C('blue')) is a single con- nected component and in turn that each agent is connected either directly or indirectly to each member of the terrorist community. ( 14) T(C('red')) = <unk>1,..., 1<unk> T•S(C('red'), C('blue')) = <unk> |T•U(C('red'), C('blue'))| = 1 An implementation of this intervention can be determined using Algorithm 3. The first step in this implementation is to determine the red and blue communities corresponding to agents and terrorists, respectively (lines 2 and 3). Next, the community membership of each vertex in the red community is changed to <unk>'blue','red'<unk> using the operation C <unk> (lines 4 to 6). Finally, an edge is added between each pair of vertices in the red and blue communities (lines 7 to 11). Algorithm 3: Infiltrate a Terrorist Group Input: A social network G = (V, E) <unk> G, L = <unk>'blue','red'<unk> and C <unk> C. 1 begin 2 (V r, E r ) = C('red') 3 (V b, E b ) = C('blue') 4 for v <unk> V r do 5 C <unk> (v, <unk>'blue','red'<unk>) 6 end 7 for v <unk> V r do 8 for v <unk> V b do 9 E + (v, v ) 10 end 11 end 12 end Applying this algorithm to the social network displayed in Fig. 5(b) results in an implementation containing the sequence of operations C <unk> (e, <unk>'blue','red'<unk>), a) and E + (e, b). Figure 5(c) displays the result of applying this implementation. In Theorem 4 we prove that this method for determining an implementation of the intervention in question generalises to all social networks. C <unk> (d, <unk>'blue','red'<unk>), E + (d, a), E + (d, b), E + (e, Theorem 4 Consider a social network where G = (V, E) <unk> G, L = <unk>'blue','red'<unk> and C <unk> C plus a set of feasible opera- tions containing C <unk> and E +. If we assume that initially the conditions in Eq. 13 are satisfied, Algorithm 3 determines an intervention implementation which satisfies the necessary and sufficient conditions in Eq. 14. Proof Initially the conditions in Eq. 13 are satisfied; therefore. the first condition in Eq. 14 is immediately satisfied. Applying the operation C <unk> (., <unk>'blue','red'<unk>) to all vertices in the red community will result in S(C ('red') --- Reducing the spread of HIV In this section we describe a social network intervention in the health domain with respect to a hypothetical social network. A common social network intervention concerns attempting to influence members of, or spread information within, a social network (Smit et al. 2021). This type of intervention can be modelled in terms of topological relationships. To illustrate this consider the two communities displayed in Fig. 7(a) where the blue community corresponds to a particular set of individuals who have a high risk of HIV infection (e.g. men who have sex with men and do not practice HIV prevention techniques), while the red community corresponds to a set of individuals educated in HIV preventing techniques (e.g. use of condoms, limiting number of sexual partners). In this graph a directed edge represents the presence of assimilative social influence whereby the source individual influences the target individual towards reducing differences (Flache et al. 2017). The topological relationship between the communities in question is disjoint, and this may be considered a contributing factor to the existence of the high-risk community. Modelling the topological relationship between the communities allows the automated detection of such contributing factors. Furthermore, applying an intervention which alters the topological relationship so that the red community is contained in the blue community would eliminate this factor. A necessary and sufficient condition for this topological relationship is: If we assume a set of feasible operations containing the operation C <unk>, an implementation of this intervention can be determined using Algorithm 4. The first step in this implementation defines a new community, which we call the green community, containing highly influential members of the red community (line 2). Next, the community membership of each vertex in this community is changed to <unk>'red', 'blue'<unk> using the operation C <unk> (lines 3 to 5). This operation in turn has the effect of, through influence, changing the community membership of other vertices in the red community to <unk>'red', 'blue'<unk>. Algorithm 4: Reducing the Spread of HIV Input: A social network G = (V, E) <unk> G, L = <unk>'blue','red'<unk> and C <unk> C. 1 begin 2 (V g, E g ) = C('green') 3 for v <unk> V g do 4 C <unk> (v, <unk>'red', 'blue'<unk>) 5 end 6 end Applying this algorithm to the social network displayed in Fig. 7(a) results in an implementation containing the single operation C <unk> (d, <unk>'red', 'blue'<unk>). Figure 7(b) displays the result of applying this implementation. This operation in turn has the effect of changing the community membership of all other vertices in the red community to <unk>'red', 'blue'<unk>. This is displayed in Fig. 7(c). In Theorem 5 we prove that this method for determining an implementation of the intervention in question generalises to all social networks. Theorem 5 Consider a social network where G = (V, E) <unk> G, L = <unk>'blue','red'<unk> and C <unk> C plus a set of feasible operations containing C <unk>. If we assume a highly influential green community which is a subset of the red community and directly connect to all other vertices in this community, Algorithm 4 determines an intervention implementation which satisfies the necessary and sufficient condition in Eq. 15. Proof Applying the operation C <unk> (., <unk>'red', 'blue'<unk>) to each vertex in the green community will change the community membership in question to <unk>'red', 'blue'<unk>. Since the green community is directly connected to all other vertices in the red community, this will have the effect of changing the community membership of all other vertices in this community to <unk>'red', 'blue'<unk>. <unk> --- Reducing network support for drinking In this section we describe a social network intervention in the health domain with respect to a real-world social network. Michell and Amos (1997) collected a social network where vertices correspond to students in a school in Scotland and edges correspond to the existence of a friendship. Each student was asked to indicate if they consume alcohol more than once a week, once a week, once a month, once or twice a year or never. This social network was collected at three different time points. For the purposes of this work we consider the social network collected at the second time point and a excerpt containing fifty students which can be downloaded from the Internet1. We consider two communities in this social network corresponding to frequent and infrequent drinkers. Specifically, the first community corresponds to those students who drink once a week or more than once a week, while the second community corresponds to all remaining students. This social network is illustrated in Fig. 8 where students belonging to the frequent and infrequent drinker communities are represented by red and black vertices, respectively. The network support for drinking refers to the degree to which an individual's social connections encourage drinking (Litt et al. 2007). Network support for drinking has been found to be predictive of drinking behaviour (Havassy et al. 1991;Ivaniushina and Titkova 2021). In fact, studies have found that social network interventions which alter the network support for drinking can improve drinking behaviour (Litt et al. 2007). We now demonstrate how the model proposed in this work provides a useful abstraction for performing such interventions. Let G = (V, E) <unk> G denote the social network graph in question. Also, let L = <unk>'frequent', 'infrequent'<unk> denote the set of community types in question corresponding to frequent and infrequent drinkers. Let N be the following map from a vertex to its corresponding ego community: Informally, the ego community of a vertex v is the graph containing v plus all vertices adjacent to v. Consider the social network displayed in Fig. 9(a) where a single vertex v is indicated. The corresponding ego community N(v) contains four vertices and is displayed in Fig. 9 Let us assume that the network support for drinking can be reduced by performing an intervention such that each vertex either belongs to the infrequent community or is directly connected to a vertex belonging to this community. A necessary and sufficient condition for this topological relationship is: (b). (16) N <unk> V <unk> G v <unk> (<unk>v<unk> <unk> <unk>v <unk> (v, v ) <unk> E<unk>, <unk>) For example, the value |T•I(N(v), C('infrequent'))| cor- responding to the vertex v in Fig. 9(a) is 2. If we assume a set of feasible operations containing the operation E +, an implementation of this intervention can be determined using Algorithm 5. The first step in this implementation determines the frequent and infrequent communities (lines 2 and 3). Next, for each vertex v in the frequent community where the above condition does not hold, a vertex v ′ belonging to the infrequent community is selected uniformly at random and the operation E + (v, v ) is applied (lines 4 to 9). --- Algorithm 5: Reducing Network Support for Drinking Input: A social network G = (V, E) <unk> G, L = <unk>'frequent', 'infrequent'<unk> and C <unk> C. 1 begin 2 (V f, E f ) = C('frequent') 3 (V i, E i ) = C('infrequent') 4 for v <unk> V f do 5 if |T • I(N (v), (V i, E i ))| = 0 then 6 v = random(V i ) 7 E + (v, v ) 8 end 9 end 10 end (17) |T•I(N(v), C('infrequent'))| <unk> 1, <unk> v <unk> V This result of applying this intervention to the social network displayed in Fig. 8 is displayed in Fig. 10. The intervention in question added six additional edges and we can see that each vertex now either belongs to the infrequent community or is directly connected to a vertex belonging to this community. In Theorem 6 we prove that this method for determining an implementation of the intervention in question generalises to all social networks. Theorem 6 Consider a social network where G = (V, E) <unk> G, L = <unk>'frequent', 'infrequent'<unk> and C <unk> C plus a set of feasi- ble operation containing E +. If we assume that initially the infrequent community contains one or more vertices, Algorithm 5 determines an intervention implementation which satisfies the necessary and sufficient conditions in Eq. 14. Proof For each vertex in the infrequent community, the condition in Eq. 14 is immediately satisfied. For each vertex in the frequent community for which this condition is not satisfied, an edge is added connecting the vertex in question to a random vertex in the infrequent community. This results in the condition in Eq. 14 being satisfied for each vertex in the infrequent community. <unk> --- Conclusions In this work we proposed a novel model of social network interventions which considers topological relationships existing between communities. We subsequently demonstrated that this model provides an abstraction which in many cases is useful for solving problems involving social network interventions. To the authors' knowledge, this is the first such model to consider topological relationships. As such, there exist many worthwhile directions for future research and development of the model. Some possible directions include the following. The proposed model assumes a set of feasible operations which can be applied to a given social network to implement an intervention. This is an abstract view and does not consider how each operation is performed in reality. For example, removing a vertex from a social network may be performed in reality by detaining the individual in question or by confiscating their mobile communication device. The former approach may be feasible in the security domain if the individual is a known criminal and those performing the intervention are national police. However, in most domains detaining an individual is illegal. Therefore, it is important that the set of feasible operations is defined with respect to the application domain in question where how each operation is implemented in reality is clearly specified. Furthermore, the proposed model does not model the fact that different intervention implementations may have different probabilities of being successful. Modelling such probabilities would be useful in many situations. For example, where one has many possible implementations of a given intervention and wishes to select the one with the highest probability of success. The task of defining the intervention with highest probability of success could potentially be posed as an optimization problem. The proposed model makes a distinction between defining and implementing an intervention where these tasks are performed independently. That is, one first defines an intervention and then determines how best to implement it. This may be a suboptimal approach whereby in many cases it may be beneficial to perform both tasks jointly. For example, by doing so one could define an intervention which both achieves a desired objective and is inexpensive to implement. The task of jointly defining and implementing an intervention which meets a specified objective could also potentially be posed as an optimization problem. In this article we have considered a handful of specific applications in the domains of health and security. However the proposed model is very general in nature with many potential applications beyond these considered here. An interesting direction for future research would be to consider applications of the model to event-based interventions discussed in the related works section of this article. Finally, in this article we have highlighted many potential benefits of using social network interventions. However, existing models generally only consider the direct consequences of interventions and fail to consider the potential for indirect or secondary consequences. These indirect consequences can potentially be very significant. For example, consider the interventions, of reducing face-to-face interactions, performed by many governments to reduce COVID-19 transmission. The indirect long-term impact of these interventions on the education of children due to school closures is not yet fully understood. Therefore, more research and improved modelling is needed in this space. --- Data availability The datasets generated during and/or analysed dur- --- ing the current study are available from the corresponding author on reasonable request. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.

A social network intervention is a process of intentionally altering a social network to achieve an objective. The objective in question may concern accelerating behaviour change or improving organisational performance. In this work we propose a novel model of social network interventions which considers topological properties of relationships existing between communities. Broadly speaking, topological properties of such relationships include properties described by natural language descriptions such as contains, partial overlap and disjoint. The proposed model provides an abstraction which in many cases is useful for solving problems involving social network interventions. We demonstrate this by simulating interventions on a number of hypothetical and real social networks in the domains of health and security.

oral disease (Habashneh et al., 2005;Payscale.com, 2007;Yahoo, 2010). Indeed, several studies over the last decade have shown that parity (number of children) is related to tooth loss (Rundgren and Osterberg, 1987;Halling and Bengtsson, 1989;Christensen et al., 1998;Russell et al., 2008), but the reason for this relationship is unclear. Few studies have examined whether parity is related to dental caries (Walker et al., 1983;Scheutz et al., 2002), a prerequisite to tooth loss. The purpose of this study was to determine whether parity is related to dental caries, and to examine whether this relationship can be explained by the effect of parity on socio-behavioral variables related to dental caries. --- METHODS Study Population and Sample Selection We used data from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). Of 7073 Black and White non-Hispanic women aged 18-64 yrs, we included women who (1) had received a dental examination, (2) retained at least one tooth, (3) reported at least one pregnancy, and (4) were not missing parity or socio-economic status (SESincome, education, occupation) data. Of the 6501 White and Black women who received a dental examination, 95.2% (6186/6501) retained at least one tooth. Of these, 18.9% (1172/6501) reported no pregnancies, and 9.6% (593/6501) were missing data on SES or parity (number of live births). Since the aim of this analysis was to identify pathways by which parity affects dental caries, we excluded those with multiple missing explanatory variables (1786/4421), and our analysis therefore included 60.0% of the eligible women (2635/4421). The Institutional Review Boards of New York and Yale Universities approved this study. --- Theoretical Model Our theoretical model of the parity-caries relationship was adapted from that of Adler et al. (1993), who suggested that socio-economic status (SES) may affect health through three pathways: (1) health care, (2) psychosocial factors, and (3) health behaviors. We hypothesized that parity (which is closely related to SES) would influence dental caries through: (1) dental health care, (2) psychosocial factors, and (3) dental-health-damaging behaviors. (See online Appendix for theoretical model.) --- Parity & untreated Dental Caries in uS Women --- Measurements Tooth surfaces were scored as sound, decayed, missing, or filled according to the DMFS Index (USDHHS, 1998). Dental caries was expressed as the proportion of surfaces/total examined surfaces, and included: (1) cumulative caries experience (DFS), (2) the proportion of filled surfaces (FS), and (3) the proportion of decayed surfaces (DS). All women were asked: "What is the total number of live births (live-born children) you have had?" SES included: (1) the poverty income ratio (PIR), ( 2) education (years of school), and (3) occupation [Duncan Socioeconomic Index (SEI), a measure of occupational prestige]. Dental care included dental insurance (covered by health insurance paying for dental care) and frequency of dental visits. We included two measures of psychosocial status: financial stress and social support. Women reporting one or more days during the previous month with no food/money for food were considered to have financial stress. Social support was measured with six questions exploring frequency of social contacts, attendance at church/meetings, and club memberships. Dental-health-damaging behaviors included smoking, which included (1) self-reported smoking, (2) number of cigarettes smoked/day, and (3) serum cotinine level, and cariogenic diet, which combined a monthly consumption of four groups of cariogenic foods [cakes/cookies, chocolate candy, sugared beverages (e.g., Kool-Aid ® ), and sugared sodas]. Age, marital status (yes/no), time since last live birth (yrs), and race were included in all models. --- Statistical Analysis We created summated standardized scales for SES, smoking, and age/time since last live birth, to maximize use of the available data and avoid collinearity for modeling. To create scales, we examined correlations between items, standardized the items, and examined Cronbach-<unk> reliabilities. We then stratified by parity, and by SES, and conducted univariate and bivariate analyses using ANOVA or the Kruskal-Wallis test. Since we found that many respondents had missing values on multiple explanatory variables in the model (dental insurance, etc.), we used multiple imputation with PRELIS 2 (SSI, Chicago, IL, USA). We began with candidate regression models to predict nonmissing endogenous variables with assorted other explanatory/ auxiliary variables and used Monte Carlo analysis with multiple chains to simulate five datasets with which to impute missing values along with the covariance structure among them. For all other analyses, we used Stata/SE (Stata Corporation, College Station, TX, USA). We used Dunn-Sidak corrections for multiple comparison adjustment. We used path analysis to explore complex relationships among variables. Because of skewed and non-normal distributions of multiple variables, and influential outliers and notable heteroskedasticity in the data, we performed robust path analyses using two algorithms: the first symptotically attenuated heteroskedasticity with a White sandwich variance estimator (White, 1980), and the second down-weighted the influence of the outliers. Path analysis for each robust regression algorithm included: (1) performing general-to-specific regressions for variables loading significantly on the outcome variable (Hendry and Richard, 1982), (2) trimming the full models of non-significant paths, and (3) creating path diagrams based on the final models. To compute total effects, we calculated zero-order relationships between the exogenous variables that loaded on each endogenous variable in the path diagram. We performed intermediate regressions for each of these variables, identified all indirect paths, and calculated the sums of each of these indirect effects as the products of direct paths. Finally, we computed the unexplained effects for each independent variable as the difference of zero order and total effects, and calculated an error term for each endogenous variable. Since our participants represented only a small subpopulation compared with that anticipated by the sample design, we chose not to perform a weighted analysis. When comparing our sample with the US population of women giving birth over the years 1988-1992 in the National Vital Health Statistics birth records for the same years as the NHANES III (1988)(1989)(1990)(1991)(1992), we indeed found the demographics of our sample to be dissimilar to that of the general US population of childbearing age (i.e., giving birth). Consequently, because our analysis was unweighted, our results cannot be generalized to the US population. --- RESulTS --- Scale Construction Education, PIR, and SEI were correlated at levels of 0.42 (education, PIR), 0.36 (PIR, SEI), and 0.49 (education, SEI). Smoking, number of cigarettes, and serum cotinine were correlated at levels of 0.67 (smoking, number of cigarettes), 0.70 (numbers of cigarettes, cotinine), and 0.64 (smoking, cotinine). Age and time since last live birth were correlated at 0.84. Cronbach-<unk> reliabilities for the summary variables SES, smoking, and age/time were 0.69, 0.87, and 0.89, respectively. Women with missing data were older (47 vs. 39 yrs, Mann-Whitney test, p <unk> 0.001), had higher parity (2.9 vs. 2.3 births, Mann-Whitney test, p <unk> 0.001), were less educated (11.9 vs. 13.1 yrs, p <unk> 0.001), had lower incomes (PIR 2.1 vs. 3.0, Mann-Whitney test, p <unk> 0.001), and were more likely to be Black (56.0% vs. 49.1%, <unk> 2 = 26.14, df = 1, p <unk> 0.001) than those in our selected subsample. --- Descriptive Analyses Parity was inversely related to SES (Table 1). Women with the highest parity levels (4-6, 7+ births) exhibited similar total amounts of filled + decayed surfaces (median of 17.9% and 18.5%), but had more untreated decay (21.7% vs. 6.1% of all affected surfaces) than women with lower parity (Fig. 1). --- Robust Regression Modeling Race, SES, dental insurance, dental care frequency, and age/ time since last live birth were significant predictors of (a) the proportion of filled surfaces, and (b) the proportion of decayed surfaces (Table 2). Parity was an important predictor of decayed, but not filled, surfaces, and marital status was an important predictor of filled, but not decayed, surfaces. --- Robust Path Analysis Robust path models show variables that significantly (via both algorithms) relate to (a) the % filled surfaces (model a) and (b) the % of decayed surfaces (model b) (Fig. 2). Standardized robust regression coefficients (betas) are on the paths, and error terms are in grey. With the exception of SES and social support, higher measurements of all variables indicate less favorable characteristics. Direct paths leading to both filled surfaces and decayed surfaces include those from SES to dental insurance and dental frequency. The directionality of these relationships was reversed between the two path models: Higher SES, having dental insurance, and visiting the dentist at least once a year were all related to more filled and fewer decayed surfaces. The relationship between dental visit frequency and decayed surfaces was especially strong (robust beta = 0.27, p <unk> 0.001). Common paths for both models included those from SES to dental insurance and to dental frequency, and the path between these two variables. Women of higher SES were more likely to report going to the dentist at least once a year and were more likely to have dental insurance. The relationship between SES and dental visit frequency, however, was almost twice as strong as the relationship between SES and dental insurance (robust beta of -0.25 vs. -0.14, both p <unk> 0.001). Additional consistent paths included those between SES and parity, SES and marital status, and marital status and parity. Higher-SES women were more likely to be married, and married women had higher parity. The SES-parity relationship was twice as strong as the SES-marital status relationship (robust beta of -0.25 vs. -0.13, both p <unk> 0.001). Cariogenic diet was unrelated to caries. A small indirect effect of SES through smoking and dental frequency was found for both filled and decayed surfaces (-0.002). Major differences between the two path diagrams included: (1) a path between marital status and filled surfaces, indicating that married women were more likely to have more filled surfaces; and (2) a path between parity and decayed surfaces, demonstrating that higher-parity women were more likely to have more decayed surfaces. --- DISCuSSIOn This is the first evidence in a large, heterogeneous sample of US women that parity is related to untreated dental caries, regardless of SES, race, and age. Despite the public perception that childbearing causes oral health deterioration, only two studies have specifically examined the relationship between parity and caries (Walker et al., 1983;Scheutz et al., 2002). While neither of these previous investigations identified a relationship between parity and caries, it is possible that, because these existing studies were performed in Africa, the results are not completely relevant to women with access to dental care. The old wives' tale "a tooth for every child" is generally attributed to the idea that pregnancy depletes maternal teeth of calcium, making them more caries-susceptible. In truth, the developing fetus actually draws needed calcium from the skeleton (Casamassimo, 2001), but other biologic mechanisms for an increase in susceptibility to caries during pregnancy have been proposed. Many of these physiologic mechanisms-including variations in saliva (Laine, 2002), oral flora alterations (Laine, 2002), and the immunosuppressed state of pregnancy (Luppi, 2003)-are those that possibly contribute to a documented mild, but persistent, sex/gender disparity in caries rates in the US (Brown et al., 2002;Dye et al., 2007;Lukacs, 2008). Our finding that increased parity is associated with untreated decay, along with other evidence that relates parity to tooth loss (Rundgren and Osterberg, 1987;Halling and Bengtsson, 1989;Christensen et al., 1998;Russell et al., 2008), suggests that greater caries susceptibility associated with higher parity may not be solely biological, but also socio-behavioral. It is possible that higher-parity women are more likely to have carious teeth extracted, while lower-parity women are likely to have teeth restored. Pregnancy and maternity alter patterns of dental treatment, and traditionally dentists have been advised that routine dental care for pregnant women should occur only during a limited window, the second trimester (Gaffield et al., 2001;Pistorius et al., 2003;AAP, 2004;ADA, 2006). Also, because of a lack of knowledge regarding the safety of treatment during pregnancy, fear of malpractice, or fear that a woman may go into labor, dentists may refuse outright to treat pregnant women (Strafford et al., 2008), may revise treatment plans when they discover a woman's pregnancy, or may postpone care until after the woman has given birth (Livingston et al., 1998;Pistorius et al., 2003). Additionally, some pregnant women feel that going to the dentist is unsafe during pregnancy (Strafford et al., 2008) and may postpone treatment until after the birth, but at that point access to dental care may be restricted due to childcare and time or financial constraints (Redford, 1993). Pregnant women in the US have high levels of dental disease (Silberman et al., 1980) and treatment needs (Gaffield et al., 2001;Lydon-Rochelle et al., 2004), but the proportion of pregnant women who report having a dental visit is low (22.4-43.2%) (Mangskau and Arrindell, 1996;Gaffield et al., 2001). In fact, even pregnant women with a dental problem are unlikely to see a dentist (Gaffield et al., 2001). Our finding that being married was related to filled surfaces supports the findings from a previous study that most pregnant women who reported a dental visit were non-minority, married, and educated beyond high school (Timothe et al., 2005). Unfortunately, since rates of dental access and utilization among pregnant women vary significantly by SES (Timothe et al., 2005), those pregnant women most at risk for dental disease are least likely to receive dental care when pregnant. There are several limitations to this study. Because we did not use the sampling weights supplied by NHANES III, our results are not generalizable to the US population. Second, because of the complexity of our analysis, we chose to limit the study to only Black and White women. Mexican-American women are likely different from non-Hispanic women regarding issues related to parity, including culture and psychological factors related to parity, such as social support. In the future, studies should examine the parity-oral health relationship among different ethnic/cultural groups. Third, we were limited to those variables measured as a part of NHANES III. Finally, these data are cross-sectional, and although the directionality of the associations in the path models were created based on judgment of how relationships would work in reality, we should emphasize that one cannot assume directionality in the case of this study (i.e., models in Fig. 2 would be equivalent if the arrows were reversed). Receiving dental care during pregnancy is safe (Michaelowicz, 2009), and guidelines have been published that advocate for dental care for pregnant women (Kumar and Samelson, 2006;Russell and Mayberry, 2008). Interventions aimed at pregnant women, and women with small children, could have a bearing on the dental health status of this significant proportion of the US population, not only because most women do have children, but also since maternal oral health is related to a child's oral health. Efforts to correct disparities in parity-related dental caries may serve to correct this imbalance by addressing specific needs of women with children regarding issues including care of dental disease during pregnancy, access to dental care, and dental programs aimed at families.

While parity (number of children) reportedly is related to tooth loss, the relationship between parity and dental caries has not been extensively investigated. We used path analysis to test a theoretical model that specified that parity influences dental caries levels through dental care, psychosocial factors, and dental health damaging behaviors in 2635 women selected from the NHANES III dataset. We found that while increased parity was not associated with a greater level of total caries (DFS), parity was related to untreated dental caries (DS). The mechanisms by which parity is related to caries, however, remain undefined. Further investigation is warranted to determine if disparities in dental caries among women are due to differences in parity and the likely changes that parallel these reproductive choices.

Introduction Ugandan academic, Mahmood Mamdani, has been dividing his academic activity between Columbia University in the United States of America (USA) and Makerere University (MAK) in Uganda for a long time. Mamdani has been the Herbert Lehman Professor of Government at the School of International and Public Affairs, Columbia University, as well as professor of anthropology, political science and African studies at the same institution. 1 Concomitantly, Mamdani has been director of the Makerere Institute of Social Research (MISR 2 ), a social sciences institute whose space he has used to focus his academic energies to train a new generation of social science and humanities academics. In other words, Mamdani holds at least two formal academic appointments in two countries on two continents. In 2018, years following a clash over his proposed core course on Africa at the University of Cape Town in South Africa in 1997, dubbed the 'Mamdani Affair' (Kamola 2011), which led to his resignation, the Langa: African Diaspora and its Multiple Academic Affiliations distinguished scholar was reappointed as an honorary professor at the Centre for African Studies (CAS). 3 In addition, Mamdani is a respected political commentator on Africa and a widely published author. He can therefore be acknowledged as an African diaspora scholar (ADS) with multiple translocal scholarship engagements. While Mamdani might epitomise the prominent public intellectual and ADS, the literature shows a growing tendency of scholars -some less publicly visible -holding multiple academic appointments (Hottenrott and Lawson 2017). In the era of the so-called global academic marketplace, possibilities for multiple international academic appointments have increased significantly (Altbach, Reisberg and Rumbley 2009). As exemplified by Mamdani in the case of Uganda, most African countries have their own class of translocal academics. These scholars can either be African-based diaspora scholars (ABDS) taking up appointments in a country other than their country of origin, or ADS based outside the continent but collaborating, through temporary appointments, with universities in Africa. The elements uniting these scholars are international leadership in their respective disciplines, high productivity in terms of scientific publications and impact measured through citations, and their status as global public intellectuals (Mamdani 2016). These particular academics possess high levels of scientific and symbolic capital (Langa 2010). Academics with multiple appointments and affiliations are no longer an uncommon phenomenon in the global higher education context (ESF 2013;Hottenrott and Lawson 2017). While on a global level, academics display high local and international mobility, the data on academic mobility, particularly in Africa, remain inaccurate and insufficient (Ogachi 2015) and, consequently, a persisting challenge. Despite the growing tendency to collect data on student mobility, a paucity of data on academic staff mobility in general, and MMAs in particular, remains the norm on the continent. According to Altbach et al., 'the academic profession will become more internationally oriented and mobile, but will still be structured in accordance with national circumstances'(2009:1). Hence, although academic profiles similar to Mamdani's are becoming more common and more visibleespecially in the context of the globalised academic marketplace (Altbach et al. 2009) -not all institutions and academics have the ability to attract and engage in such appointments. In general, globalisation tends to concentrate wealth, knowledge and power with those already possessing these elements (Altbach and Knight 2007). By and large, in developed countries, institutions and corporations own most knowledge, knowledge products and information technology infrastructure, though South-to-South collaborations and networks are increasing, especially in Asia, Latin America and Africa. Different circumstances might determine whether the mobility of scholars is classified as brain drain, particularly when there is departure to the diaspora, or brain gain -when an academic returns to his or her country of origin after a position abroad. In general, academics go from developing countries to North America, Western Europe and Asia-Pacific. There are also significant flows from sub-Saharan Africa to South Africa, from South Asia to the Middle East and Africa, from Egypt to the wealthier Arab countries, and from the United Kingdom to Canada and the USA (Zeleza 2014). A key motivator for the direction of this flow is the level of salaries, but, among other factors, improved working conditions, research support infrastructure, opportunities for advancement and academic freedom may also play a role. Those in the diaspora can exert a strong influence by keeping in contact with the academic communities in their home countries and by sharing research and experience (Ogachi & Sall 2015;Zeleza 2014). However, the global flow of academic talent works to the disadvantage of emerging countries, although there are indicators that this status quo is changing. More Chinese scholars are choosing to return home after sojourns elsewhere, for example. Universities in Singapore, Hong Kong, China and elsewhere are attracting Western academics with high salaries and favourable working conditions (Altbach 2004). In fact, the volume of South-South cooperation in higher education and research has significantly increased in the past decade (ECOSOC 2008;OBHE 2001-10). One common argument for South-South cooperation by southern countries is their similar phase of development, and, hence, their mutual capability to develop practices relevant to each other's contexts (OBHE 2001-10). Compared with North-South partnerships, South-South cooperation is often also cheaper to implement in terms of mobility and is based on fewer prerequisites, thus facilitating the start as well as ongoing administrative procedures. However, developing countries in sub-Saharan Africa are rarely involved in intra-African cooperation. Accurate growth data on South-South, including intra-African, cooperation are often unavailable because they are not systematically collected at the national or international level. Initiatives and programmes, largely financed by the North, are focused on the South. Additionally, international academic mobility favours well-established education systems and institutions, thereby compounding existing inequalities. The international mobility of African academics, particularly to developed countries, has been regarded as a negative consequence of global market forces. Since the early 1990s, there has been an almost uncontested narrative that developing countries have been losing higher-level skilled professionals each year to the developed world (Adams 2003). This alarming description of a dangerous human capital exodus from Africa to the developed world has dominated the political and academic discourse. The Economic Commission for Africa (ECA) claims that between 1960 and 1989, some 127,000 highly qualified African professionals left the continent. According to the International Organization for Migration (IOM), Africa has lost 20,000 professionals each year since 1990 (Tebeje 2011). The idea that Africa suffers from brain drain thus became the conventional wisdom in media and academic circles. There are no indications to date that scholarly opinion has shifted significantly. However, in the era of relatively easy air travel and ever-increasing digitalisation, many internationally mobile academics retain close links with their home countries or continent. A more optimistic approach regards the current status quo as brain gain or brain circulation, and can offer many opportunities for developing countries (Teferra 2005;Tung 2008). The article argues that is that the concepts of MAAs and brain-sharing, particularly in the age of digitalisation, broaden both the scope and the possibility of a win-win situation by sharing the academic and intellectual capacity of highly productive (African) academics through capitalising on MAAs and collaboration between (African) universities and their diaspora scholars. While the article provides insight into the extent and structure of MAAs, further research into the contractual and organisational nature of MAAs in Africa is needed to inform policy and decision-making on the issue. The article concludes by suggesting that, if properly managed, MAAs, together with the effective use of information and communication technology (ICT) and e-learning platforms, can offer an opportunity to curtail the undesired consequences of brain drain. --- Literature Review Brain Drain: A Bleak Picture of African Diaspora at the Transition into the Twenty-First Century The body of literature on the African academic diaspora has grown significantly in the last two to three decades (Ogachi & Sall 2015;Zeleza 2013Zeleza, 2014Zeleza, 2016)). However, there continues to be a paucity of literature and research on the kinds of appointments diaspora academics occupy in their collaboration with African institutions. Even literature which presents the notion of brain circulation as an antidote to the undesired effects of brain drain, does not elaborate on the actual forms of engagement diaspora academics undertake with their partner institutions (Tung 2008). Often, examples provided from those countries which are considered to have adopted strategies to curb brain drain, such as China and India, do not provide the particularities of the contractual agreements these academics make with both the home and host institutions. Likewise, studies on the contractual nature of MAAs are still rare (Hottenrott and Lawson 2017). In general, the literature tends to focus on brain drain in the context of human capital losses or gains (Tafah 2004). This trend is related to a perspective from the discipline of economics, which diaspora studies have frequently embraced. Hence, while human capital gains enhance economic growth, losses generate important problems in the growth process of any country. Notwithstanding this recognition, research attention on the international movement of economic resources has focused more on the physical movement of people across borders and continents as opposed to the virtual exchange of human capital via ICT and e-learning platforms, in a world increasingly characterised by virtual connectivity and the rise of the network society (Castells 2010). The recurring definition of the international movement of human capital as loss, brain drain, is generally accepted, as it is perceived as the drainage of talented people from one country, region or continent to another in search of better professional and personal opportunities. Usually, the concern with brain drain becomes relevant in the context of competition amongst nations, which may lead to scarcity of skills and talents. In this sense, brain drain constitutes a great loss for the country from which migration takes place, because it is the exodus of the most educated stratum of a particular society. The concept of brain drain is therefore used to describe the loss of advanced professional and technical skills, such as scientists, academics, doctors, engineers and other professionals with university training. In that sense, it alludes to the most trained fraction of a particular society (Giannoccolo 2009(Giannoccolo, 2010a(Giannoccolo, 2010b)). The literature on the African diaspora denounces the academic mobility of high-level, skilled personnel from emerging countries, for example in Africa, to Western countries. This view assumes that the diaspora negatively affects the socioeconomic and sociocultural prospects of developing nations, since they lose human capital to the developed world (April 1998;Obia 1993;Smyke 2001). Literature produced in the late 1990s and early 2000s proposed remedial measures to deal with brain drain, which was regarded as a national threat to developing nations (Commander, Kangasniemi and Winters 2004). This dreary picture was often based on imprecise figures and presented a worrisome situation. --- Figures on African Brain Drain In the case of Africa, the idea that the best and brightest are fleeing the continent has been documented and supported with figures provided by various sources including organisations such as the International Organisation of Migration (IOM), the United Nations Educational, Scientific and Cultural Organisation (UNESCO), The World Bank and researchers (Tafah 2004;Mohamoud 2005;World Bank 2007;Capuano and Marfouk 2013;Chukwudum Oforka 2015). According to the IOM, Africa had already lost one-third of its human capital and continues to lose its expert personnel at an increasing rate, with an estimated 20,000 doctors, university lecturers, engineers and other professionals leaving the continent annually. According to the IOM, over 300,000 African professionals live outside of the continent, and approximately 20,000 African professionals migrate to Western countries every year (Ite 2002). The IOM estimates over 300,000 highly qualified Africans were in the diaspora, 30,000 of whom were PhD holders (Boyo 2013;Chukwudum Oforka 2015). At the same time, Africa was spending US$4 billion per year (representing 35 per cent of total official development aid to the continent) to employ some 100,000 expatriates performing functions generically described as technical assistance. While skilled Africans leave the continent, non-Africans work in skilled jobs on the African continent (Barka 2000). In Figure 1 below Capuano and Marfouk (2013) use a dataset (DMOP) developed by Docquier, Marfouk, <unk>zden, and Parsons (2011) to compare the highly skilled emigration rates when emigration to non-OECD countries is also considered. The figure shows that the brain drain is mostly underrated in sub-Saharan African countries, such as Burkina Faso, Chad, Lesotho, Namibia, Swaziland, Niger, and Mali. For instance, "for Lesotho, the high skilled emigration rate to the OECD and non-OECD countries (23 per cent) is approximately six times higher than the high-skilled emigration rate to the OECD countries (4 per cent)" (p.309). Capuano and Marfouk (2013) also in Figure 1 show that "the magnitude of the brain drain is also underrated for non-African countries. In fact, DMOP only considers 76 receiving countries. Due to the low quality of the data, the information on sending countries is partial" (p.310), but enough to give an overall idea of the immigration trends of high skilled people. Furthermore, in the year 1999, Africa as a whole counted only 20,000 scientists (0,36 per cent of the world total) and its share in the world's scientific output had fallen from 0.5 per cent to 0.3 per cent as it continued to suffer a brain drain of scientists, engineers and technologists (Deen 1999, Anonymous (n.d). Reports based on figures from IOM and UNESCO show that the problem of brain drain has reached quite disturbing proportions in certain African countries, with Ethiopia ranked first on the continent in terms of rate of loss of human capital, followed by Nigeria and Ghana. Over the past 10 to 15 years, about 50 per cent of Ethiopians who went abroad for academic training did not return after completing their studies. According to the IOM, Ethiopia lost about 74.6 per cent of its human capital from various institutions between 1980 and 1991. The report states that, while Ethiopia had only one single full-time economics professor, there were more than one hundred Ethiopian economists in the USA (Deen 1999, Barka 2000, Anonymous [n.d.]). This bleak brain-drain scenario resulted in the United Nations recognising that the emigration of African professionals to the West was an obstacle to Africa's development. Studies in the first 15 years of the new millennium show that research collaborations between African scholars and international academics recorded a slight improvement in African research output, a major area of African governments' higher education policies have tended to respond to the migration of African professionals, including academics, to the North in one of three ways. First, they admonish the brain drain and engage in mutual accusations with the diaspora. Governments of originating countries may view their migrants as unpatriotic for leaving their countries when they are needed the most. Attitudes can also shift from positive to negative if migrants gather resources, become more organised and hence become politically influential, implying a potential threat to the status quo (Mohan 2008). Second, some governments have pursued the brain gain argument to encourage the diaspora to return permanently. For instance, Ghana's main concern has been the health sector and it acts to prevent the departure of its health professionals. At the same time, it encourages Ghanaians abroad to provide temporary service in the national health system (Vezzoli and Lacroix 2010). Furthermore, policies can be developed as ways to promote the extension of rights of (former) citizens residing outside national boundaries. Relevant policies include the political incorporation of migrants, either by allowing dual citizenship and providing expatriates with passive and active voting rights or by granting migrants access to civil and social services (Gamlen 2006(Gamlen, 2008)). In this respect, the government of Ghana passed a dual citizenship law in the year 2000 and, more recently, provided Ghanaian migrants with the right to vote in elections in Ghana. Another example is the government of India, which has created a systematic method to attract the skills and human capital of its diaspora for the development of various sectors of the Indian economy (Vezzoli and Lacroix 2010). The third governmental response is the 'diaspora' option, which recognises migrants as new diasporas. Efforts are made to build effective strategies of brain mobility or brain circulation between them and their countries of origin as well as the continent as a whole (Mensa-Bonsu and Adjei 2007). The latter requires developing innovative strategies for knowledge and skill circulation, such as the creation of national, regional and continental knowledge networks facilitating brain mobility through academic exchanges, consultancy assignments and temporary return migration movements. --- Changes in the Academic Profession in the Knowledge Society Globally, substantial research has been produced on the changes taking place in the academic profession in the era of the knowledge society (Balbachevsky, Schwartzman, Novaes Alves, Felgueiras dos Santos and Birkholz Duarte 2008;Brennan 2006;Cummings and Arimoto 2011;Finkelstein, Walker and Chen 2009;Henkel 2007;Higgs, Higgs, Ntshoe and Wolhuter 2010;Höhle and Teichler 2011). However, with the exception of South Africa (Higgs et al. 2010;Wolhuter 2015), Africa has generally been neglected in such studies. In the new era, the framework of higher education has experienced major changes. Similarly, the backgrounds, specialisations, expectations and work roles of academic staff have undergone transformation (Teichler, Arimoto and Cummings 2013). The academy is expected to become more professional in teaching, more productive in research and more entrepreneurial (Harman and Meek 2007). Concomitantly, knowledge has come to be identified as the most vital resource of contemporary societies (Arimoto 2010). To respond to the multiple demands and challenges of the knowledge society, academic work has been adapting itself by developing new content and reshaping its forms. Translocal and transnational institutional affiliations and engagements with multiple stakeholders, both face-to-face and online, have become part of the portfolio of many academics as an integral part of their academic work. Thus, academic affiliation is becoming an elusive home (Ordu<unk>a-Malea, Ayllón, Mart<unk>n-Mart<unk>n and López-Cózar 2017). However, in some cases the academic profession still maintains certain features that are not always compatible with the new demands on the translocal context of higher education. This is the case particularly in the African context, where academics still tend to be employed on manual worker-type contracts which require physical presence in the workplace. This situation is amplified whenever academics are remunerated on the basis of the number of hours they are supposed to dedicate to teaching activities and research, and where outreach is not specified as part of their work. In an era marked by increasing globalisation and internationalisation of the academic profession and Langa: African Diaspora and its Multiple Academic Affiliations scholarly work, with academics engaging in multiple international institutional affiliations, certain traditions and practices in academic management, such as single institutional contracts, are being challenged. --- Research Approach and Data Sources Being an exploratory study, the information and data used in this article derive from multiple sources, including a literature review, conversations with African-based and African diaspora scholars, 4 and reports of bibliometric databases on academic collaborations. The conversations with African-based scholars (ABS) and ADS took place in the context of their participation in the establishment of two postgraduate programmes and an academic staff exchange and mobility programme. The Council for the Development of Social Sciences Research in Africa (CODESRIA), through its programme African Diaspora Support to African Universities (ADSAU), sponsored seven academic exchanges between ABS and ADS from 2016 to 2018. Through these, a number of joint activities took place, including: i) curriculum design of two new PhD programmes in Higher Education Studies at the University of the Western Cape (UWC) and Eduardo Mondlane University (UEM); ii) co-supervision of postgraduate students; iii) delivery of public lectures; iv) seminars with doctoral and postdoctoral fellows at the Institute of Post School Studies (IPSS) of UWC and UEM; v) joint grant applications; and vi) reciprocal institutional visits between ABS and ADS. The collaboration between ABS and ADS has since continued by means of another funding source, the Carnegie Corporation of New York (CCNY), for the period 2016-2019. The CCNY also sponsored seven doctoral students and three postdoctoral research fellows in higher education studies at UWC's IPSS. Enabled by CODESRIA and CCNY sponsorship combined, more than ten ABS and ADS visited the IPSS between 2016 and 2018. The article interweaves a theoretical research exploration together with the perspectives of those ABS and ADS who participated in the Doctoral Programme in Higher Education Studies (DPHES) at the IPSS. The main research objective is to explore the types of engagement and the nature of contractual arrangements diaspora academics engage in. All academics and visiting fellows in the DPHES display different contractual arrangements and MAAs with various African institutions as well as with their current or permanent universities in Europe or America. A variety of topics are discussed in what follows, reflecting concerns and views regarding opportunities and challenges of engagement with the academic diaspora. The research focus was on multiple international appointments/affiliations (MIAAs), which are emerging as a global trend in the academic profession, with implications for African academia. --- Brain-Sharing: Exploring Multiple Academic Affiliations Studies by Paul Zeleza on engagements between ADS in the USA and Canada and African institutions of higher education shed much-needed light on possible roles that the African academic diaspora can play in supporting African universities (Zeleza 2004(Zeleza, 2013(Zeleza, 2014;;Zeleza, Akyeampong and Musa 2017). Although Zeleza's studies mostly turn a blind eye to intra-Africa or internal African academic diaspora, they are nevertheless an invaluable contribution to scholarship on the role of academic diasporas. A dimension that is largely absent in Zeleza's research on diaspora, as in most literature on the African academic diaspora, is the specific forms of affiliation scholars engage in, including contractual arrangements. Indeed, as far as the African research community is concerned, little is known about the modalities of engagements and contractual arrangements to promote collaboration between African academic diasporas and their academic peers on the continent. In fact, Zeleza (2013) acknowledges that many African diaspora academics have established vibrant, albeit largely informal, engagements with individuals and/or institutions across Africa. These engagements range from research collaboration to curriculum development and graduate student supervision. He also recognises that diaspora engagements frequently face institutional and attitudinal barriers. Zeleza's work identifies some of the major obstacles that hinder engagement with the diaspora: i) differences in resources and facilities; ii) a mismatch in expectations between African-based and African diaspora academics; iii) different academic status, teaching loads and institutional priorities; and iv) scheduling around incompatible academic calendars between the sending and receiving institutions. This study reinforces Zeleza's observations, in that traditional structures, paired with a lack of knowledge about new trends in the academic profession, impede new, creative and f lexible modes of promoting Langa: African Diaspora and its Multiple Academic Affiliations collaboration between ADS and ABS. The next section explores the challenges and opportunities of MIAAs in the African context. For a comprehensive overview, see Table 1 below. --- The Sports Contract Mentality An internationally competing football player cannot perform in and be contracted by two national teams. Therefore, strict rules from football governing boards, such as the International Federation of Association Football, subscribed to by national football confederations, sanction and prevent players from double contracts with clubs. Obviously, the circumstances of professional athletes in high-performance sports, which imply physical engagements and presence, are decisive in contractual obligations. Unlike in professional sports, the academic profession and the nature of academic work is more flexible as it allows for virtual, non-face-to-face interactions. In the age of Web 4.0, even laboratories can be shared virtually. The rise of e-classrooms is no longer an imagined reality. There has been a profound structural and morphological transformation of the conditions under which learning and teaching, as well as research, take place (Berk 2009). Downes (2007) argues that new technologies allow for the deinstitutionalisation of learning. The rise of virtual classrooms is well documented, as are various e-learning tools and technological resources -for example, Moodle, blogs, Facebook, wikis -which have revolutionised the meaning of a classroom. The rapid spread of ICT has changed traditional ways of communication and information-sharing. New technologies have brought innovations to different aspects of society and, of relevance here, to teaching and learning processes in higher education. These innovations have improved the types of communication, interaction and knowledge-sharing engaged in between individuals and groups (Avci and Askarl 2012). A new generation of students -known as 'digital natives', the 'Net Generation' or 'Generation Y' -has not known the world without the internet (Oblinger and Oblinger 2005). Nowadays, it is possible to share the knowledge of ADS or any other international experts without them having to physically move to Africa. Likewise, it is possible for ABS to teach in universities in the North. Technology has become both a facilitating element and a tool to create bridges between African universities and institutions in other parts of the world. Nevertheless, most African universities treat their academics as manual workers who have to be physically present at their workplace. This trend is related to the following factors: i) most African (public) universities have seen an increase in student intake on campuses, therefore requiring the physical presence of lecturers in classes and lecture halls; ii) academic work is mostly conceived of in the traditional way of teaching usually very large classes, thus requiring physical presence; iii) some institutions have introduced attendance registration books to keep a record of the physical presence of lecturers in classes. In some cases, fingerprint-enabled digital control of lecturers' physical presence in class is taking place, particularly in private institutions that pay staff per hour taught. The traditional idea of academic work being defined as teaching in class reinforces the predisposition of most African universities to oppose international collaboration and mobility. The professional athlete mentality therefore obstructs the mobility and ability of ADS to engage in multiple affiliations and international academic collaborations. Academic staff managers and human resource departments in most African universities have set rules and regulations to control the 'local' mobility of academics. Although claiming to promote academic mobility, Langa: African Diaspora and its Multiple Academic Affiliations university managers regularly apply restrictive regulations and measures which infringe on this principle. The digital fingerprint tool mentioned above, for instance, is utilised as a control mechanism to monitor academic staff's class attendance, thereby reinforcing the prevalent physical presencebased, face-to-face teaching culture. --- The 'Turbo Lecture': The Downside of Multiple Local Institutional Affiliation African-based academics commonly teach in more than two institutions, or in different time shifts in the same institution, as a way to supplement their relatively meagre salaries. Usually, these lecturers carry a heavy workload, leaving little or no time for research. The absence of national and institutional databases facilitating staff administration contributes towards the poor management of academic affiliations. In order to curb the so-called turbo lecture -that is, an individual with multiple teaching appointments -it would be necessary to establish 'one-size-fits-all' regulations which prevent academics from engaging in collaborations with other national and international institutions. While it may seem reasonable for universities to want to counteract the 'turbo lecture' -as denounced by Mamdani (2007) -as an unpleasant side effect of the commercialisation of higher education (a result of the transformation of African universities towards being more market-driven), they also need to promote the international mobility of their academic staff. While turbo lectures may represent the decay of African academia, internationally mobile and engaged academics are outliers and represent the positive side of multiple international engagements. Global networks and multiple international engagements contribute to giving African institutions a positive reputation (Overton-de Klerk and Sienaert 2016). Outlier academics have profiles that are similar to those of their peers in research universities in the North, yet, unlike their counterparts, they do not usually receive the same recognition. Furthermore, they are usually confronted with the demands of a heavy teaching load and overcrowded classrooms in their home institutions, with their physical presence being required at all times. Despite the advantages that MIAAs can bring to African universities, most do not seem ready to explore their benefits. In the context of changing incentives and reward systems, it is increasingly important for academics to cooperate and co-publish internationally (Abramo, D'Angelo and Di Costa 2009;Kwiek 2018). For instance, '"Internationalists" increasingly compete with "locals" in university hierarchies for prestige and for access to project-based research funding across Europe' (Kwiek 2018:136). In Africa, despite the paucity of data, research shows that more productive academics are likely to engage in multiple networks of collaboration with international partners (Langa 2010;Overton-de Klerk and Sienaert 2016). A study conducted by Kyvik and Reymerton (2017:951) shows that 'Membership in a research group and active participation in international networks are likely to enhance publication productivity and the quality of research'. Collaboration is hence central to the viability of engagement with the diaspora. Collaboration in research can take different forms, from giving informal advice to colleagues to working closely together via institutional agreements. Teamwork can be undertaken between colleagues in a university department, between peers in different departments, with other universities or research institutes, with industry, and with research establishments in other countries. Collaboration can take place between two individual researchers or between many scientists as members of large teams (Kyvik and Reymerton 2017). Paradoxically, in order for African academics to be more productive, they need the autonomy to engage in MIAAs and networks of collaboration with translocal research groups. This requirement often clashes with the inflexibility of their academic job descriptions and the contractual obligations at their home institutions. --- Joint and Double Degrees: An Opportunity for Reciprocity in MAAs A recent development in African higher education is the establishment of joint and dual or double degree programmes, particularly at postgraduate level, in collaboration with international universities in Europe, America and Asia. A joint degree programme, usually at master's or PhD level, is offered jointly by two or more international universities and results in a joint diploma which is formally accepted by all degree-awarding partner universities. A double degree programme -also known as dual degree, combined degree, conjoint degree, joint degree, simultaneous degree or double graduation programmeinvolves students' registering and studying for two different university degrees in parallel, either at the same institution or at different institutions, including in different countries at times, and completing those degrees in less time than it would have taken to earn them separately. The two degrees might be in the same subject area -applicable in particular when the course is split between countries -or in two different subjects (Fourie-Malherbe, Botha and Stevens 2016). Langa: African Diaspora and its Multiple Academic Affiliations In Latin America and South-East Asia, the number of North-South double/joint degree programmes has grown, for example between a Latin American country and France, Spain, the USA or Germany, and between Japan, South Korea and Vietnam, Cambodia or Mongolia (Gacel-<unk>vila 2009). In Africa, joint degree programmes are also taking off. In Europe, the process of establishing joint degree programmes was started by the Bologna Declaration in 1999. It formulated a set of goals, including the development of a European Higher Education Area, to promote citizens' mobility and employability, to achieve greater compatibility and comparability of the systems of higher education, and to increase the international competitiveness of the European system of higher education, as well as its worldwide attraction for students and scholars (Bologna Declaration 1999). Some North-South double degree programmes have received international funding, for example from the European Union (EU) or via the German Academic Exchange Service (Deutscher Akademischer Austauschdienst, or DAAD) programmes from Germany, aimed at promoting the development of these types of degrees. African universities have also benefited from such programmes, particularly through the EU-funded intra-Africa mobility programme. The number of North-South dual and joint degree programmes appears to be growing. Currently, dual degree programmes still dominate as they have to adhere to fewer regulations and are thus easier to establish. In addition, not all countries legally allow the creation of joint degree programmes. Joint degree programmes are one example of promoting equal collaboration between ABS and ADS, where all sides have similar opportunities for academic exchange and MAAs. However, as it stands, European partners, including the African diaspora, regularly benefit more than their ABS partners from these programmes. In most cases, the engagement of African diaspora and northern partners is viewed by the latter as a generosity resulting in intellectual and academic remittances to African universities. --- African Diaspora as an Intellectual Generosity The idea that engagement with ADS results in intellectual and academic remittances to ABS raises some questions. This understanding leads to ABS being placed in a disadvantaged position when compared to their counterparts. Academic collaboration involves a free sharing of ideas and the possibility of co-production of new knowledge for mutual benefit. However, ADS frequently position their collaboration as an expression of intellectual generosity through nurturing the development of less experienced colleagues. ADS thus position themselves as mentors providing a platform for the better visibility of ABS through joint publications. The exploitation of junior researchers by those in positions of power and seniority -a constellation also referred to as collaboration-as-parasitism -is also sometimes observed in ADS and ABS collaborations. Whilst collaboration has always been at the heart of academic work, its paradoxes illustrate how individual and collective goals can conflict, through measuring academic performance, on the one hand, and the way in which such audits reduce the meaning of collaboration to absurdity, on the other. --- New Dynamics in African Diaspora Engagement with Africa In 2017, a consortium comprised of Harvard University, the University of Johannesburg, the United States International University-Africa, the Ford Foundation, CODESRIA, the CCNY and the Institute of International Education organised a conference entitled 'Role of the Diaspora in the Revitalization of African Higher Education' (Zeleza et al. 2017). The conference gathered some of the most prominent ADS, including the authors of the post-conference report. The report is a comprehensive document featuring current debates and ideas about diaspora academics' role in advancing Africa's higher education to curtail the continent's brain drain and introduce a cycle of brain gain and brain circulation (Zeleza et al. 2017). Some of the key conclusions extracted from the report suggest that ADS represent a huge asset for the continent in meeting the challenges of African higher education and exploiting all opportunities (Zeleza et al. 2017). South Africa, for example,

Scholars with multiple affiliations have become more visible by assuming their particular role in redressing global knowledge production inequities. This article explores multiple academic affiliations (MAAs) as one way to curb the effects of brain drain, particularly in African universities. It argues that MAAs, is an effective way to reverse the effects of brain drain and promote brain circulation and sharing. The article proposes the concept of translocal academic engagement (TLAE) as a form of international academic exchange and brain-sharing which is not limited to physical mobility (circulation) from one geographical location to the other, but which includes virtual exchange and knowledge-sharing through blended learning delivery methods, e-pedagogies and the use of digital communication technology platforms such as Communities of Practice. The article concludes by suggesting that MAAs, if properly managed, can be a success factor in TLAE activities, particularly in the age of Web 4.0, in mitigating or shifting currently dominating knowledge production flows. TLAE offers possibilities for a win-win situation of academic exchange between higher education institutions in emerging systems.

, through measuring academic performance, on the one hand, and the way in which such audits reduce the meaning of collaboration to absurdity, on the other. --- New Dynamics in African Diaspora Engagement with Africa In 2017, a consortium comprised of Harvard University, the University of Johannesburg, the United States International University-Africa, the Ford Foundation, CODESRIA, the CCNY and the Institute of International Education organised a conference entitled 'Role of the Diaspora in the Revitalization of African Higher Education' (Zeleza et al. 2017). The conference gathered some of the most prominent ADS, including the authors of the post-conference report. The report is a comprehensive document featuring current debates and ideas about diaspora academics' role in advancing Africa's higher education to curtail the continent's brain drain and introduce a cycle of brain gain and brain circulation (Zeleza et al. 2017). Some of the key conclusions extracted from the report suggest that ADS represent a huge asset for the continent in meeting the challenges of African higher education and exploiting all opportunities (Zeleza et al. 2017). South Africa, for example, is amongst those African countries that have benefited the most from the presence of intra-African immigrants, despite many of them being met with hostility (Kalitanyi and Visser 2010). According to the report, ADS 'are an indispensable player in Africa's rapidly growing and increasingly diversified education sector. Their intellectual remittances are fundamental to the realization of integrated, inclusive and innovative sustainable development envisioned in numerous national and regional development agendas' (Zeleza et al. 2017:4). The authors also indicate that there is 'huge demand by African institutions for diaspora academics and there is need to expand beyond fellowships to other modalities of engagement to appeal to different stakeholders' (Zeleza et al. 2017:4). While the report highlights the role diaspora academics can assume as remitters of intellectual capital, it does not outline a role that internal African-based diaspora should or could take up. There is an implicit notion that the African diasporic condition is restricted to those academics outside the continent, based in Europe, America and Australasia. The report thus fails to acknowledge the intracontinental diaspora. In fact, it refers to the following Afro-diaspora categories as claiming 'the entire African diaspora; Africa-Americans, Afro-Brazilians, Afro-Europeans, Afro-Asians and others' (Zeleza et al. 2017:16). The report also does not extensively consider the forms of affiliation engaged in by African academic diaspora. The fact that some diaspora academics, especially those working in the USA, get three months unpaid leave -mostly during their holidays -is habitually presented as a window of opportunity to engage in academic mobility and exchange on other continents, including Africa. For instance, there are records of USA-German academic exchange, dubbed 'elective diasporas', occurring since the end of World War II (Jöns, Mavroudi and Heffernan 2014). The notion of elective diaspora stresses the 'elective nature of diasporic identities and belonging by emphasising that individuals can choose whether they wish to support diasporic networks of one or more communities and cultures they feel connected to' (Jöns et al. 2014:113). It also suggests that this 'civic rather than "ethno" territorial understanding of diasporic networks has wider relevance for theorisations of diaspora, for studies of transnational mobility and knowledge transfer, and for university and public policies seeking to attract talent from abroad' (Jöns et al. 2014: 113). The occasional affiliation, especially during holidays, may be complemented by new forms of joint, dual or multiple appointments. Academics who are based on the continent as well as in the diaspora can explore new forms of engagement which are mutually beneficial. New forms of research collaboration which include joint curriculum development, shared graduate student supervision, joint research projects and joint grant applications, require a much longer-term type of engagement beyond the duration of a summer holiday. Therefore, there is a need for new institutional arrangements and the removal of barriers, as well as research on the changes in the academic profession in Africa, including the new forms of academic work taking place. --- Conclusion The main discourse around the African academic diaspora follows a typical pattern of focusing on the wide-ranging costs of losing some of the continent's best and brightest intellectual's through brain drain. This focus on the disadvantages, however, obstructs the expansive and often innovative interactions that ADS and ABS have forged on both sides, involving their home and host institutions. Emerging patterns of multiple institutional and international academic affiliations between both ADS and ABS are reinforcing scholarly and personal engagements. While there are still many challenges to overcome, particularly in African institutions, the collaborations between ADS and ABS are gradually gaining financial support from international funding agencies, with the aim to build capacity in African universities. Funding schemes such as the EU's ERASMUS+ programme and the Intra-Africa Academic Mobility Scheme, CODESRIA and the Carnegie Corporation of New York African Diaspora Fellowship Program are crucial in promoting more equitable and fair ADS and ABS engagements, but also need to be aligned with revised contractual conditions for academic staff, allowing more flexibility and multiple affiliation. The professional athlete contract mentality exhibited by some academic staff managers at African universities is not compatible with the global trend of internationalisation of the academic profession. There is evidence that a significant and growing proportion of scholars with multiple affiliations also display high levels of academic integrity and productivity. This evidence validates the need for African scholars to attribute the necessary importance to studying multiple affiliations in the context of scientific research and institutional capacity development. This article discussed multiple affiliations and their conditions as a possibility to curb the effects of brain drain, while promoting brain-sharing. It argued that multiple affiliations not only reflect the dynamics and competitive advantage of the higher education sector in specific countries, but also that they can make a valuable contribution in minimising knowledge production inequities globally. The use of ICT and associated e-learning platforms represents an advantage for all actors involved by promoting a more integrated culture of blended-learning environments. In conclusion, MAAs have not been studied extensively, despite their enormous potential to redress knowledge and academic inequities globally, but specifically in emerging countries. By curbing the effects of brain drain and promoting brain gain, brain circulation and brain-sharing, it is recommended that MAAs be explored in more detail in future research and policy.

Scholars with multiple affiliations have become more visible by assuming their particular role in redressing global knowledge production inequities. This article explores multiple academic affiliations (MAAs) as one way to curb the effects of brain drain, particularly in African universities. It argues that MAAs, is an effective way to reverse the effects of brain drain and promote brain circulation and sharing. The article proposes the concept of translocal academic engagement (TLAE) as a form of international academic exchange and brain-sharing which is not limited to physical mobility (circulation) from one geographical location to the other, but which includes virtual exchange and knowledge-sharing through blended learning delivery methods, e-pedagogies and the use of digital communication technology platforms such as Communities of Practice. The article concludes by suggesting that MAAs, if properly managed, can be a success factor in TLAE activities, particularly in the age of Web 4.0, in mitigating or shifting currently dominating knowledge production flows. TLAE offers possibilities for a win-win situation of academic exchange between higher education institutions in emerging systems.

Introduction Parental oral health knowledge and behaviors are critical for prevention of early childhood caries (ECC) in young children [1]. Among Latino families in the US, children are more likely to experience ECC than non-Hispanic white and non-Hispanic black children [2]. Also, Latino children have the lowest average number of dental visits of all racial and ethnic groups and the highest rate of untreated tooth decay [2,3]. According to a recent report based on the National Health and Nutrition Examination Survey, 2011-2012, dental caries prevalence was higher for Hispanic (46%) children than for non-Hispanic white children (31%) aged 2-8 [4]. Among Colorado's Latino population, oral health screenings conducted by the Colorado Department of Public Health and Environment in 2011-2012 revealed 55% of Latino children, aged 5-6 years, have had dental caries experience, while 32% of white children in the same age group had experienced dental caries [5]. Reasons for disparities in ECC prevalence in Latino children are not well studied. Initial research has shown that the Latino population experiences oral health disparities related to access to care [6]. It has been suggested that Latino mothers might lack knowledge related to risk factors associated with dental caries [7], and cultural beliefs and norms may negatively influence oral health behaviors [8]. Few studies have focused on the oral health knowledge, attitudes, and practices of Latino mothers/parents. Existing studies show that Latina mothers are aware of sugar consumption and inappropriate bottle use being the risk factors for dental caries, although the depth of knowledge was limited [7,9,10]. In a qualitative study, Latina mothers strongly agreed that oral hygiene routines contribute to good habits in children, but they were often inconsistent in adherence and had limited depth of knowledge about the benefits of fluoride [7]. Latino primary caregivers had limited knowledge about the etiology of dental caries and preventive concepts [9]. Another study found that Latino parent's beliefs about sugar-sweetened beverages were limited and many parents did not understand nutritional labeling related to store bought beverages; they viewed some beverages as healthy for their children despite high sugar content [11]. This purpose of this study was to conduct a needs assessment with Latino families to better understand the challenges in maintaining oral health for their children. The study followed community-based participatory research (CBPR) methodology to develop and conduct the study. CBPR is an approach that intends to involve community members, stakeholders, and community organizations representative, with academic investigators in all aspects of the research processes, and enhancing integration of the produced knowledge into the community [12]. Following the guidelines of CBPR methodology, goals for the academic-community partnership were developed and followed throughout the research conduction. We started the partnership development process before the grant application was submitted and had set the responsibility and expectations for both the academic and community team. The mission of the partnership and partner roles were decided before the grant application. The goals of this partnership were to develop a deeper understanding of the oral health knowledge, oral health behavior, and attitudes of Latino parents towards their children. The academic researcher relied on the community partner's expertise in connecting with the community and recruiting community members, mainly primary caregivers (mothers, grandmothers, and fathers) of preschool children for the focus groups. The community partners relied on the academic researcher to conduct the research and dissemination of the results. --- Methods The study was approved by the Colorado Multiple Institution Review Board. Thirty Latino primary caregivers who had at least one child under the age of six were recruited. The study enrolled the primary caregivers for the child, which will include grandparents and other relatives, apart from the mother and father of the child. Information about the study will be provided in English and Spanish, with a consent form detailing the approach of the study. All participants were recruited by Servicios Da La Raza's staff, which is a Latinoserving community organization working in the Denver Metro Area. The community organization approached Head Starts and kindergartens to recruit participants for the focus groups. Six focus groups were conducted. The focus group was conducted using a semi-structured focus group guide, consisting of ten open-ended questions that were developed by the investigators before the start of the study. The questions were developed based on previous qualitative studies conducted with Latino communities [7,9,11] and based on the experience of the investigator and the community partners working with the Latino population. A translator was provided for all the focus groups. Each session lasted 45-50 minutes and the time taken by the translator was additional. All focus groups were digitally recorded, translated from Spanish, and transcribed into English. Grounded theory approach was used to develop the code structure. A systematic approach that allows for open discovery of emergent concepts with a focus on generating a theory was used to analyze the data. With this approach, the coding was done using a purely inductive technique, which helped to minimize the potential for "forcing" a preconceived result and thus provide for a more valid reflection of "the ground" or the true experiences of participants. Quotations provided in the results section reflect some sentiments and comments expressed by mothers during the focus groups. Both the research and a community partner independently coded the data and then conducted several meetings to discuss the codes, and once they felt saturation was reached they finalized the codebook. The focus groups were analyzed using QDA Miner. The coding frequency was calculated for all codes under each of the three themes, using the frequency tool within the QDA Miner software. The code frequencies represent the percentage of the codes being repeated under each theme in the entire data. --- Results --- Focus Group Findings. Focus group participants were primary caregivers of children under the age of six years. There were about 20 mothers, seven grandmothers, one father, and two aunts who participated in the focus groups. The focus group themes and codes are reported in Box 1. --- Oral hygiene 20% Diet/sugars 27% Frequency 10% Protective foods 12% --- Use of bottle 1% Microorganism 1% Fluoride 25% --- Primary teeth 4% Figure 1: Percentage of codes that were repeated under etiology of dental caries. --- Etiology of Dental Caries. Many factors were reported as being responsible for causing dental caries in children, including diet, poor oral hygiene, the frequency of consumption of sugary foods and drinks, and the role of microorganisms in development and progress of dental caries (Figure 1). Primary caregivers reported that diet was a major factor in dental caries development and gave examples of high sugar foods, such as candies, soda, cookies, and juice. About 28 percent of the participants reported some sugary food being responsible for the development of dental caries in their children (Figure 1). Participants mentioned the frequency of consumption of these sugary foods and drink as a cause of dental caries in their children. The frequency code appeared about 10 percent in the transcripts, within the theme for etiology of dental caries. Participants said that their children had soda or juice 2-3 times a day, but the frequency of consumption increased over the weekends or while visiting the family, where the participant had less "control" of the food choices of their children. Participant comment: "There is a lot of sugar in everything, things that you do not even know about. If they go to sleep at night without brushing their teeth, it just stays on their teeth all night." Participant comment: "I think the frequency is going to be the biggest factor. How may time they drink soda is important to manage?" Fruits and milk were mentioned as protective foods (12%) for teeth, as it has calcium, which is good for teeth. Milk was specified as protective food repeatedly by most parents, and they emphasized that it was good for teeth. Only two participants mentioned that milk should not be given to the child during bedtime and that adding sugar to milk increases the risk for caries development in children. --- Participant comment: "I know that milk is good, it has calcium, but if you put your child to sleep with a bottle then that's going to decay their teeth, so you have to be careful." Only a handful of participants knew that microorganism caused caries in their children. The code appears less than 2 percent within the theme for etiology of dental caries (Figure 1). Even after several probes, participants did not mention microorganism as one of the causes for the development of dental caries. Most of the participants said that sugary foods were the main reason for caries development and had not heard that "bugs" were responsible for cavities. Most of the focus groups participants related poor oral hygiene practices to dental caries development. They understood the importance of good oral hygiene and 30 percent of the focus group thought teeth should be brushed at least two times daily. They also spoke about the importance of supervising their children while brushing or helping them brush their teeth. However, more than half of the participants said that they did not supervise their children over the age of 4-5 years during brushing. They said it was hard to find time to do that and thought they told their children to brush in the morning and at bedtime. Another important discussion was based on fluoride and its role in dental caries prevention. Only two participants in the entire group knew the sources of fluoride including tap water, toothpaste, and fluoride varnish. Mechanism of action of fluoride in the prevention of caries was not known. Most participants had not heard about fluoride, and when probed they reported that neither the pediatrician nor the dentist had mentioned fluoride. They had no knowledge that tap water was the source of fluoride. Additionally, when probed about fluoride varnish, some of the participants remember their children receiving fluoride varnish during dentist appointments; they did not know that it had fluoride and recollected that it was mentioned as "vitamins for teeth." --- Experience of Parents at Dental Visits. All the participants said that they have a dental home for their children or grandchildren. When discussing their experience during dental visits, most participants said that the environment at the dental clinic made a difference in changing their oral health behaviors. The code "environment at the dentist" appeared 53 percent within the theme (Figure 2). Two types of environments were described. Few participants received a supportive environment, where the dental team gave preventive recommendations to the children; they had toys, information pamphlet, and videos in the waiting area that captured the parent and child's attention. Participant comment: "At the clinic where I go, in the waiting room, they show some videos. A video got my attention. My children also paid attention to it because it shows you a soda and asks you, how many tablespoons of sugar does a soda have? -12 tablespoons sugar. They say, in your right mind, would you give 12 tablespoons of sugar to your child?" However, the majority of the participants were not satisfied with their dentist. Interactions were more with the hygienist, and dental assistants and dentist spent the least time interacting and educating the parents. --- Participant comment: "I feel like dentists have not been very personable. I think it is always very fast pace. You spend most time maybe with a technician rather than with the dentist, and they don't provide enough information to really understand how to prevent cavities." Few parents reported that some intricacies related to treatment decision were not discussed in detail and other stated that reasons for applying fluoride varnish at the end of the visit were not explained. Nevertheless, for some parents, the environment at the dentist was a cause of frustration because they felt judged. These parents had children who had higher dental caries experience and went more often to the dental clinic. --- Participant comment: "I have these frustrating conversations with the dentist and they almost think that you are lying. I am like, No, I am not lying, and they do not drink sugary drinks. He was off the bottle very early. I have tried to make it different from my older son, and it still happened the same way." Apart from the dental office, the participants also received some oral health knowledge from the pediatrician or at Women Infant and Child Clinics. The participants wanted the dentist to demonstrate the oral hygiene practices or provide the reason for a recommended oral health behavior. Participants mentioned that some dental offices had a show and tell method that was very useful in engaging and educating the children. Participants felt motivated when the dentist or other medical personnel were polite and showed concern for their children's oral health, rather than just giving them instructions. --- Oral Health Beliefs of Parents. Child temperament had the highest frequency (28 percent) with this theme (Figure 3). Participants faced challenges when brushing their children's teeth, mainly those related to the child's behavior, and most mothers believed this affected their children's oral health. They were not able to engage their children in brushing when they started to cry or refused to brush. In addition, they said it was difficult to make it into an interesting exercise for the child. Child temperament was also mentioned in restricting them from consuming sugary foods and drinks. If the child had a liking for soda or candies, the parents struggled in controlling the frequency of consumption. Participant comment: "We prohibit all sweets, but that is what she likes most -sweets, soda, apple soda, apples. What can I do?" Lack of time on their part was another challenge. Participants mentioned jobs and other chores that prevented them from finding time to supervise their children while brushing or encouraging their children to brush. Self-efficacy of the participants was an important factor controlling their oral health behaviors towards their children. Parents thought they had no control over their child's food habits and they felt helpless. Participant comment: "If they are hungry and they just grab something; it is hard to say no." Participants discussed cultural variations in their community related to oral health knowledge and access to care. Some participants mentioned they struggled to overcome peer and familial pressure when they took their children to the dentist for preventive visits. They mentioned their family and friends suggested visiting the dentist if the child has pain and that preventive dentist's visits were unnecessary. Another topic they discussed was about multiple caregivers, especially grandmothers and aunts who provided care when the mother was at work. Participants had little or no control over the feeding practices of additional caregivers. They mentioned their children have easy access to high-risk foods such as soda and candies in the US as compared to children in their (home) countries, which they deemed as a negative effect on the oral health of their children. Participant comment: "My mother-in-law lives in Mexico. When she comes, she stays for two months, and when she is watching him, it is a harder to control his diet, because she eats breakfast with Coca-Cola. So then trying to get her not to give the baby these juices and stuff gets a little harder." The role of schools and Head Starts in educating the children about oral health was emphasized by many participants. Children spend most of the time at schools that would be a suitable place for the child to learn about oral health. --- Discussion The results of this study highlight that although Latino parents have some understanding of factors associated with dental caries their knowledge did not translate into positive oral health behaviors, however. The focus group findings have provided some in-depth information on the challenges these parents may face in implementing their knowledge into actions. Few culturally tailored studies conducted with Latino parents to improve oral health knowledge and behaviors have been well accepted by the community and have shown sustained improvements in oral health knowledge and behavior change in Latino parents [6,13]. Child temperament and self-efficacy of the parents were two concepts that surfaced several times during the discussions. Parents discussed their child's resistance towards tooth brushing and lack of time in supervising the children during brushing as some other reasons for poor oral hygiene for the children. Evidence suggests child temperament has been strongly associated with ECC. Positive temperament appears (such as positive anticipation and soothability) protective, and negative temperament (such as attentional shifting, fear, frustration, low-intensity pleasure, and sadness) may increase the risk of ECC [14,15]. It also has been shown that negative child temperaments can exacerbate parental stress and worsen parental feeding and oral health practices [15]. Additionally, some of the participants reported the lack of self-confidence in engaging the child in oral hygiene activities mostly because they did not know how to teach the oral hygiene techniques to their child. The dentist, physician, and the schools were held responsible for teaching oral hygiene to children, and only a few parents felt that they were accountable for their child oral health. Skill building exercises with parents have shown improvements in tooth brushing behaviors in parents for their children [13,16]. A peer based skill building study concluded that, after a 3-month intervention of teaching tooth brushing skills to parents, there was a significant increase in parents' confidence to ensure brushing twice a day, as well as in perceptions of the importance of tooth brushing, and in self-efficacy for tooth brushing skills [16]. In addition to providing oral health knowledge, approaches such as Motivational Interviewing (MI), which provides supportive guidance for choosing behavioral goals and strategies, may be more appropriate and culturally sensitive in a Latino population [17]. Few studies that have used MI have reported that this approach can positively impact behaviors addressing infant feeding practices and diet, oral hygiene behaviors, and dental attendance [18]. Limitations of this study include the relatively small sample size and a convenience sample. These results may not be generalizable. Further research is warranted with a larger sample to validate these results. --- Disclosure Contents are the authors' sole responsibility and do not necessarily represent official NIH views. --- Conflicts of Interest The authors declare that there are no conflicts of interest regarding the publication of this paper.

The aim of this study is to describe oral health knowledge, behaviors, and beliefs of Latino parents with children under the ages of 6 years and to conduct a needs assessment with Latino families to better understand the challenges in maintaining oral health for their children. The investigator collaborated with a community serving the organization to recruit Latino primary caregivers for focus groups interviews and 30 primary caregivers were recruited. The focus groups data was transcribed and analyzed using a grounded theory approach using QDA Miner software. Findings from the focus groups demonstrate that the primary caregivers described barriers in maintaining oral health for their children including cultural barriers, child's temperament, lack of time, and easy access to high-risk foods. All participants said that they wanted to receive information on the oral health of their children; they wanted the dentist or the hygienist to demonstrate oral hygiene practices and explain to them the reasons for oral health behaviors. Although the primary caregivers recognized some factors related to caries development, their knowledge was limited in depth. Culturally appropriate oral health education is required for this population, which could lead to more adherent oral health behavior and a higher sense of self-efficacy in Latino parents.

Historically, undernutrition primarily affected children under five years of age but today its influence on the health condition of older adults is more widely known (1). Undernutrition is the pathological state resulting from inadequate consumption of one or more essential nutrients. It involves weight loss associated with caloric and protein deficits and low levels of other specific nutrients that are necessary for the adequate homeostasis of the organism (2). In the case of children, those who are affected have limitations in their physical, mental, and psychomotor development. They can suffer biochemical and physiological disorders such as growth delays, cognitive impairments, and lower physical and intellectual capacity (3). In older adults, undernutrition increases the risk of mortality, hospitalization, hip fractures, and institutionalization due to the reduction of functional autonomy (1). The Colombian Health Situation Analysis (HSA) surveillance system (4) shows that the country had a decreasing trend in undernutrition-related mortality rates in children under five, from 14.87 per 100,000 children under five in 2005 to 6.82 deaths in 2014. In the case of older adults, a study by Cardona, et al. (5) found that in 2008 in Colombia, the mortality rate from nutritional deficiency in those over 65 years was 34.5 deaths per 100,000. The same study also highlighted the great variability within the country in mortality risk: with the highest rate (550.5 deaths per 100,000 people over 65 years) in the department of Vaupés and the lowest (13.5 deaths per 100,000 people over 65 years) in Tolima (5). Other departments that exceeded the national rate were Guaviare, Guain<unk>a, Bol<unk>var, and Atlántico. Regarding the determinants of undernutrition-related mortality, one of the most important factors is families poverty level, as their financial restrictions mean limited access to healthy food (6), while among older adults, it is associated with living alone, deficient social support networks, and limited functional ability (7). Several studies have emphasized the relationship between undernutrition and the place of residence showing that children and older adults living in poor areas have a higher risk of undernutrition (6,8), as do those living in areas with low availability of healthy food (9). Additionally, there are other factors associated with undernutrition, especially in children, such as unfavorable socioeconomic conditions related to inadequate sanitation (10), food, and health care practices (11,12). In Colombia, poverty and development levels in municipalities are very heterogeneous and, therefore, we can assume that these differing conditions contribute to an unequal distribution of undernutrition-related mortality. In such context, our study focused on establishing if the differences between municipalities also reflected on their undernutrition-related mortality rates in children under five years of age and adults over 60 between 2003 and 2016. Additionally, we aimed to determine the relationship of those mortality rates with the socioeconomic conditions of the municipalities. --- Materials and methods We conducted a longitudinal ecological study to analyze aggregated data of Colombian residents under five and over 60 years of age between 2003 and 2016. The geographic units of analysis were: six regions, 18 subregions, and 1,096 municipalities. To improve municipal estimates, we created a geographic map at this level where the non-municipalized areas were added to their respective cities. Likewise, the four municipalities created after 2005 were regrouped into their original municipalities. Additionally, the municipalities of the Archipiélago de San Andrés, Providencia and Santa Catalina were excluded because they did not have contiguous or neighboring geographic areas allowing reliable municipal estimates of their mortality risks. Consequently, we analyzed data from 1,096 municipalities (figure 1). --- Information sources We obtained the data on deaths from the vital statistics available on the National Administrative Department of Statistics website (13) and aggregated them according to the geographic units of analysis. The data regarding municipal socioeconomic characteristics were obtained from the Sistema Nacional de Vigilancia en Salud P<unk>blica (SIVIGILA), the United Nations Development Programme (UNDP), and the Departamento Nacional de Planeación (DNP). --- Variables Dependent variables. We analyzed two aggregated variables: 1) The municipal undernutrition mortality rate in children under five per 100,000 children under five, and 2) the municipal undernutrition mortality rate in people over 60 per 100,000 inhabitants over 60 years of age. Undernutrition deaths were defined as those with primary cause codes according to the 10th Revision of the International Classification of Diseases corresponding to undernutrition (E40-to-E46), other nutritional deficiencies (E50.0-to-E64.9), or nutritional anemia (D50.0-to-D53.9). Independent variables. These included the following municipal socioeconomic conditions: • The percentage of the population with unsatisfied basic needs (UBN) was measured in 2005 to characterize poverty in municipalities by quantifying the proportion of people experiencing at least one of the following conditions: overcrowding, inadequate housing, inadequate water supply, lack of sewers, and poor school attendance (14). Municipalities were categorized into quintiles, the lowest one comprising the wealthiest municipalities and the highest one, the poorest. --- • The human development index (HDIm) measured in 2005 represents the degree of development achieved by a municipality in terms of quality of life, education, and per capita gross domestic product (GDP) (15). Municipalities were categorized into quintiles, the lowest one including those with low human development and the highest one, those with very high human development. • The multidimensional poverty index (MPI) identifies multiple deficiencies in the areas of health, education, and living standards in the period 2005-2014. Municipalities were categorized into quintiles, the lowest one including the richest group of municipalities and the highest one, the poorest municipalities ( 16). • The institutional capacity of the municipal government (<unk>ndice de desempe<unk>o integral), an index that sorted and compared municipalities between 2006 and 2015 based on the following aspects: effectiveness in meeting the goals of their development plans, efficiency in the provision of basic services, compliance with budget execution requirements defined by law, and administrative and fiscal management. The municipalities were classified into four performance groups: outstanding or satisfactory, medium, low, and critical (17). • The dynamics of the index of water quality for human consumption (<unk>ndice de riesgo de la calidad del agua, IRCA) 2007-2010, which measures the water quality-related risk (18) and classifies municipalities into five water-quality risk groups: none, low, medium, high, and unviable sanitary risk. Given the variability of the index during the available period (2007, 2008, 2009, and 2010), its dynamics pattern was summarized into one variable for the present analysis. The resulting variable classifies the municipalities into five groups: improving (municipalities with constant changes toward the no-risk category), constant positive (municipalities oscillating between the no-risk or lowrisk categories), constant negative (municipalities oscillating between the low, medium, high, or unviable sanitary risk categories), and worsening (municipalities with constant changes towards the unviable sanitary risk category). --- Data processing For the descriptive analysis, we estimated national and regional mortality age-specific crude rates for two periods: 2003-2009 and 2010-2016 using the total number of undernutrition deaths (under five years old or over 60 years old) as the numerator. The denominator was either the total population of children under five or people over 60 multiplied by 100,000. As for the municipal rate estimates, we used the Bayesian hierarchical model proposed by Besag, et al. (BYM), to obtain smoothed rates for the whole period: 2003-2016 (19), which improved the precision of the estimated rates, especially for those municipalities with a low number of deaths due to undernutrition and/or a small population. In brief, this model combined the aggregated number of deaths in each municipality with the average of the neighboring municipalities, thus decreasing the variability of the estimates. The BYM model was specified as follows: where n i is the denominator in each municipality and the rate in each municipality, i, is represented by p i The model has two random effects that represent non-spatial and spatial variability, v i v i, and u i u i. These effects allow for the estimation of the smoothed rate for each municipality with the equation: exp(<unk> 0 +v i + u i ). The a priori distributions of spatial effects was assigned through an intrinsic conditional autoregressive (ICAR) distribution with variance <unk> u 2 while for the non-spatial effects we used a normal distribution with zero as mean and variance <unk> v 2 (19). A half-normal distribution with a mean of 0 and a precision of 0.0001 was assigned to the standard deviations <unk> v and <unk> u (20). For parameter, we assigned a normal "vague prior" distribution. The model estimated the smoothed mortality rate (SMR) with the corresponding 95% confidence interval for each municipality, as well as the a posteriori probability (PrP), which indicates whether each municipality had a smoothed rate significantly higher than the rate of Colombia (p<unk>0.05). This was calculated as PrP i = Probability (smothed P i > rate in Colombia)The model was estimated by using the integrated nested Laplace approximation (INLA) method available in the statistical package R.2.15.3 INLA library (21,22). --- Statistical analysis Tables and maps were used for the descriptive analysis of regional and municipal estimates by period and age-group. We extended the ecological Bayesian hierarchical model at level two to to include socioeconomic (SE) variables and analyze their relationship with municipal smoothed rates. NBI, HDIm, and MPI were categorized into quintiles and included in separate models as four dummy variables (QSE) with the less poor or less developed areas serving as the reference group. For the other two socioeconomic variables, outstanding performance and risk-free water quality were used as reference: where each municipality is represented as i and <unk> j is the effect of the category of the socioeconomic variable on the smoothed rates. By using exp [<unk> 1 ] (j=1,...,4), the results of the models are presented as the relative risk (RR) of mortality in each socioeconomic group along with the corresponding 95% confidence intervals (95% CI). The research protocol was approved by Universidad de Antioquia Ethics Committee for the health area (reference number 161, 09/March/2017). --- Results Between 2003 and 2016 a total of 2,754,943 deaths were reported in Colombia and 24,388 of them were due to undernutrition, i.e., a rate for the period of 3.85 per 100,000 inhabitants. According to the age group, 23.8% (n=5,804) of the total mortality due to undernutrition corresponded to children under five and 61.4% (n=14,974) to people over 60. The estimated rate during the period was 8.6 deaths per 100,000 children under five and 24.5 deaths per 100,000 adults over 60. When we compared the two periods (2003-2009 vs 2010-2016), we found a general decrease in mortality rates: from 10.0 to 7.2 deaths per 100,000 children under five and from 26.0 to 23.2 deaths per 100,000 people over 60. As for the mortality by region (figure 2), the Atlantic and the Orinoquia-Amazonia regions registered the higher mortality risk for children under five in the two periods. In the case of those over 60, the Atlantic, Oriental, Pacific, and Orinoquia-Amazonia regions showed the highest risks in both periods and the smallest decreases over time. Figure 3 displays the smoothed mortality rates (SMR) by municipality for the whole period. The areas with the highest risk for children under five were located in the north of the country within the Guajira, Cesar, and Magdalena subregions followed by Barranquilla (metropolitan area) and the Atlantic and Pacific Coasts. In contrast, the lowest mortality risks were observed in the municipalities of Medell<unk>n and Bogotá subregions. In the case of mortality for people over 60, municipalities with the highest risk were located within the Atlantic, Oriental, Pacific, and Orinoquia-Amazonia subregions. Table 1 describes the distribution of deaths from undernutrition according to the socioeconomic indicators. For children under five, the risk of mortality was higher in municipalities with a higher proportion of population with unsatisfied basic needs, less development, and poorer and worse overall performance evidencing a negative social gradient of undernutrition for this age group. In contrast, for those over 60 the social gradient of undernutrition was positive with higher risks of mortality in municipalities with better economic advantages and development (table 2). The results of the ecological regression were consistent with these findings (table 2). According to the results for children under five, the risk of dying from undernutrition is higher in the poorest municipalities, i.e., in areas with more unsatisfied basic needs, less development, critical comprehensive performance, and drinking water quality representing low or medium risk. In these municipalities the risk was approximately 50% higher than in reference municipalities. The risk of mortality from undernutrition in children under five was not statistically associated with water quality. In contrast, adults over 60 had a higher risk of mortality from undernutrition in more developed affluent municipalities with no water quality risk exceeding significantly that of reference municipalities. This risk was not statistically associated with water quality or the municipality's comprehensive performance. --- Discussion In general, we found that the mortality due to undernutrition in Colombia decreased during the 2003-2016 period. Moreover, risk maps revealed substantial geographic variations in the size of the risk with reductions over time. Most importantly, we found an association between mortality caused by undernutrition and the socioeconomic indicators of the municipalities. Our results highlighted a more significant decrease in the risk of undernutrition-related mortality for children under five than for people over 60. This finding may be explained by the fact that Colombian nutritional policies have focused mainly on the population under five to meet the millennium development goals (MDGs) and the sustainable development goals (SDGs) that include the eradication of hunger, the decrease of child mortality and undernutrition, and the development of food and nutrition surveillance systems (23). However, despite this decreasing trend, there are regions that still show a high risk of child mortality. For example, the high mortality rates for children under five in the municipalities of the Atlantic region could be explained partly by the presence of the large mining and energy companies that have caused a decrease in food production resulting from the lack of water sources used elsewhere (11). In the Orinoquia and Amazonia region, the highest rates of mortality due to undernutrition in children under five could may respond to the fact that this region has the highest rates of chronic (29.5%) and global undernutrition (7.5%) in this age group compared to the rest of the country (13.2 and Next to each mortality map there is a map with the probability of the SMR being above the national rate (PrP). The red color indicates a probability of 90-100% that the SMR is higher than the Colombian rate and the green color indicates the same probability that it is lower. --- Mortality in under ve years old --- Mortality in adults over 60 years old Rate by 100.000 Rate by 100.000 3.4%, respectively) (24). Besides, this region has the highest percentage of indigenous communities whose food production and eating patterns have changed to the detriment of their identity and culture resulting in the loss of their food sovereignty and the substitution of native foods for products that must be purchased (25) thus limiting food availability due to their low income levels (26). On the other hand, although all regions have decreased their undernutritionrelated mortality rates in children under five, the poorest municipalities continue to have the highest rates. Consistent with the literature review, some of the social conditions associated with these higher mortality rates are the lack of potable water, the scarce institutional infrastructure to carry out social and health programs, the low social security coverage, and the difficulties in food distribution and the supply chain (27). In terms of public policies, this situation highlights the need to develop specific strategies to close social gaps. The situation regarding mortality in adults over 60 is different as mortality rates have decreased very little and are higher in more developed and affluent municipalities, which evidences that, due to different factors such as limited income, this population group does not have adequate access to food, which impacts their health status and those factors that make them more vulnerable in this stage of life (28)(29)(30). The lower mortality rates in the poorest municipalities would respond to their location in rural areas where there is a greater availability of food from family farming, the breeding of small animals, self-sufficiency, and family support for obtaining food (31,32). The risk of mortality due to undernutrition in the urban population over 60 years of age is a global challenge because many of the world's largest cities are in the least developed countries where the aging process is not occurring slowly and families or states do not have the resources to respond in contrast with the situation in industrialized countries. In these urban centers, inequalities regarding the health conditions of older adults are evident. In Colombia, for example, according to the 2015 National Survey on Health, Welfare, and Aging (Salud, Bienestar y Envejecimiento, SABE), eight out of 10 older adults live in urban areas (78.1%) and of the total population surveyed, 30% do not receive assistance from the state or the family (33). In conclusion, the mortality from undernutrition in children under five is an unmet objective and remains a social issue because the rates continue to be high, especially in the poorest municipalities. Simultaneously, the mortality from undernutrition in adults over 60, especially in city residents, constitutes a huge challenge due to the accelerated growth of urban populations in the developing world and their aging process. Regarding the data quality, a special consideration must be made. Studies on death cause registration in Colombia have shown that this process has improved considerably in the last 30 years and continues to improve (34). Cendales, et al. (34) state that: "It is possible that the classification of Colombia rises to the category country with high quality in the certification of mortality since our percentage of deaths certified as signs, symptoms, and illdefined conditions is less than 10%. Likewise, the last WHO coverage report of death shows that Colombia's coverage rose from 79.9% in the period 1990-1994 to 88.1% in 1995-1999, 93.1% in the period 2000-2004, and 98.5% in 2009". Thus, we assumed the data used in our study had enough quality. An initial review of the data showed that 40% of municipalities consistently reported zero cases of undernutrition in children under five, whereas 9% of the municipalities reported zero cases of mortality in adults over 60. The present analysis assumed that all zero counts represented a true absence of cases in the year analyzed. To improve the accuracy of the municipal estimates, the mortality and population counts were aggregated in a single period (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016). In this way, undernutrition rates were estimated for each of the 644 municipalities that reported at least one case of mortality in children under five and for the 992 municipalities reporting at least one case of mortality in adults over 60. Besides, we used the Bayesian model, which averages the data of neighboring municipalities conservatively decreasing the possible quality/under-registration problems of some municipalities. On the contrary, as this is an ecological study, our findings can only contribute to the evidence of a possible association between inequality in malnutrition and urban territory conditions, but we cannot affirm that this is necessarily a causal relationship. Additionally, although this design allowed us to detect and evaluate socioeconomic inequalities in malnutrition, it was not possible to identify whether inequalities in the risk of malnutrition among municipalities were due largely to the characteristics of the municipalities (contextual effect) or to the differences between the individuals residing in them (compositional effect). This design does not allow for evaluating the role of individual conditions such as confounders, mediators, or modifiers of the effect of the municipality. In this sense, the ecological relationships we found could be further explored with multilevel analyses taking into account the exploration of both individual and contextual factors. Finally, we stress the importance of extrapolating our results exclusively at the area level. Given the aggregated nature of the data, it would be erroneous to assume that the statistical association between the socioeconomic variables at the municipal level would be equal to the association between the corresponding variables at the individual level. A multilevel analysis would be the next step in this research to properly explore both individual and municipal-level relationships. --- Conflicts of interest: The authors declare that there are no conflicts of interest.

Children under five years of age living in poor areas and with low availability of healthy food have a higher risk of undernutrition-related mortality. However, this relationship has not been well established among older adults. Objective: To analyse socioeconomic inequality trends related to undernutrition mortality in children under five years of age and adults over 60 in Colombian municipalities during 2003-2009 and 2010-2016.We conducted an ecological study of trends between 2003 and 2016. The study population consisted of children under five years of age and adults over 60 residing in the Colombian municipalities during the study period. We estimated smoothed and standardized mortality rates by fitting a hierarchical Bayesian model and explored their relationship with five socioeconomic area-level variables. Results: In most of the municipalities, undernutrition-related mortality was three times higher in older adults compared to children. Moreover, the difference in the risk of undernutrition-related mortality between municipalities showed a marked reduction. Finally, the poor and less developed municipalities had higher rates of undernutrition-related mortality in children; conversely, wealthier territories had higher rates in older adults. Conclusions: Although in most of the municipalities the mortality rates due to undernutrition in children under five and older adults have decreased, their socioeconomic conditions influence in different ways the risk of mortality for these two populations so there is the need to develop age-specific strategies to close social gaps considering the structural conditions of the areas.

Introduction Why does a meal at Tokyo's Aragawa Steakhouse cost more than one from a franchised restaurant? Essentially, consumers are willing to pay extra for a meal that provides a unique experience (Chang, 2018). The experience economy suggests that industries can generate high revenues to the extent that additional experiential value is offered. Pine and Gilmore's (1998) experience economy framework has been extensively applied in hospitality and tourism (e.g., Quadri-Felitti & Fiore, 2012;Radder & Han, 2015;Shim, Oh, & Jeong, 2017), mainly because associated contexts depend on creating memorable encounters (Gilmore & Pine, 2002). The experience economy framework effectively conceptualized the tourist experience until the sharing economy altered the consumer landscape (Heo, 2016). Mody, Suess, and Lehto (2017) attempted to compare the experiential value of Airbnb with traditional hotels. The sharing economy presents an attractive experiential value proposition, as suggested by many hotel practitioners who have lamented the challenges of competing on the basis of tourist experiences. Although some have contended that governments should shift this new business model away from the existing market to maintain a fair playing field (Tobin, 2019), others hold a different perspective. For example, former World Tourism Organization Secretary-General Taleb Rifai warned the global tourism industry that fighting the sharing economy would be a losing battle (The Diplomat, 2016). Conceptualizing the sharing economy's appealing experiential value proposition is timely and necessary because the experience economy asserts that "selling services is not enough" in service industries, including hospitality (Gilmore & Pine, 2002, p.87). The key driver behind successful hospitality businesses involves staging enjoyable experiences on top of an existing product or service. Yet research on visitor experiences remains thin (Jiang, Ramkissoon, & Mavondo, 2016), with most studies failing to consider experiential staging within the sharing economy. Traditional businesses thus tend to overlook the unique experiential value proposition of sharing-economy businesses and create disparities in the tourist experience (Mody et al., 2017). Private social dining has rapidly emerged as a new consumption experience in the food and beverage sector of the sharing economy but has received scarce academic attention (Frenken, 2017). In this setting, tourists are provided "a unique opportunity to try an authentic homecooked meal at the host's home" (PlateCulture, 2015). By staging innovative consumption activities within the sharing economy, such services are perfectly aligned with growing tourist demand for authentic dining experiences (Yung, 2014). This novel form of experiential consumption thus requires "new and subjective" research methods that identify "difference and uniqueness rather than similarity and patterns" (Williams, 2006, p. 493). Hence, the present study adopts an inductive approach to (a) expand Pine and Gilmore's (1998) experience economy framework to include private social dining and (b) investigate how service providers stage innovative dining-related tourist experiences. --- Literature review --- Experience economy A prevailing belief around consumption is that placing a price tag on a product or service based on its costs leads service providers to rely on simplistic pricing strategies while neglecting other elements that may increase revenue (Pine & Gilmore, 2011). Chang (2018) demonstrated that consumers' subjective perceptions of a product's experiential value can boost company revenue because customers tend to pursue multisensory hedonic consumption over utilitarian consumption (Addis & Holbrook, 2001). This phenomenon has been conceptualized as the experience economy. More specifically, Pine and Gilmore (1998) proposed a two-dimensional plane consisting of two continuums (i.e., immersion-absorption and passive participation-active participation) from which four experiential values emerged: entertainment, educational, esthetic, and escapist values (Figure 1). Their theory implies that service businesses should transition from delivering tailored services to staging multisensory, memorable experiences. *Insert Figure 1 The concept of the experience economy has been emphasized throughout the tourism industry because satisfaction and quality are insufficient in operationalizing tourists' destination experiences (Kim, Ritchie, & McCormick, 2012). Although the first four experiential domains in Figure 1 present a concise conceptual framework of the tourist experience, they only became assessable when Oh, Fiore, and Jeoung (2007) developed an initial scale of tourists' destination lodging experiences. Kim (2009) pointed out that Pine and Gilmore's (1998) model fails to explain customers' behavioral intentions and then proposed a seven-dimensional construct of the tourist experience (i.e., hedonism, refreshment, local culture, meaningfulness, knowledge, involvement, and novelty). Yet this sevendimensional construct has been underutilized, possibly given its limited generalizability due to using a non-representative sample of students who were mainly unemployed and could not fully manage their travel options (Chandralal & Valenzuela, 2015). Therefore, Pine and Gilmore's (1998) framework is most often applied when considering the tourist experience. Oh et al.'s (2007) scale has typically been adopted to measure various types of tourist experiences, such as those involving wineries (e.g., Quadri-Felitti & Fiore, 2012;Vo Thanh & Kirova, 2018), cruises (e.g., Hosany & Mark, 2010), casinos (e.g., Shim et al., 2017), and historic sites and museums (e.g., Radder & Han, 2015). These diverse experiential contexts convey the broad applicability of the original model in tourism. No prevalent framework is available to conceptualize every tourist experience; the approach must be tailored to each situation (Williams, 2006). Pine and Gilmore's (1998) framework is therefore unlikely to serve as a hard-and-fast rule; hence, scholars' continued efforts to classify the four experiential domains (Oh et al., 2007). Although most relevant studies have recognized dining as part of the tourist experience, the role of dining varies across these experiences. Similar to Quadri-Felitti and Fiore (2012), who focused on wine experiences, Musa, Kayat, and Thirumoorthi (2009) framed dining as an educational experience among cultural tourists. Later, Shim et al. (2017) acknowledged dining as an esthetic experience in casinos. These distinct positions reflect features of diverse tourism activities and corroborate Mason and Paggiaro's (2012) stance that dining plays multiple roles in the tourist experience. The current conceptualization of the dining experience remains superficial, simply presented as a combination of food quality, service quality, and atmosphere (Ha & Jang, 2010;Jeong & Jang, 2011). Compared with other tourist activities, research on tourists' dining experiences is limited (Ko et al., 2018). The lens of the experience economy has not yet been expanded to dining, thus ignoring the experiential connection or encounters between diners and dining-related products or services (Gilmore & Pine, 2002). The notion of "dining experiences" describes how diners' experience, rather than strictly the manner of eating (de Albeniz, 2018). This theoretical problem has hindered catering service providers from appropriately designing tourist experiences and remains particularly challenging as the sharing economy complicates tourist experiences overall (Pappas, 2019). --- The experience economy within the sharing economy The sharing economy is supported by Web 2.0, which enables people to share and exchange underutilized products or services (Karlsson & Dolnicar, 2016;Ketter, 2019). Airbnb, a key player in the sharing economy established in 2008, has been commended for its role in establishing "a decentralized, equitable, and sustainable economy" (Martin, 2016, p. 154). However, recent protests against Airbnb's expansion have challenged the romanticism surrounding the sharing economy. Traditional hoteliers believe they are facing an unfair playing field alongside accommodation-sharing service providers. This disparity is attributable to two main elements. First, the traditional hotel industry has higher operating costs due to the required occupancy taxes and stringent safety standards (Elliott, 2016). Second, the unique experiential value proposition leveraged by accommodation-sharing service providers has introduced disruptive innovations into traditional accommodation experiences (Oskam & Boswijk, 2016). This experiential proposition addresses tourists' increasing demands for more meaningful social interaction with locals and authentic travel activities (Tussyadiah & Pesonen, 2016). Such activities may be more striking to tourists not only because these opportunities diversify travelers' overall experiences, but also because perceived low commercialization improves tourist experience quality (Sun et al., 2019). From this perspective, accommodation-sharing service providers offer services beyond the four experiential domains proposed by Pine and Gilmore (1998) to develop more attractive tourist experiences. Mody et al. (2017) empirically verified this pattern by demonstrating the inferior competition of the hotel industry in terms of the tourist experience. That is, the authors added four experiential domains related to accommodation-sharing services: serendipity, localness, communitas, and personalization. Similarly, Shi, Gursoy, and Chen (2019) noted that accommodation-sharing services stage cultural and authentic experiences in addition to the first four experiential domains. Pine and Gilmore's (1998) framework thus appears deficient in conceptualizing the tourist experience amid the sharing economy. --- Dining experiences with strangers in the sharing economy Transactions with strangers are common in the sharing economy (Botsman & Rogers, 2011). Generally, transactions with strangers (especially face-to-face) are considered unsafe primarily because they are unregulated. Karlsson and Dolnicar (2016) summarized the provision of social and informal experiences as key successes of accommodation-sharing services. Airbnb's rapid development has led to transactions among strangers in other economic sectors. Private social dining services, as mentioned by Euromonitor International (2014), represent a noteworthy trend in the tourism/hospitality industry that has reshaped how people travel and eat (Lawler, 2014). Peer-to-peer dining services connect tourists with local hosts to enjoy a private meal in hosts' place. Similar to accommodation-sharing services, these dining services highlight an experiential value proposition as reflected in relevant marketing campaigns, such as "Book unforgettable culinary experiences" on Eatwith (2019) and "PlateCulture experience" on PlateCulture (Yap, 2014). The above campaigns indicate that dining experiences are at the heart of private social dining services. Michelin, the founder of Eatwith, stated that people's cooking skills are not the most important criterion for a private social dining service provider; a provider's ability to communicate and the ambiance of their home are essential as well (Lawler, 2014). In other words, private social dining is far more than simply an eating activity-it affords tourists a unique opportunity to explore, socialize, and travel in a community, particularly because dining is a popular way to become immersed in a destination's culture (Bjork & Kauppinen-Raisanen, 2019). Ketter (2019) supported this notion and pointed out that private social diners are motivated by "a trendy, authentic and social consumption experience" (p. 1072) to fulfill their sophisticated dining needs and realize experiential travel (Chang, 2018;Kivela & Crotts, 2006;Su, Johnson, & O'Mahony, 2018;Tikkanen, 2007). Qian, Law, and Fan (2020) believed that tourists gain satisfaction from three types of experiences in private social dining (i.e., sensory, emotional, and spiritual experiences), providing compelling evidence that private social dining is indeed an experiential travel activity. In light of growing competition between sharing-economy vendors and traditional businesses in terms of the tourist experience, Pine and Gilmore's (1998) four original experiential domains should be extended to encompass private social dining services. This expansion will clarify the design of private social dining experiences and provide meaningful insight into how conventional dining activities can be improved to provide more enriching tourist experiences (Walls et al., 2011). Therefore, this study aims to investigate diners' experiences in private social dining and update Pine and Gilmore's (1998) four experiential domains accordingly. --- Methodology --- Data collection In this exploratory study, personal interviews were conducted to thoroughly examine the nature of private social dining from tourists' perspectives. Snowball sampling was used to obtain a sample of respondents with previous private social dining experiences. The first 16 participants were recruited from researchers' networks and asked to provide referrals to individuals who may be eligible to participate. Despite potential sample selection bias, this sampling technique has been deemed effective when gathering information about emerging and niche tourism behavior (Chen & Chen, 2015;Meng & Choi, 2019). This study focuses on the development of a theory-based integrative framework rather than population representation. Snowball sampling was thus accompanied by a theoretical sampling technique to "decide what data to collect next" by engaging in data collection and analysis concurrently (Coyne, 1997, p. 625). This approach also allowed for greater flexibility in data collection when exploring private social dining experiences in detail. Efforts were made to recruit participants from various socioeconomic backgrounds. The final sample consisted of 29 respondents, most of whom were women (75.9%). The gender imbalance supports Ignatov and Smith's (2006) finding that females are more interested in food tourism than males. Nationality of the sample ranges from such Asian countries as mainland China and Taiwan, to such American countries as the United States and Canada. The majority (82.1%) were repeat private social diners familiar with the nature of private social dining experiences. Interview questions were developed to suit the context of private social dining based on prior studies involving restaurant selection (Chan & Lam, 2009;Kivela, 1997), the experience economy (Kim et al., 2012;Mody et al., 2017;Radder & Han, 2015), and dining experiences (Jeong & Jang, 2011;Qian et al., 2020). At the start of each interview, the interviewer prompted participants to describe private social dining in general and compare it with traditional dining services. Mody et al. (2017) believed that this comparison would highlight experiential differences between sharing-economy businesses and conventional hospitality businesses. Then, participants were invited to elaborate on their overall patterns of private social dining consumption (e.g., frequency, price range, and type of cuisine). Further, participants were asked to reflect on their most memorable private social dining experiences. The authors opted to focus on participants' most memorable experience, rather than their most recent one, because many studies on the experience economy have suggested that an appealing experience is one which triggers consumers' memorability (Kim et al., 2012;Radder & Han, 2015). In this context, participants were asked to discuss the drivers behind their dining activities (e.g., "Why did you choose to use a private social dining service at that time?"; "What does private social dining mean to you?"), their overall dining experience (e.g., "Can you describe your private social dining experience at that time?"; "What were the experiences that made the activity memorable?"), and their emotional reactions (e.g., "How did you feel when you were dining there?"). Participants were also asked to describe other memorable private social dining experiences (if any) to consolidate their private social dining experiences at the end of the interview. Interviews were held via phone or in person. They lasted roughly 40-60 minutes on average and were performed in either Chinese or English by the first and third authors, both of whom are native Chinese speakers and fluent in English. All interviews were audio-recorded and transcribed verbatim in their original language (i.e., Chinese or English) by a professional transcription company independent from this study. The first author then translated all Chinese transcripts into English for further analysis. --- Data analysis Data analysis consisted of two stages. The first stage followed Braun and Clarke's (2006) six-step thematic analysis in NVivo 11, advancing from content analysis to "pay[ing] greater attention to the qualitative aspects of the material analyzed" (Joffe & Yardley, 2004, p. 56). This approach enables researchers to transfer concrete textual information into an abstract, general concept for knowledge. Given the method's flexibility in research designs and overall accessibility to an educated public (Braun & Clarke, 2006), it is popular in tourism studies for new theory development (e.g., Medhekar, Wong, & Hall, 2020;Qian et al., 2020). Pine and Gilmore's (1998) four experiential domains provided a foundation for exploring the nature of private social dining experiences and determining how these experiences can enhance the traditional conceptualization of tourists' dining experiences. The first and third authors followed all six steps when performing independent thematic analysis, while the second author served as an auditor to verify both processes and the reliability of the analysis. All authors discussed discrepancies in their results until a consensus was reached. Building on the first stage, the frequencies of identified themes were calculated in the second stage of data analysis to assess their relative importance (Creswell & Guetterman, 2018). This approach is common in tourism and hospitality studies to establish new theories (e.g., Kirillova et al., 2014;Lin et al., 2017). In the present study, the process facilitated the authors' investigation of whether private social dining involves experiential domains apart from the four original domains when staging tourists' dining experiences. --- Results and discussion Data analysis generated nine experiential domains that composed a hierarchical framework of private social dining experiences (Figure 2). The resultant framework substantiated the complex nature of dining experiences, which Ryan (2011) described as including multiple phases, influences, and outcomes. --- Personalized experience In the case of private social dining, tourists can communicate with service providers either online or by phone prior to engaging in the activity. This kind of direct communication enables tourists to make special requests, while service providers gain a better understanding of visitors' expectations. Unlike conventional restaurants that usually discover diners' preferences and then stage corresponding experiences during a meal (Shen & Ball, 2009), private social dining service providers begin preparing customized dishes, tableware, and services in the pre-dining stage to deliver personalized experiences (Wijaya et al., 2013). Mody et al. (2017) also mentioned customized experiences as a consequence of online communication via e-platforms for accommodation-sharing services. Only when tourists' needs and expectations are fulfilled do they start to acknowledge other levels of their experience, as one participant indicated below: I would say private social dining is a mixture of personalized and customized dining activity. Although I know that the chef may provide authentic dishes from some countries and provinces, I still prefer to make some adjustments. This is the reason why I go to private social dining. (Informant #29) In terms of the difference between personalized experiences staged during private social dining and in conventional restaurants, tailored experiences in private social dining are not limited to tourists' dining preferences; providers can also account for special requests (e.g., arranging a party for a large group of diners; ordering a special dish and takeaway services) and personal characteristics (e.g., adjusting their service style accordingly). Although smoking is generally prohibited when dining in a destination, even at private social dining events, some service providers appeared to cater to diners' needs regardless: We could smoke inside, which was very convenient because smoking is usually prohibited in conventional restaurants. (Informant #7) --- Sensory experience Sensory experiences are poignant during dining. In particular, private social diners seem only to value sensory experiences once their personal needs have been satisfied: Every place has its uniqueness in terms of its food products. It is hard to evaluate which one is best. Thus, I think [private social dining] should cater to my tastes. (Informant #4) As the core product of any culinary format, food should be a crucial reason why tourists participate in private social dining (Qian et al., 2020), as exemplified by a participant who cited a desire to eat good food as a key motivation for private social dining: Unlike other conventional restaurants that usually provide similar and standardized menu items, private social dining represents the chef. The chef provides [a] private social dining service because they are good at cooking. I went there because I wanted to eat some tasty and special foods. (Informant #20) Consistent with other literature (e.g., Carvalho et al., 2015;Kivela & Crotts, 2006) suggesting that dining is a multi-sensory experience, our data analysis indicated that food helps providers stage sensory experiences by appealing to private social diners' senses of taste (83.9%; 125 text units), sight (15.2%; 19 text units), touch (2.7%; 4 text units), and smell (0.7%; 1 text unit). Consistent with sensory experiences in conventional restaurants, taste and sight were the top two senses involved in private social dining (Chen & Lin, 2018); however, sensory experiences during private social dining highlighted taste above all. While some respondents stated they were visually satisfied with the food presentation, the taste was pivotal in stimulating sensory experiences: Food taste is the key. It is not necessary to be visually appealing, but it must be tasty. (Informant #11) This finding potentially characterizes private social dining as a niche and advanced form of conventional dining, intended to satisfy tourists seeking high-quality, flavorful food (Stone et al., 2018) as described below: [A private social dining service provider] must cook well. Otherwise, no one will go, especially if it is private social dining in which customers are looking for [a] high-quality dining experience. (Informant #26) --- Emotional experience Seven experiential domains were classified based on participants' emotional private social dining experiences stimulated by the senses. In other words, tourists could realize other emotional domains only once their key motivation to eat flavorful foods was achieved. This kind of experience, therefore, extends beyond diners' senses to involve emotional interactions with the food service itself. Chen and Lin (2018) also discussed the relationship between sensory and emotional experiences in the restaurant context. The tourist experience is born from engaging sensory encounters that emotionally sustain experiential value (Barnes et al., 2020;Oh et al., 2007). Experience-based encounters arise from the interplay between the extent of customer involvement and consumers' influences on overall experiential performance (Pine & Gilmore, 1998). Along this line, our seven identified emotional, experiential domains were organized into a bi-dimensional plane consisting of two continuums (i.e., immersion-absorption and passive participation-active participation), as suggested by Pine and Gilmore (1998). --- Quadrant I: Absorption-passive participation Quadrant I represents tourist experiences associated with travelers' absorption and passive participation in activities (Pine & Gilmore, 1998). As proposed by Pine and Gilmore (1998), entertainment (0.7%; 4 text units) fell into this quadrant. Entertainment is a form of experience purely staged by service providers to capture and occupy consumers' attention (Oh et al., 2017). Cruises, casinos, and wineries are among the many tourism settings heavily skewed toward this experiential domain (Hosany & Witham, 2010;Shim et al., 2017;Vo Thanh & Kirova, 2018) because travel is inherently entertaining (Hsieh, O'Leary, & Morrison, 1992). Interestingly, as indicated by the smallest number of text units in the dataset, entertainment was rarely reflected in private social dining. While this particular finding contradicts the literature on the tourism experience, it highlights the uniqueness of dining experiences that cannot be fully explained by Pine and Gilmore's (1998) four original experiential domains. Despite scarce investigations into the dimensionality of dining experiences, such activities are often recognized as belonging to either educational (e.g., Quadri-Felitti & Fiore, 2012), esthetic (e.g., Shim et al., 2017), or escapism experiences (e.g., Ji et al., 2018). Among the four categorizations of food tourists proposed by Hjalager (2003) (i.e., recreational, existential, diversionary, and experimental), only recreational food tourists who preferred self-catering in self-contained accommodations seemed to exhibit absorptive and passive participation (i.e., features of entertainment experiences) during dining activities. More specifically, these tourists tend to consider dining activities an unimportant part of travel experiences (Kivela & Crotts, 2006). Recreational food tourists may be intimidated by additional efforts to become immersed or actively participate in dining activities that may require them to communicate with strangers or learn new things, as mentioned by a tourist who was dissatisfied with private social dining: I was not satisfied with [my private social dining experience] because the chef kept socializing with us, telling us about how the foods were prepared, about food history, and even about themself. However, I just wanted to eat, and I found it stressful to socialize with the chef while dining with my family. (Informant #28) Several participants also believed that entertainment elements contradicted the private social dining setting, in which a quiet and private atmosphere was highly expected. This finding is exemplified by an interviewee's dissatisfaction with excessive entertainment: The staff changed their clothes and performed during the meal. I think once is okay, but it was too much.... I think it is inappropriate to have so much entertainment because the reason for private social dining is to eat good food in a quiet and private dining atmosphere. (Informant #25) --- Quadrant II: Absorption-active participation Quadrant II included instances in which diners could absorb and actively participate in their experiences. Two types of educational experiences were observed in this quadrant: food knowledge (8.2%; 46 text units) and cultural elements (12.1%; 68 text units). In the context of this study, education refers to knowledge absorption, particularly private social diners learning new things. Educational experiences, in which tourists acquire foodrelated knowledge, exhibited the largest variance among all categories due to its dependence on the nature of experience and a service provider's willingness to deliver knowledge (Oh et al., 2007). In private social dining events, education varied across two operational forms. At one end, private social dining could be designed as a cooking class during which participants discover how to prepare and taste their own food. This operational form is a purely educational experience deliberately staged to deliver food knowledge: I went to a private social dining event in Vietnam, which was like a cooking class. I followed the host's instructions when cooking. The activity allowed me to learn cooking. (Informant #19) At the other end, and to a lesser extent, educational experiences during private dining can serve a supporting role. Similar to previous findings (e.g., Hosany & Witham, 2010;Shim et al., 2017;Vo Thanh & Kirova, 2018), the supporting role of education can enhance tourists' private social dining experiences. Service providers can also indirectly identify diners' desire to learn something new through food delivery: I found the food delicious when I was enjoying the meal. Hence, I asked the host how to cook [it] and why it was delicious. I asked the host how to prepare the tasty food. (Informant #20) In addition to gaining food-oriented knowledge, tourists may also seek cultural elements during private social dining. This finding echoes that of Kim and Eves (2012), who named cultural elements as prime motivators behind tourists trying local foods. With respect to the distinctions between cultural experiences in private social dining settings and local restaurants, private social dining involves more than a destination's culture; it also concerns an operator's biography or cultural background when staging a cultural experience. Different from conventional restaurants, which usually rely on the history of local foods or the destination's culture to offer an educational experience (Adongo, Anuga, & Dayour, 2015), private social dining seems more closely tied to the operators themselves: I think it is important for private social dining to represent the chef because private social dining relies on the chef. Perhaps the chef [got] very famous and then started doing private social dining. Then, it would be unique if the chef could incorporate his/her personal stories or cooking ideas into the dining experience. (Informant #17) --- Quadrant III: Immersion-passive participation The original experiential domain proposed by Pine and Gilmore (1998) in Quadrant III is esthetic experience, which denotes diners' simultaneously passive feelings about and immersion in their surroundings (Oh et al., 2007). The present study confirmed that the esthetics of private social dining include man-made physical and natural environments: The decorations were memorable. The artwork provided a good dining atmosphere. I think the artwork was beautiful, valuable, and full of cultural connotations. (Informant #4) The private social dining event was hosted on the mountainside with a three-floor building surrounded by beautiful flowers and trees. Yes, [I think it was special]. (Informant #11). Heung and Gu (2012) proposed four atmospheric elements restaurants use to stage esthetic experiences, including the spatial layout, ambiance, facility aesthetics, and window views. While these elements have been found to influence esthetic experiences in restaurants, exactly how diners judge whether a dining experience is esthetic remains unclear (Kirillova et al., 2014). The present study filled this gap by identifying two types of esthetic experiences in private social dining-unrestrained (15.9%; 89 text units) and localness (31.1%; 174 text units). The first domain, unrestrained, is related to refreshment and relaxation, which are distinctive characteristics of tourism activities (Kim & Ritchie, 2014;Pearce & Lee, 2005). Participating in such activities "is a no-work, no-care, no-thrift situation" (Cohen, 1979, p. 181), particularly when attending special events (Lscerblanc, 2003) such as private social dining. Chan and Lam (2009) suggested that a homelike feeling is relatively important in private kitchens (i.e., a predecessor of private social dining services) (Ma & Zhang, 2019). In a similar vein, private social diners identified a private social dining esthetic-in which case an experience feels similar to enjoying a casual meal at a neighbor's home-as representing a "downshift" in lifestyle: The private social dining event allowed me to relax compared with the noisy and impetuous [dining places] outside... It was a lifestyle of downshifting internally. (Informant #15) The second experiential domain in Quadrant III was localness, representing an esthetic experience that enables diners to become immersed in local citizens' daily lives (e.g., eating local food or visiting local markets). Localness was the top experiential domain based on coded text units in this study; "enjoying the authentic regional cuisine in local restaurants" was one of the most appealing food-related tourism experiences (Robinson & Getz, 2012, p. 701). Localness experiences are particularly pertinent to cultural tourism (Wang, Huang, & Kim, 2015) and the sharing economy (Mody et al., 2016). Thus, as a special form of cultural tourism in the sharing economy, private social dining enriches tourists' pursuit of localness experiences in a destination (Skinner, Chatzopoulou, & Gorton, 2020). Tourists can observe many local elements through the interior design of private social dining while experiencing everyday local life: It was a local experience in a local's home. I went to a private social dining [event] in Japan, and it was held in a local home. There were some Japanese swords and I realized how they look. When the host was preparing the food, I also saw the host's daughter was writing calligraphy, which cannot be seen in conventional restaurants. (Informant #6) --- Quadrant IV: Immersion-active participation Quadrant IV included two domains of escapism experience requiring diners to be actively involved and strongly immersed in private social dining: adventure (12.3%; 69 text units) and social (19.6%; 110 text units). Our findings revealed that one's sense of escapism depends on the location of private social dining events. Other tourism attractions are typically concentrated within a tourism cluster to form a wholly different area where tourists can escape their daily routines (e.g., Sentosa in Singapore). By contrast, private social dining events are commonly dispersed and separate from tourism clusters (Lawler, 2014), leading to experiential variances in different dining locations. In particular, diners' feelings of escapism were positively correlated with the distance between private social dining and their usual living environments, as illustrated by an interviewee living in a Chinese urban city: It took me around 40 to 50 min to drive to the private social dining event from my home. The event was located in a remote area surrounded by mountains and rivers. A farm and several ducks were owned by the host. I felt like I was experiencing farm life. (Informant #7) Our notion of adventure is akin to the serendipitous experience identified by Tung and Ritchie (2011). Tourism businesses are highly encouraged to create unexpected situations that generate unique bonds with tourists, as stated by Mody et al. (2015), in terms of accommodation-sharing services. However, serendipitous experiences cannot fully describe private social dining experiences. Surprises or uncertainty are created by service providers but can emerge from the events themselves as well. Such experience operates on a paradox: tourists seek what they believe to be risky or unfamiliar to the extent that they feel safe from perceived risks (Mackenzie & Kerr, 2012). Having a meal in a stranger's home involves greater risk than staying at a stranger's home, riding in a stranger's car, or dining in a normal restaurant due to higher uncertainty around legal issues and unstable food supply. These ambiguities can stage an adventurous experience through private social dining. Indeed, some interviewees defined social dining as an adventurous activity where many mysteries await for exploration: The final dimension of social reflected the active and immersive components of private social dining. This dimension mainly involved social interaction between operators and consumers, although Schmitt (2010) noted that the relationship construct should be extended to highlight social elements among consumers. The roles of business platforms can also become vague in the sharing economy because firms such as Airbnb, Uber, and Eatwith are somewhat external to actual experiences and instead function as mediators by linking consumers (Martin, 2016). Thus, we redefined social experience in the sharing economy by proposing two subdimensions, interactions with strangers (76.4%; 84 text units) and interactions with companions (23.6%; 26 text units). Dining out can satisfy people's physiological and social needs. Kivela (1997) suggested that dining may occur as a social occasion, business necessity, or celebration. Private social dining is a gathering where diners can socialize with others. Similarly, Ketter (2019) revealed that private social diners are socially motivated. Most interviewees in this study believed that private social dining involves the development of a friendship between diners and the host, who are otherwise unfamiliar with each other: The private social dining event was held in the host's home. We chatted about the food. The host was funny and loved teas, and the host's daughter loved calligraphy.... Yes, [I had a detailed conversation with the host]. (Informant #6) In addition to relational experiences with strangers, the relaxed and quiet atmosphere of private social dining enables diners to socialize with companions: The private social dining event had a place for diners to drink tea. The host had a professional tea set and tea table. We were able to sit together, drinking tea and chatting. (Informant #15) --- Conclusion This current study provides a fresh understanding of two main tourism areas, the experience and sharing economies, by investigating tourists' experiences during private social dining. A three-stage hierarchical relationship was uncovered to demonstrate how private social dining encompasses nine experiential domains to deliver a compelling experiential value proposition beyond the first four experiential domains suggested by Pine and Gilmore (1998) from pre-dining phase to the during-dining phase. As the core domain to satisfy diners' niche needs, personalized experience can be observed before the dining experience. During the

While private social dining has emerged as a new activity in the sharing economy, associated research is limited. This study aims to conceptualize tourists' private social dining experiences by incorporating the concept of the experience economy with the sharing economy. Thematic analysis of 29 interviews unveiled a hierarchical framework, beginning with a personalized experience and leading to sensory experience before ending with emotional experience in private social dining settings. Seven identified emotional experiential domains were then situated within a four-quadrant framework to address how private social dining can enrich the four original experiential domains of the experience economy (i.e., entertainment, education, esthetic, and escapism) to trigger tourists' emotional pleasure. These results lay a theoretical foundation for future studies and provide practical implications for the development of food tourism.

dining event was held in the host's home. We chatted about the food. The host was funny and loved teas, and the host's daughter loved calligraphy.... Yes, [I had a detailed conversation with the host]. (Informant #6) In addition to relational experiences with strangers, the relaxed and quiet atmosphere of private social dining enables diners to socialize with companions: The private social dining event had a place for diners to drink tea. The host had a professional tea set and tea table. We were able to sit together, drinking tea and chatting. (Informant #15) --- Conclusion This current study provides a fresh understanding of two main tourism areas, the experience and sharing economies, by investigating tourists' experiences during private social dining. A three-stage hierarchical relationship was uncovered to demonstrate how private social dining encompasses nine experiential domains to deliver a compelling experiential value proposition beyond the first four experiential domains suggested by Pine and Gilmore (1998) from pre-dining phase to the during-dining phase. As the core domain to satisfy diners' niche needs, personalized experience can be observed before the dining experience. During the dining experience, private social diners recognize sensory experience by utilizing their four senses (i.e., taste, sight, touch, and smell) to interact with the personalized dining experience prepared by the hosts. In the end, the highest level of emotional experience can be observed if private social diners are satisfied with the personalized and sensory experiences. --- Theoretical contributions First, amid the conceptualization of the experience economy, this study is among the first to incorporate the experience economy into the sharing economy by focusing on tourists' experiences with private social dining. The unstoppable rise of the sharing economy has had clear implications for global tourism, from the accommodation to transportation and catering sectors. Although nascent private social dining services may face various legal and safety issues, they continue to progress in delivering novel experiences. Hence, the present study evaluated the nature of experiential consumption in private social dining to explore how the sharing economy changes the rules of the game by leveraging experiential domains to create a compelling experiential value proposition. Second, in response to a call from Walls et al. (2011) to expand Pine and Gilmore's (1998) framework, this study presents an extended framework (Figure 2) to visualize how private social dining events stage tourism experiences. While the hierarchy beginning with personalized experiences to sensory experiences and ending with emotional experiences does not exist in isolation, this hierarchical framework provides a theoretical foundation for future research into the dimensionality of other tourism experiences in the sharing economy. Finally, our study provides insight into an ongoing debate on whether food tourism is a viable market segment (Quan & Wang, 2004). Localness, as the most common experiential domain in the current study, reaffirms the strong linkage between food and cultural tourism (Ellis et al., 2018). This finding supports Au and Law's (2002) claim that "food signifies cultural meaning to those who consume it" (p. 828). As such, this study deepens academic understanding of how food tourism can benefit from localness experiences staged through private social dining. --- Practical contributions Apart from its theoretical implications, this study also presents actionable guidance for industry practitioners. First, our investigation on private social dining should enable practitioners to stage tourist experiences based on the intricate linkages between various experiential domains of memorable private social dining. This study indirectly supports findings from Tsai (2016), who determined that local culture, knowledge, and refreshment had the strongest effects on the formation of memorable tourism experiences in dining settings. These three dimensions are theoretically similar to localness, education (i.e., food knowledge and cultural elements), and unrestrained domains in this study. Conventional hospitality and tourism service providers should, therefore, focus on these elements to craft memorable dining experiences, as such factors are frequently highlighted in the sharing economy. Second, conventional hospitality and tourism operators should be proactive and expansive in designing compelling tourist experiences that go beyond dining satisfaction and the original experiential domains suggested by Pine and Gilmore (1998). The current study expanded their four-dimensional conceptualization to a seven-dimensional construct of emotional private social dining experiences. Results suggest that rules are malleable when delivering tourist experiences through private social dining because this type of dining enriches Pine and Gilmore's (1998) initial experiential domains to a degree that sparks diners' emotional pleasure. For example, private social dining includes localness and an unrestrained experience to aesthetically appeal to tourists. Third, private social dining may offer a "blue ocean" strategy for food tourism development. This marketing concept suggests that demand is created rather than fought over in the tourism industry (Jones, 2010). Traditional dining activities are engendered by rich tourist experiences. Whether food tourism is a viable market segment (Quan & Wang, 2004) remains uncertain, but private social dining may offer an attractive means of promoting other niche tourism markets. For example, private social dining events could be framed as "adventure tourism" activities when offering mysterious or exotic dining experiences. --- Limitations and future research This study has limitations given our use of snowball sampling to recruit 29 private social diners. These participants may share similar characteristics and values. Thus, our research findings cannot be generalized to broader contexts. Tourist experiences are also inherently subjective and may vary by personal (e.g., nationality) and external variables (e.g., type of cuisine), none of which were considered in this study. Future research should incorporate these variables to empirically validate the proposed framework for private social dining. Comparative studies are also needed to compare the effects of each experiential domain on outcome variables (e.g., visitors' dining satisfaction or intentions to recommend) at private social dining events and traditional restaurants. As indicated, private social dining emphasizes authenticity to enhance tourists' experiences and illuminates new modes of destination branding. However, how and which promotional strategies are most likely to cultivate sufficiently authentic experiences require further investigation.

While private social dining has emerged as a new activity in the sharing economy, associated research is limited. This study aims to conceptualize tourists' private social dining experiences by incorporating the concept of the experience economy with the sharing economy. Thematic analysis of 29 interviews unveiled a hierarchical framework, beginning with a personalized experience and leading to sensory experience before ending with emotional experience in private social dining settings. Seven identified emotional experiential domains were then situated within a four-quadrant framework to address how private social dining can enrich the four original experiential domains of the experience economy (i.e., entertainment, education, esthetic, and escapism) to trigger tourists' emotional pleasure. These results lay a theoretical foundation for future studies and provide practical implications for the development of food tourism.

BACKGROUND The promotion of gender equality represented one of the eight global Millennium --- Key questions --- What is already known about this topic? <unk> There is an ongoing debate about the risk that bride price poses to the general and mental health of women in developing countries. <unk> In Timor-Leste, bride price (incorporated into the traditional practice of barlake) includes an obligation that the husband and his family have to provide money or material goods to the wife's family, including for life events such as future weddings and funerals. <unk> This form of bride price commonly involves a long-term obligation which requires payment over extended periods of time. What are the new findings? <unk> Problems with bride price were strongly associated with sudden episodes of explosive anger, experiencing excessive anger and severe psychological distress among women. <unk> Women with the most severe problems with bride price reported twice the level of poverty as those with no problems with bride price. <unk> There was a threefold increase in conflict with the male spouse and a fivefold increase in conflict within the family among women with the most severe problems with bride price. --- Recommendations for policy <unk> Bride price should be considered as a risk factor for mental health problems among women in low-income countries. <unk> Bride price should be considered in all family interventions, particularly where there is family conflict. <unk> Training of mental health professionals and those working in psychosocial support services should include an understanding of the impact of bride price on mental health. Development Goals (MDGs), the overall objective being to advance the status of women and promote their participation in socioeconomic development in low-income and middle-income countries. The importance of promoting gender equality and the empowerment of women has been further underlined by the inclusion of these objectives in the recently adopted Sustainable Development Goals. 1 Achieving these goals has remained elusive, however, particularly in low-income, conflict-affected countries. 2 One obstacle may be the ongoing problems families and women in particular encounter in meeting traditional obligations, such as the ceremonial bride price. We report a mixed-methods study in Timor-Leste investigating whether problems with bride price were associated with poor mental health (symptoms of explosive anger, experiencing excessive anger and general mental distress), family problems (conflict with spouse and family, poverty) and heightened preoccupations with injustice among women. --- Bride price There is an ongoing debate, particularly in Africa and Southeast Asia, about the risks that the practice of bride price pose to the security, health and status of women. 3 Although the bride price custom may have positive effects, for example, by encouraging parental investment in their daughter's education, 4 critics point out that the practice tends to 'commodify' women by representing them as objects of transaction, thereby increasing risk of early marriage, subsequent reproductive health problems (including vulnerability to HIV-AIDS) and ill treatment by the indebted husband and/or his family. [4][5][6][7][8] Bride price is often inter-related with a complex system of material remittances in traditional societies. In Timor-Leste, the term barlake encompasses more than a bride price in that it refers to a range of ritual contributions as well as exchanges made between the fetosan (husband's family) and the umane (wife's family). 9 In the prevailing patriarchal system, the bride's family or clan is commonly categorised as wife-givers (or lifegivers, manegsan/umane) and the husband's family as wife-takers (or life-takers, fetosan). This complex practice of bride price obliges the husband's family to offer the wife's family gifts, offerings and contributions of traditional items such as livestock, food, handmade craft and jewellery for ceremonies and other significant life events such as marriage and funerals, throughout the period of marriage. 9 In addition, at the time of the marriage, gifts are exchanged, although the most valuable are generally provided by the groom. 10 Barlake (also known as lia) commonly involves remittances made over extended periods of time from the husband's family to the bride's family, and in the modern context, often involves cash payments. Barlake has the positive effect of acting as a symbol of mutual respect between families brought together by marriage, providing material assistance to family members in need of support, and establishing clarity regarding future inheritance rights. The responsibility of meeting obligations also has the function of committing the fetosan (husband) to valuing and ensuring the safety and well-being of the new wife. 9 11 Nevertheless, it is possible that the protracted nature of the husband's obligations to offer gifts or outlays to the wife and her family, and the growing cost of this form of bride price in the modern cash economy, may have adverse consequences over time, including increasing resentment within the wider network 9 11 and potentially conflict with and even violence against the female spouse. 10 Owing to the sociocultural complexities and regional variations in the use of the terms barlake and lia in Timor-Leste, for the purposes of our study, we operationalised the terms used in our inquiry to represent the core construct of bride price. While most often referred to by participants in the region of our study as lia, we ensured that the definition we used was clearly understood to mean the husband's and/or his family's obligations to make material contributions (money or other goods and items) to the bride's family for cultural, social or ritual purposes, including commitments that might extend over a prolonged period of time following the marriage. We provide further information about our operationalisation of bride price in the Method section. --- Poverty and bride price The prolonged period of war and conflict in Timor-Leste has left many families in a state of extreme poverty, with Timor-Leste ranked as one of the poorest nations in the world. 9 Obligations related to bride price therefore may exacerbate already strained family resources, impacting on the capacity of the woman to meet basic necessities including food and the educational, housing and healthcare needs of the family. 11 12 As with many cultural practices, the mode of discharging bride price has evolved over time, being subject to the effects of rapid social and economic change typical of postconflict countries such as Timor-Leste. Traditionally, bride price was paid in domestic animals, for example, in cattle in Zambia, and water buffalo in Timor-Leste. 11 13 Nevertheless, social and economic development and the shift to a cash economy have meant that in contemporary times, bride price is commonly paid in monetary currency, a transition associated with a rapid inflation in the cost to the husband and his family. The contemporary practice of bride price is therefore attended by several risks: financial pressures, particularly in conditions of poverty in low-income, conflict-affected countries such as Timor-Leste; an incentive for parents to'sell' their daughters prematurely; the potential for recipients to demand that bride price debts are discharged more rapidly to meet urgent debts or immediate needs; 14 entrapping women in a violent marriage for fear of parents having to repay the large bride price; and in modernising environments, generating competing demands within families, for example, to fund their children's ongoing education as opposed to saving for a future bride price. The prolonged period of obligation associated with bride price in Timor-Leste, in particular, may lead to mounting resentment by the indebted husband and his relatives, increasing the risk of conflict among spouses and the wider family. 5 7 11 15 Bride price and mental health Little attention has been given in the research literature to the relationship between bride price obligations and women's mental health in low-income and mediumincome countries. The only relevant data we could identify were gathered in a cross-country study whose primary focus was on domestic violence. A subsidiary finding from that inquiry was that dowry obligations showed no association with suicide attempts among women. 16 17 It is possible, however, that problems associated with bride price contribute to more general and common forms of mental distress among women, as suggested by preliminary data we have gathered in Timor-Leste. 18 Background data from our programme of research in Timor-Leste has documented high rates of explosive anger among men and women in that country, a reaction pattern that is associated with a range of general factors, including past exposure to traumas related to human rights violations, ongoing deprivations and feelings of injustice. 15 In our qualitative research, however, women specifically highlighted the problem of bride price as a contributor to poverty, a source of conflict with the spouse and family and a possible cause of their anger. 18 These preliminary findings warranted a closer examination of the possible role of bride price as a factor leading to mental distress among Timorese women. --- Setting of conflict and poverty Timor-Leste was invaded and occupied by Indonesia in 1975, provoking a protracted period of conflict and persecution that culminated in the humanitarian emergency of 1999. During the period of conflict, it is estimated that a quarter of the indigenous population (of 600 000 persons) died as a consequence of atrocities, warfare, burning of villages, murder, famine and untreated illness. 19 In addition, there was widespread loss of property and livelihoods, and extensive forced displacement of whole communities. In the postconflict period, further episodes of internal violence, particularly in 2006-2007, led to injuries, deaths and internal displacement of communities. Socioeconomic development in the newly independent country has been slow, with many families confronting extreme levels of poverty and deprivation. The present inquiry forms part of a programme of mental health studies that our team has undertaken in Timor-Leste over two decades. The quantitative data for the present analysis were drawn from a second survey of two villages conducted in 2010-2011, undertaken concurrently with a qualitative study whose aim was to understand more fully the manifestations and sources of women's anger. 15 18 In the present analysis, we hypothesised that problems Timorese women experienced with bride price would be associated with explosive anger (the prevalence and excessive nature of the reaction) as well as with more general symptoms of severe psychological distress. We also postulated that problems with bride price would be associated with several adverse psychosocial consequences relevant to women's mental health, including conflict with the spouse and family, ongoing poverty and distressing preoccupations with injustice. --- METHOD The mixed methods approach included an epidemiological survey and a qualitative component. Qualitative and quantitative interviews were completed on separate days with different interviewers employed for each component. Qualitative interviewers were not aware of trends or findings from the quantitative study until after its completion. In our Quant-QUAL analysis, 20 we first examined for quantitative associations between bride price and indices of explosive anger and mental distress, and then with relevant psychosocial factors including poverty, preoccupations with injustice, conflict with family and conflict with spouse. 15 18 Our focus was on whether there was a regular dose-effect relationship between problems with bride price and all our indices of mental distress and psychosocial difficulties. The subsequent qualitative analysis aimed to explore further the contextual nature and sequencing of these factors from the perspective of women, specifically examining how bride price intersected with other factors ( poverty, preoccupation with injustice related to past conflict and contemporary hardship, and conflict with spouse and family) in generating distress. --- The epidemiological sample All adults, 18 years or older, living in all dwellings in each of two administrative units or sucos were eligible for inclusion. The sucos included an urban settlement in Dili, the capital, and a rural site situated <unk>1 hour's drive from the urban area. Global positioning system (GPS) coordinates and maps generated by the National Directorate of Statistics allowed us to identify all dwellings in the two villages. Excluded were those who were too ill or incapacitated to participate including those with overt psychosis, intellectual impairment or organic brain disorder such as severe dementia. We achieved a 92.6% response from the eligible women approached. Given that the focus of the study was on the personal experiences of bride price among women, we excluded women who were single or never married (n=320) from the whole sample (n=1513) 15 for the present analysis, yielding a final analytic sample of 1193 women. --- Personnel and training for the epidemiological survey The quantitative survey was undertaken by 18 Timorese fieldworkers with prior survey experience and/or public health degrees, supervised by expatriate staff. All field staff received 2 weeks' research training followed by 2 months of field testing and questionnaire piloting in areas separate from the sites of the main study. Pairs of interviewers were required to achieve a consistent 100% level of inter-rater reliability with supervisors on key mental health measures. The survey was conducted between June 2010 and October 2011. --- The qualitative sample We assessed the data available from the epidemiological study to identify a sample of women (n=77) weighted towards those meeting full criteria for explosive anger (n=64) 18 (defined according to the criteria of intermittent explosive disorder (IED), as outlined hereunder). The inclusion of a minority of women without IED allowed us to gather observer perspectives from participants not personally affected by explosive anger or aggression. The qualitative component was undertaken in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist, 21 the approach aiming to facilitate a safe exploration of gender-sensitive issues in a setting where cultural and religious factors might constrain disclosure of personal information. The full methodology has been reported previously. 18 Personnel and procedure for the qualitative study For the qualitative research, an Australian project director and a Timorese in-country manager supervised three fieldworkers who were trained in maternal and child health at the Alola Foundation, the peak nongovernment agency for women in Timor-Leste. In conducting the qualitative interviews, we applied strict provisions of confidentiality and privacy according to WHO guiding principles. 22 In brief, phase 1 of the qualitative study involved open-ended and in-depth interviews with 19 of the 77 women exploring domains informed by the existing literature (non-peer-reviewed reports and peerreviewed publications) pertaining to the psychosocial conditions of women in Timor-Leste, explosive anger and the manifestations and factors associated with that emotion. Phase 2 involved 58 participants and included a semistructured interview designed to confirm the factors associated with anger that were compiled from the data gathered in phase 1, and to establish more fully how and why these factors might precipitate or aggravate women's anger. This included a further examination of bride price given that this issue was raised repeatedly by women in the phase 1 interviews. Phase 3 involved a professional sample focus group with workers from government and non-government organisations in Timor-Leste working specifically with women, including in the violence against women and mental health sectors. Data generated from the field interviews were discussed, clarified and checked by way of feedback from this professional sample. --- Measures for the quantitative survey Bride price As indicated, we derived our definition of bride price from preliminary qualitative work identifying culturally specific practices of barlake and lia. 18 To ensure precision, we operationalised bride price for the purposes of the study as the customary practice in which the husband and his family were obliged to make remittances of money or other goods to the bride's family for cultural, social or ritual purposes, a commitment that often extended over prolonged periods of time following the marriage. --- Explosive anger The community measure of explosive anger, based on the Diagnostic and Statistical Manual edition IV (DSM-IV) criteria for IED, was tested and modified serially during piloting to ensure its cultural appropriateness and comprehensibility in the local language, Tetum. 18 The measure identified sudden attacks of explosive anger and associated acts of aggression including loss of control, verbal aggression, destruction of property and physical aggression towards others. The measure was assessed in a convergence study against IED determined by the Structured Clinical Interview for DSM-IV applied in a blinded manner by experienced expatriate psychologists familiar with Timor-Leste, working with interpreters. 22 There was a high level of concordance between the two measures for assigning IED: area under the curve (AUC) 0.90 (95% CI 0.83 to 0.98). 22 In the present study, we focused on two indices, sudden attacks of explosive anger (0=absence, 1=presence) and attacks judged to be excessive by the women (0=attacks not excessive; 1=attacks experienced as excessive). --- Severe psychological distress We included the Kessler-10 scale (K10) 23 as a measure of severe psychological distress, the index comprising symptoms of depression, anxiety and somatic complaints. Past studies have indicated that the K10 provides a general index of mental disorder. 23 24 Our aforementioned study based on a stratified sample of 97 community respondents drawn from our household survey in Timor-Leste compared the K10 with the category of major depressive disorder of the Structured Clinical Interview for DSM-IV, applied in a blinded manner by experienced psychologists. 22 There was a sound level of convergence between the K10 and the gold standard interview: AUC for the K10 0.79 (95% CI 0.67 to 0.91) (full data will be provided on request). The international cut-off score of 30 or more provided the best balance between sensitivity (92.3%) and specificity (66%). The lower level of specificity was most likely related to the structure of the K10 which includes symptoms of anxiety and somatic symptoms in addition to depression. --- Daily living difficulties A list of 27 items was included in the household survey to measure living difficulties that had been experienced over the past 12 months. Items were identified following extensive community consultation. A subset of seven items was used to generate a poverty index. Poverty items included: not enough food; not enough money in general; not enough money for school fees; having to work too hard; poor shelter; unemployment; and being too old to work. Each item was scored on a scale of 1-5: (1) not a problem, (2) a bit of a problem, (3) a moderately serious problem, (4) a serious problem and (5) a very serious problem. The total poverty score reflected the sum of all item scores. --- Conflict with spouse and conflict with family Conflict with spouse and conflict with family were individually measured by single-item questions asking if each occurred and if so, whether they were a moderate, serious or a very serious problem. --- Preoccupations with injustice To assess preoccupations with injustice, we asked respondents to identify and describe the worst acts or conditions of injustice they had experienced in each of the three defined historical periods: the Indonesian occupation, the period of internal conflict and in contemporary times. In most instances, qualitative data indicated that the focus of respondents' preoccupations with injustice related to past human rights violations and, in relation to contemporary times, ongoing deprivations. The composite measure covering three successive historical periods therefore reflects a general index of the preoccupation with injustice the person experienced, feelings which, we hypothesised, could be exacerbated by grievances related to bride price obligations. Responses were scored as 0 for no event nominated; 1 for the experience of an unjust event; 2 for experience of an event and persisting preoccupations of injustice; and 3 for an event experienced, persisting preoccupations of injustice and associated ongoing distress related to the preoccupations. In our analysis, we included a composite index of injustice based on the summary respondent scores (0-3) for all three historical periods. --- Ethics and partnerships The study was undertaken in partnership with the Alola Foundation. The Human Research Ethics Committee of the University of New South Wales and the Timor-Leste Ministry of Health approved the study. The information sheet outlined the objectives and was read to all participants because of low literacy in the community. For the same reason, we requested verbal consent. Participants then made the choice to provide verbal informed consent in the presence of a respected Timorese person and the interview staff. The interviewer signed the consent form stating that the participant had understood the information sheet and had agreed voluntarily to participate. The process for verbal consent to participate was approved by The Human Research Ethics Committee of the University of New South Wales and the Timor-Leste Ministry of Health. The study was funded by grants from the Australian National Health and Medical Research Council (Grant 568732) and the Australian Research Council (DP0987803). --- Statistical analyses We present descriptive statistics for sociodemographic characteristics and mental health and psychosocial indices. We apply bivariate analyses to examine associations between problems with bride price and indices of mental health including explosive anger (two indices, one based on sudden explosive anger attacks, the second on the excessiveness of attacks), and threshold for severe psychological distress (<unk>30). Bivariate analyses were also used to explore associations between problems with bride price and conflict with a spouse, conflict with family, preoccupations with injustice and ongoing poverty. The results of the bivariate analyses were expressed as percentages, <unk> 2 tests and F tests. Univariate logistic regression was used to generate ORs with 95% CI. For the qualitative data, interviews were independently assessed by two raters. After each rater coded the raw data, minor differences were reconciled by consultation. We used QSR NVivo 9 25 for data management and analysis in order to examine dominant and dissonant themes and their inter-relationships. 26 Triangulation of the key sources of data was accomplished by using the quantitative data as the scaffolding on which the qualitative data were applied to build a more comprehensive picture, the findings being crosschecked with nongovernment organisation personnel in two focus groups held following the survey, once the preliminary qualitative data had been analysed. 26 The focus groups were conducted with the Alola Foundation and included representatives from health and mental health nongovernmental organisations, local women's organisations, the Ministry of Health and the Ministry for Social Solidarity. Qualitative themes and associated findings are represented in quotations. We have not included the ages of the women quoted to protect their identities. All quotations are from different participants. --- RESULTS --- Quantitative sample characteristics Table 1 presents descriptive data for the quantitative survey including the sample of 1193 women. Approximately 1 in 10 (11.3%) of the sample was 25 years or younger, a third (36%) was aged 25-34 years and 23% were 50 years or older (table 1). The majority (69.6%) lived in the rural area, and 87.3% were married. Two-thirds (64.3%) had either never attended school or had completed primary school only, 22% had completed senior high school and 4.7% had obtained a degree or other postschool qualification. Fewer than a quarter (23.8%) of women were in paid employment. A minority (12.7%) reported no problem with bride price, 30.8% experienced a moderately serious problem with the custom and 19.4% reported that the practice was a serious problem. Over a third (38.6%) had sudden attacks of explosive anger and close to a half (48%) reported attacks that they considered to be excessive. Approximately one in six (15.8%) participants reached the threshold for severe psychological distress on the K10 (score <unk>30). One in five women (18.9%) reported moderate to very serious conflict with the spouse and 14.0% a comparable level of conflict with the family. A total of 7 out of 10 women (71.8%) were preoccupied with injustice. The mean poverty score was 16.3 (range 7-35). --- Qualitative sample characteristics Of the 77 women interviewed in the qualitative study, the age range was 25-54 years, the majority (62.3%) lived in the rural area and most (68.9%) were married, the remainder being divorced, separated or widowed. The number of children per household ranged from 1 to 10. Half (48%) were occupied with subsistence farming supplemented by tending a small shop or stall selling produce. --- Associations between bride price and mental health measures The analysis reported in table 2 indicates a regular dose-effect relationship between increasing problems with bride price and all three indices of mental health problems, including sudden attacks of explosive anger, experiencing excessive anger and severe psychological distress (all p<unk>0.001). Sudden attacks of explosive anger were almost three times as common among women with the most severe problems with bride price (55.0%, n=127) compared with women with no problems with bride price (19.7%, n=30) (OR=3.3 95% CI 2.2 to 5.1). For severe psychological distress, there was a threefold greater prevalence for those with the most severe problems with bride price (29.9%, n=69) compared with women with no problems with the custom (10.5%, n=16) (OR=3.6, 95% CI 2.0 to 6.5). A participant articulated the connections she recognised between bride price (identified as lia), explosive anger and mental distress: For me, if I feel angry I just keep quiet and go to sleep, but what makes me feel very sad is my family always come for lia. They don't care whether we have money or not. All they know is that if we get married that means that we have money, and are ready to participate for bride price at any time. We can't do anything in response because this is our tradition. Now we lost our house because of floods in January this year. We are now staying in a government-provided house and I worry because they will force us to leave this house one day. --- Bride price, poverty and explosive anger A regular dose-effect relationship was evident in examining problems with bride price and poverty (F=115.2, p<unk>0.001) (table 3). Women with the most severe problems with bride price had twice the level of poverty (mean=25.2; 95% CI 23.4 to 26.9) as those with no problem with the custom (mean=12.6; 95% CI 12.0 to 13.2). Women often used the term hanoin barak (thinking too much) to refer to intense worry or preoccupation with the problem of poverty associated with bride price. I'm thinking a lot when I couldn't support money for my children at the time they need for their school needs and for their future and sometimes no money for lia. My relatives said that they will not help me if one day I face the same difficulty like what they have now. These things made us very angry. A woman highlighted the interconnection of bride price, living hardships, family challenges and anger: Women mostly get angry just because of dealing with children at home, no money, not enough food, children --- Bride price and preoccupations with injustice Table 3 indicates a dose-response relationship between the severity of problems with bride price and preoccupations with injustice ( p<unk>0.001); those experiencing the most severe problems with bride price (74.9%, n=173) had a significant increase in preoccupations with injustice compared with those with no problems with bride price (OR=1.9, 95% CI 1.2 to 2.9). The qualitative data shed light on these findings, in particular, highlighting associations of preoccupations with injustice related to war-related conflict, explosive anger and the burden of paying bride price. This quote also suggests that the payment of lia is sometimes bidirectional and related to the exchange of gifts, with the husband's family in this case wanting some of the lia in addition to the wife's family. After the 2006 violence (the internal conflict) we fled to W. When we were there, my husband's family wanted some of our money; they all want to share lia. This made me really angry and I was having regular attacks of extreme anger and being violent. --- Spousal conflict, family conflict and wider implications A dose-effect relationship again was evident when examining associations between the severity of problems with bride price and conflict with the husband (OR=5.7, 95% CI 2.5 to 13.0) and with the family (OR=4.1, 95% CI 2.3 to 7.5) (both associations, p<unk>0.01) (table 3). Specifically, rates of conflict with the male spouse increased from 9.9% for those who had no problems with bride price to 31.2% among those with the most serious problems with bride price, a threefold increase. In relation to conflict in the family, there was a fivefold increase (4.6-21.6%) in the dose-effect relationship between the lowest and highest category of problems with bride price (table 3). Qualitative data endorsed the quantitative findings on the impact of bride price on conflict with the spouse and the family, particularly in the context of poverty. Life is so hard but sometimes we have to contribute to lia, family members always force us to bring lots of money. It created problems between my husband and me, just because of no money. About lia my husband always complains. Every time we have lia my family always forces us (my husband and me) to give them goat and buffalo. This demand makes my husband and I always argue and angry with each other. Those to whom bride price was owed indicated that there was a reciprocally negative effect of the practice: I can't work because I'm too old. There is no money to participate in lia. Now my son and daughter look after me and there is no money for lia. I feel angry with them because they can't afford lia. This is our own tradition, we should do it. A younger participant indicated the competing demands created by bride price, especially in relation to caring for children: I don't like lia because it forces us to give a lot of money but normally I only give some because I have to first spend money on meeting the children's needs. I respect that this is our tradition, but we have to minimise it. The tension between modern world demands and cultural traditions added pressure on the family as indicated by this quote: Lia from my husband's family is very hard but now he is studying so they understand this condition but this is our tradition so it is impossible for us to avoid it all of the time. Resentment arose in trying to meet the demands imposed by bride price and dealing with contemporary family needs such as the costs associated with children's schooling: I think we all know that in Timor when a person dies all the family from both sides only think about tradition but they don't think about the children's future. Lia led to debt, forcing some families to borrow in order to meet their traditional obligations: In the village, our relatives force us to contribute to lia. In response to this demand we have to borrow money to give to them... even if it is very hard, but this is our tradition. --- DISCUSSION In spite of the widespread nature of the tradition of bride price in low-income and medium-income countries, ours is the first study to explicitly examine the association of the practice with women's mental health and the broader psychosocial factors that are known to be associated with distress among that gender group. 15 18 A focus on this issue is important given that safeguarding and promoting the mental health of women are essential to advancing gender equity and particularly the capacity of women to engage fully in development in low-income and medium-income countries that are affected by conflict. 27 Notably, there was a two-and-a-half-fold increase in sudden attacks of explosive anger, a twofold increase in excessive anger and a threefold increase in severe psychological distress when comparing women with the most severe problem levels with bride price with those with no problems with the practice. In those with the most severe problems with bride price, half of participating women had sudden attacks of explosive anger, three-fifths had excessive anger and nearly a third had threshold levels of severe psychological distress. As hypothesised, there was a strong association between problems with bride price and conflict with spouse and family. Compared with those with no problems with bride price, those with the most severe problems with the practice had a threefold increase in conflict with spouse and a fivefold increase in conflict with family. In addition, the mean poverty score was twice as high for women with severe as opposed to no problems with bride price. Women with the most severe problems with bride price had twice the level of poverty (mean=25.2 vs 12.6). Of interest too was that women with the most severe problems with bride price were more preoccupied with feelings of injustice, a factor known to be associated with explosive anger. 28 The strengths of the quantitative study are the large sample size, the systematic approach to recruitment and the high response rate. Women participating in the qualitative study were selected on a rational basis from the same database based on their high levels of explosive anger. The pattern of convergence between the data obtained from the quantitative and qualitative arms of the study adds support to the validity of our findings. The measures for psychological distress and anger were selected because these constellations of distress have been found to be common among women in previous studies in Timor-Leste. 15 The K10 measure of psychological distress is widely used across cultures and has been found in previous studies to function well as a proxy measure for depression. 23 The community measure for anger has been shown to converge with a gold standard structured clinical interview for IED. 22 Together, these measures provide a general index of mental distress, noting that the K10 includes commonly experienced symptoms of depression, anxiety and somatisation. 23 24 The anger and psychological distress measures have been shown to correlate with disability and dysfunction. 18 29 Limitations of the study are that it is cross-sectional in design, cautioning against drawing causal inferences regarding the relationships we found. It is possible that women with severe psychological distress are prone to focus excessively on the problem of bride price. Psychological distress may limit women's capacity to manage daily challenges which in Timor-Leste often concern economic hardships. Lia may represent one aspect of the duress caused by this broader economic stressor. In addition, the correlational nature of the data does not allow a conclusion to be drawn concerning directionality in judging the association between conflict with the spouse or family and bride price. Longitudinal studies are required to identify more precisely the sequencing of these factors, in particular, the extent to which resentment about bride price leads to psychological distress or vice versa. To some extent, however, our qualitative data address these issues by pointing to the complex interaction and compounding of stresses in generating distress among women. The descriptions women provided appeared to attest strongly to bride price playing an instrumental role in this outcome. While we were able to establish an association between bride price and family and spousal conflict, we did not include a measure specific to assessing intimate partner violence. In addition, we did not explore the psychological or social impacts of bride price for men, although, anecdotally, our experience in Timor-Leste suggests that the practice is a source of substantial stress on that gender group. Future studies should address the impact of bride price on the mental health of husbands and their families. Our findings are novel in pointing to a possible hidden source of mental distress among women in a postconflict country typified by Timor-Leste. Although the genesis of explosive anger among women is likely to be multifactorial (including exposure to male violence, past trauma and ongoing poverty caused by underdevelopment), the observation that bride price may contribute to this emotional response has important implications for the society. In particular, if the obligations imposed by bride price contribute to resentment towards the female partner by the husband and his family, then a vicious cycle may be set in train; poverty, resentment, heightened feelings of injustice, conflict with the spouse and family conflict may converge to intensify the women's emotional difficulties in a mutually reinforcing way, further exacerbating difficulties in the family. We have previously proposed a cycle of violence model for postconflict countries such as Timor-Leste in which past trauma exposure and patriarchal values contribute to violence against women, impacting adversely on the mother's mental well-being and the next generation. 30 In that regard, past qualitative analysis of this dataset found strong associations between explosive forms of anger among women and a tendency to respond excessively when disciplining children. 18 The present findings add a specific component to this model by identifying bride price as a possible contributor to the postulated cycle. Whether bride price represented a similarly serious problem for women in pre-conflict times in Timor-Leste cannot be determined by our study. It seems likely, however, that bride price has led to greater difficulties in the contemporary epoch because of the increasing tension between traditional customs and the rapid social changes that have been ushered in by modernisation, accelerated in Timor-Leste by external intervention in the country following the period of mass conflict. Disruption of traditional family and community networks during the conflict may have undermined to some extent the sense of obligation that the younger generation feels to extended families in the payment of traditional gifts, contributions and offerings. Changing expectations and priorities, for example, in relation to the roles and status

Objectives: Bride price is a widespread custom in many parts of the world, including in most countries in sub-Saharan Africa and parts of Asia. We hypothesised that problems relating to the obligatory ongoing remittances made by the husband and his family to the bride's family may be a source of mental disturbance (in the form of explosive anger and severe mental distress) among women. In addition, we postulated that problems arising with bride price would be associated with conflict with the spouse and family, poverty and women's preoccupations with injustice. Design: A mixed-methods study comprising a total community household survey and semistructured qualitative interviews.

este in which past trauma exposure and patriarchal values contribute to violence against women, impacting adversely on the mother's mental well-being and the next generation. 30 In that regard, past qualitative analysis of this dataset found strong associations between explosive forms of anger among women and a tendency to respond excessively when disciplining children. 18 The present findings add a specific component to this model by identifying bride price as a possible contributor to the postulated cycle. Whether bride price represented a similarly serious problem for women in pre-conflict times in Timor-Leste cannot be determined by our study. It seems likely, however, that bride price has led to greater difficulties in the contemporary epoch because of the increasing tension between traditional customs and the rapid social changes that have been ushered in by modernisation, accelerated in Timor-Leste by external intervention in the country following the period of mass conflict. Disruption of traditional family and community networks during the conflict may have undermined to some extent the sense of obligation that the younger generation feels to extended families in the payment of traditional gifts, contributions and offerings. Changing expectations and priorities, for example, in relation to the roles and status of women and the need to conserve funding for the education of children, may have lessened the motivation to pay bride price. The growth of the cash economy may have resulted in the inflation of bride price, creating conditions of long-term indebtedness in a setting of extreme poverty. Moreover, poverty associated with conflict has likely increased tension over resources and how they are spent. Other factors, not fully assessed in our study, such as changed expectations among women who have been educated, may add to resentment over bride price. For all these reasons, there may be a growing disjuncture between bride price as a functional custom designed to bond families together and the potential for that tradition to contribute to stress and family conflict. In clinical settings, in Timor-Leste and other lowincome countries, all health professionals working with women should be aware of the possibility that bride price may be a factor contributing to mental distress and family conflict (including the potential for intimate partner violence). Any family intervention for women experiencing emotional distress in low-income and medium-income countries needs to consider the relevance of bride price, even if resolution of the problem may be difficult to achieve within a strictly clinical setting. More generally, at a society-wide level, any remedies proposed to overcome the stresses associated with bride price in postconflict countries such as Timor-Leste need to be carefully considered given the complexities of the cultural issues involved. From a policy perspective, leaders are faced with the difficult challenge of respecting and upholding traditions in the society while, at the same time, acknowledging that some customs, such as bride price, have undergone a transformation in their practice that can lead to psychological distress and family conflict in ways that are antithetical to promoting the status and equality of women. At the same time, if cultural change is to be achieved in a harmonious manner, it will need to be approached sensitively and incrementally. In that regard, the process of change is likely to be expedited more by the natural effects of modernisation and the adoption of new values than by specific measures instituted by policymakers. Engagement by leaders with the community, raising awareness of the possible unintended adverse consequences of bride price and encouraging alternative avenues for recognising traditional obligations may be a more viable approach than a more assertive attempt to curtail the practice, for example, by legislation. --- Handling editor Seye Abimbola Collaborators Alola Foundation, Timor-Leste. Contributors SR conceived of the study, served as principal investigator throughout its execution and with DS and RT wrote the manuscript. SR, DS and RT received funding for the project. MM, AKT, DS, SR and SM managed and analysed the data. ES, SR and MF collected the data and conducted fieldwork. RT, SM, ES, MF, WT, SR, DS, MM and AKT were involved with contributing to revisions of the manuscript. --- Competing interests None declared. --- Patient consent Obtained. Ethics approval The University of New South Wales and the Ministry of Health, Timor-Leste. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Unpublished data have not been sought from outside parties; however, it may be available to them by negotiation. Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons.org/licenses/by-nc/4.0/

Objectives: Bride price is a widespread custom in many parts of the world, including in most countries in sub-Saharan Africa and parts of Asia. We hypothesised that problems relating to the obligatory ongoing remittances made by the husband and his family to the bride's family may be a source of mental disturbance (in the form of explosive anger and severe mental distress) among women. In addition, we postulated that problems arising with bride price would be associated with conflict with the spouse and family, poverty and women's preoccupations with injustice. Design: A mixed-methods study comprising a total community household survey and semistructured qualitative interviews.

Introduction Globally, disability has evolved as a major public health concern. The number of people living with a disability is increasing dramatically. Population ageing and the increase in chronic diseases are dominant factors behind inflated disabilities in the past few decades [1]. According to the World Health Organization (WHO), more than one billion people worldwide live with some form of disability, and about 190 million adults living with disability have considerable functional difficulties [2]. In Australia, an estimated 4.4 million people (18% of Australians) are living with disability, and of which nearly 1.4 million (32%) are living with a severe or profound form of disability [3]. Besides, a recent study discovered a 28 percent prevalence of selfreported disability among Australian adults [4]. Available evidence suggests that people living with disabilities have an increased risk for chronic diseases and poor health-related quality of life (HRQoL), mainly attributable to a high level of sedentary behaviour among people with disabilities [5,6]. Additionally, evidence suggests that persons with disabilities are more likely to rate their physical and mental health as poor or fair [7]. Apart from the direct costs, disability has indirect costs in the form of increased absenteeism [8], rising presenteeism [9], low job satisfaction [10], and high workplace discrimination [11]. Disability is a multidimensional concept denoting impairment in body functioning or structure, limitations in activity performance, and restrictions in participation [1]. Generally, people with disabilities have poor HRQoL [12], which is described as an individual's perceived level of physical, mental and social functioning [13]. Existing evidence suggests that people with disabilities are highly susceptible to chronic diseases, including cardiovascular diseases [14] and mental disorders [15]. The high prevalence of chronic diseases and comorbidities among persons with a disability has been attributed to increased levels of sedentary behaviour or physical inactivity [16,17]. In Australia, for instance, sedentary behaviour is the second leading contributor to the burden of cancer [18], which disproportionately affects persons with disabilities [19]. It is suggested that physical, psychological, and social functioning limitations among persons with disabilities promote sedentary behaviour and minimize physical activity [20]. Regular physical activity is associated with significant improvement in physical and mental health. Existing research indicates that engaging in the recommended level of physical activity helps prevent disability [4]. It also reduces the risk for chronic diseases and comorbidities, especially among people with disability [15,21]. For instance, a meta-analysis of 18 randomized controlled trials reported that physical activity significantly improved the cognitive function and quality of life of people suffering from dementia [22]. Likewise, a meta-analysis of 39 randomized controlled trials of adults with mental illnesses found that physical activity significantly reduced depressive symptoms among people with mental illnesses [23]. A randomized controlled trial of persons with spinal cord injury found that regular exercise improved muscular strength, reduced pain and depression, and improved quality of life among the experimental group [24]. Another recent study reported that substituting 1 hour per day of sedentary behaviour with physical activity significantly improved the physical functioning of colorectal cancer survivors [25]. Although physical activity is vital to the health and quality of life of persons with disabilities, most physical activity programs do not target people with disabilities [14]. Many people with disabilities continue to experience multiple barriers to participate in physical activities [21]. Meanwhile, compared to the general population, people with disabilities tend to gain enormously from physical activities, especially in improving cognition and physical functioning [22,24]. Therefore, the WHO included physical activity recommendations for people with disabilities in its latest guidelines on physical activity and sedentary behaviour [21]. Despite several efforts to increase physical activity among Australians, the rate remains low, especially among people with disabilities [3]. For instance, a recent survey revealed that 72% of adults with disabilities in Australia do not perform the recommended level of physical activity [3]. Previous studies primarily targeted the aged population [26] or individuals with disabilities associated with specific conditions such as multiple sclerosis [27] or spinal cord injury [28] while capturing the relationships between disability and HRQoL. Thus, there is a limited information on the longitudinal association of disability and physical activity with HRQoL. Therefore, the present study examines the association between disability and physical activity with HRQoL among the Australian adult population using longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) survey. Understanding how physical activity and disability are related to HRQoL could help form policies to improve the HRQoL and may serve as the input for future economic evaluation for decision-making while allocating resources for effective health interventions. --- Methods --- Data description and sample The study used data from the HILDA survey which commenced in 2001. The dataset covers information on subjects' wealth, labour market outcomes, household and family relationships, fertility, health, and education. A multistage sampling approach was used to select an initial sample. Firstly, a probability proportional to size sampling technique was initiated to select 488 Census Collection Districts (CDs). Each of the districts covers approximately 200-250 households. Secondly, a sample of 22-34 dwellings was randomly selected from each of the CDs. Finally, a maximum of three households from each dwelling was selected, resulting in a total of 12,252 households. Since 2001, the annual data accumulation covers household members aged 15 years and over as a sample. Face-to-face interviews and telephone interviews by trained enumerators were used for data collection. A self-completed questionnaire following the University of Melbourne's ethical guidelines is used in this regard. The sample was further expanded over time. It includes any child born or adopted by groups of respondents or by any new household member resulting from adjustments of the composition of the originating households. Therefore, the annual coverage of the survey is more than 17,000 Australian adults. The details of the sampling procedure, study design and data collection strategies of the waves have been explained elsewhere [29]. Fig 1 shows participants' flow into the final analytic sample and missing data. This study utilized 19 waves of data (waves 2 through 20), spanning 2002 to 2020. These 19 waves contain detailed information on participants' socio-demographic, disability status, and physical activity, along with HRQoL information collected through the SF-36 questionnaire. To avoid the potential bias, missing observations on the outcome variable (HRQoL) and main variables of interest (disability and physical activity) were excluded. The final analytic sample consists of 247,457 person-year observations from 29,973 unique participants. --- Outcome variable The health-related quality of life (HRQoL) was the outcome variable of this study. Information on HRQoL was collected through the SF-36 questionnaire. It contains 36 questions. The taxonomy of SF-36 encompasses three levels, e.g., items, aggregate scales, and summary measures. The items are mutually exclusive. One single item is considered for scoring one scale only. These items help with the formation of eight aggregate scales, i.e. physical functioning (PF), role physical (RP), role emotional (RE), social functioning (SF), mental health (MH), vitality (VT), bodily pain (BP), and general health (GH) [30]. There is no avenue for trading off these eight domains. Each of them has unique importance. Basically, items are standardized by applying a scoring algorithm that ranges between 0 to 100. A higher score indicates better HRQoL [31]. In the last taxonomy, these eight dimensions of HRQoL are transformed into two higher-ordered clusters of summary measure, i.e., the physical component summary (PCS) and the mental component summary (MCS). The PCS and MCS transformation from the eight aggregate domains are ensured by deploying an orthogonal factor model. Here, the physical domains were weighted positively, and the mental domains were weighted negatively (vice versa). It implies a better state of mental health lowers the PCS and vice-versa [13]. Hence, a well recommended standard scoring algorithm was followed and standardized by linear Z-score transformation with a mean of 50 <unk> 10 (SD). The value of PCS and MCS ranged between 4.54 to 76.09, and -1.21 to 76.19, respectively. A higher score indicates better HRQoL [32,33]. This study also considers SF-6D, an alternative preference-based generic measure of health utility index. It estimates the respondent's choice for health status. It enables the estimation of a utility score by using SF-36 responses [34]. This is an 'off-the-shelf' measure retrieved from a set of readily available preference values from general people. 'Standard Gamble' (SG) technique is applied for the preference elicitation. This method measures the health utility from six different dimensions (constructed from SF-36), namely, physical functioning, physical role limitations, emotional role limitations, impairment of social functioning, body pain, and vitality [35]. These six domains conceive 11 items retrieved from SF-36. SF-6D considers the willingness of an individual to accept the risk of death to current living discomfort (or enjoy living in good health status with no physical and mental impairment). The SF-6D score ranges from 0.29 to 1. Here, 1 is considered as full health (all the dimensions are in the best state), and 0.29 demonstrates the worst health condition (equivalent to death) [36]. --- Exposure variables Disability and physical activity are the primary exposures. HILDA survey defines disability by following the guidelines of the International Classification of Functioning, Disability and Health (ICF) under the WHO framework [8,37]. A show card listing 17 types of disability was used for assessing the presence of disability [8]. The HILDA survey collects information on participants' disability status by asking, "is there any form of physical impairment hindering your everyday activities that lasted or expected to last for six months or more?" [38]. The responses were taken in binary form (yes versus no). Another key variable of interest is physical activity. Each of the waves of the HILDA survey to date includes data on physical activity. It intends to assess the respondent's extent of engagement in physical activity [39]. Each year a self-completion questionnaire is formed to calculate the frequency of physical activity/ per week. Participants were asked, ''In general, how often do you participate in moderate or intensive physical activity for at least 30 minutes?" [33]. The prospective answers were pre-coded into six categories: 'no involvement at all; less than once a week; 1 or 2 times a week; three times a week; more than thrice a week (but not every day) and every day [40]. Such clustering targets to capture the optimal frequency of Australian adults' involvement in physical activities. The categories were further collapsed into two clusters: less than the recommended level (no involvement at all, less than once, 1-2 times, and three times a week), and recommended level (more than three times a week, and every day). --- Potential confounding factors This study included potential confounding factors following previous literature on HRQoL, disability, and physical activity [41,42]. The potential confounding factors plugged in the statistical analyses were age, gender, relationship status, highest education level completed, household yearly disposable income, labour force status, Indigenous status, region of residence, smoking habit, and alcohol consumption. Table 1 presents the set of potential confounding factors with their nature and categories. For example, age was initially a continuous variable but collapsed into four categories: 15-29, 30-44, 45-59, and 60 years. Other confounding factors considered for the present study were gender (male versus female), relationship status (single versus couple), education (year 12 and below, certificate courses, and university degrees), household income (1 st to 5 th quintile, which indicates lower income group to upper-income group in order), labour force status (employed, versus unemployed or not in the labour force), Indigenous status (not of Indigenous origin versus Indigenous origin), and region of residence (major city versus regional or remote area). Further, the research considered the inclusion of two health-related characteristics, i.e., smoking habit (never smoked, former smoker, and current smoker), and alcohol consumption (never drunk, ex-drinker, and current drinker). --- Estimation strategy A longitudinal data covering 19 waves consisting of 29,973 (247,457 person-year observations) Australian de-identified adults were studied in this analysis. This research reported frequency (n), mean and standard deviation (SD) for the continuous variable, and percentage (%) for the categorical variables. The summary measures (PCS and MCS) and SF-6D utility score, as well as the scores of the eight dimensions of SF-36, were explored from the disability and physical activity lens. This study formed the following multivariate regression model to investigate the association between disability and physical activity with HRQoL. HRQoL it 1<unk>4 a i <unk> b 1 Disability it <unk> b 2 Physical activity it <unk> Y i SX it <unk> m it <unk> <unk> it<unk>1<unk> In Eq 1, HRQoL it stands for i th respondents' health-related summary measures of life quality over the t th time horizon (2002 to 2020). It covers PCS, MCS, and the health utility index (SF-6D), as well as the subscales of SF-36. <unk> i (i = 1 to n) refers to the unknown intercept for --- Household yearly disposable income Quintile 1 (poorest), quintile 2 (poorer), quintile 3 (middle), quintile 4 (richer), and quintile 5 (richest). Labor force status Employed, and unemployed or not in the labour force (NLF). Indigenous status Not of Indigenous origin, and Indigenous origin (Aboriginal, Torres Strait Islander, and both Aboriginal and Torres Strait Islander). --- Region of residence Major city, and regional or remote area (inner regional, outer regional, remote and very remote Australia). Smoking status Never smoked, former smoker and current smoker (smoke daily, smoke at least weekly, and smoke less often than weekly). --- Alcohol consumption Never drunk, ex-drinker, current drinker (only rarely, 1-2 days, 2-3 days, 3-4 days, 5-6 days per week and every day). https://doi.org/10.1371/journal.pone.0268304.t001 each entity (n entity-specific intercepts). Disability it and physical activity it delineate the key variables of interests, disability status and physical activity, respectively, where i = entity, t = time, and <unk>1 and <unk>2 are the coefficients for that exposures. X it demonstrates other confounding factors. <unk> it refers to between-entity error and <unk> it indicates within-entity error. This analysis fitted eleven different models, particularized by the following outcome variables: PCS, MCS, SF-6D, PF, RP, RE, SF, MH, VT, BP, and GH. Based on the nature of the dependent variables, this study deployed the random-effects GLS regression technique. Interpretation of the coefficients obtained from the random-effects GLS regression technique are tricky since it captures both the within-entity and between-entity effects. For the present study, the regression results will show the average effect of disability and physical activity over HRQoL when disability and physical activity change across time and between persons by one unit. This study considers a variable statistically significant if the pvalue is <unk>0.05. Stata version 17.0 (Stata SE 17, College Station, TX: StataCorp LLC, USA) was used to accomplish the analysis of this study. --- Ethics approval The HILDA survey commenced in 2001, and since then, the survey has been conducted annually following the University of Melbourne's ethical guidelines. This research project has been approved by the Human Research Ethics Committee of The University of Melbourne. The ethics ID number of the research project (HILDA Survey) is 1647030. This paper uses unit record data from the HILDA conducted by the Australian Government Department of Social Services (DSS). This study did not require ethical approval as the analysis used only de-identified existing unit record data from the HILDA survey. --- Results Table 2 shows the baseline, final, and pooled socio-demographic and health-related characteristics of the study sample (persons = 29,973; observations = 247,457). Over 50% of the participants were aged between 15-44 years, were female (53%), and were coupled (60%). Of the total, 25% had university qualifications, 65% were employed, 97% were non-Indigenous, 66% lived in major cities, 54% never smoked, and 82% currently drink alcohol (pooled in all waves). Table 3 displays the distribution of the analytic sample's subjective health scores, as well as their disability and physical activity status. The mean PCS, MCS, and SF-6D scores derived from the SF-36 were 49.39, 48.35, and 0.76, respectively. The results also show that the average score on four of the eight dimensions of the SF-36 was below 76 points: MH (73.75), VT (59.41), BP (72.91), and GH (67.96). As can be seen, 27% of adults have some form of disability, and nearly 34% of the study sample performed recommended level of physical activities per week (pooled in all waves). Fig 2 displays the mean scores of the measures of HRQoL by the respondent's disability status in each wave. Substantially low mean scores in the SF-36 subscales (8 dimensions), summary measures (PCS and MCS), and health utility index (SF-6D) have been observed among respondents who had a disability. For example, the mean PCS, MCS, and SF-6D scores among disabled participants (40.26, 45.06, and 0.67, respectively) are much lower compared to their counterparts without disability (52.82, 49.59, and 0.79, respectively) in wave 20. Fig 3 presents the mean PCS, MCS, and SF-6D utility scores by physical activity in each wave. The figure clearly illustrates that participants who undertook recommended level of physical activity had significantly higher average PCS, MCS, and SF-6D scores than those who engaged in less than the recommended level of physical activity per week. For example, the mean PCS, MCS, and SF-6D scores among the participants performing recommended level of physical activity (51.56, 50.58, and 0.79, respectively) are much higher compared to their counterparts engaged in less than the recommended level of physical activity per week (48.26, 47.21, and 0.74, respectively) in wave 20. Annual (waves 2002-2020) mean SF-36 domains score by disability status and physical activity were presented in S1 Appendix. Table 4 represents the random-effects GLS estimation of the association between disability and physical activity with the SF-36 component summary measures and health utility index. The results revealed that PCS (b = -5.95) and MCS (b = -2.70) scores declined by 5.95 and 2.70 units among respondents with disability compared with non-disabled counterparts. Besides, the results showed that disabled people scored six percentage points lower on the SF-6D scale (b = -0.060) compared with peers without disability. However, the estimates demonstrate a statistically significant and positive association between undertaking the recommended level of physical activity and HRQoL. For example, performing the recommended level of physical activity per week was associated with substantial gains in PCS (b = 0.96), MCS (1.57), and SF-6D (0.021) scores. Table 4 also reports a statistically significant association between the interaction of disability and physical activity with component summary measures and health utility index. The results showed that PCS, MCS and SF-6D scores have increased in disabled adults performing the recommended level of physical activity by 1.84 points, 0.82 points, and 0.013 percentage points, respectively, than their non-disabled counterparts engaged in less than the recommended level of physical activity. The association between disability and physical activity with the SF-36 domain scores is shown in Table 5. People with disabilities have considerably lower scores in each of the SF-36's eight sub-scales: PF (b = -11.08), RP (b = -23.17 recommended level of physical activity than their non-disabled counterparts who engaged in less than the recommended level of physical activity. --- Discussion This study examined the association between disability and physical activity with HRQoL among the adult population in Australia using data from the HILDA survey. The findings showed that 27% of the adult population in Australia has some form of disability, and about 34% perform the recommended level of physical activity. The study findings revealed that disability and physical activity were independently associated with HRQoL. Specifically, people who had a disability and those who did not meet the recommended level of physical activity had substantially lower HRQoL than those who had no disability and those who completed the recommended level of physical activity. The nature of these relationships did not change even after controlling for potential confounding factors. This study reveals a strong association between disability and a low score of HRQoL. The scores of HRQoL for the disabled on PCS, MCS, SF-6D and in each of the eight subscales of the SF-36 are smaller than those without disability. Similar associations between disability and HRQoL were reported in Australia [43] and North America [44]. One plausible reason for the association between disability and low HRQoL is the high perception of poor physical health due to the limitations in the performance of physical functions [43]. For example, an earlier study found that limitations in the performance of activities of daily living such as hygiene and dressing were major contributors to low HRQoL among persons with upper limb post-stroke spasticity [44]. Similarly, another study reported that limitations in self-care activities and functional mobility were the strongest predictors of poor HRQoL among people living with idiopathic Parkinson's disease [45]. Since HRQoL largely represents people's expectations of their health relative to what they actually experience, any perceived or actual limitation in bodily function will be seen as poor health and result in low HRQoL [46]. Thus, promoting active coping mechanisms with increased performance of physical activities, including activities of daily living, could improve physical functioning and HRQoL among persons with disabilities [47]. Also, findings from this study revealed that physical activity was positively associated with HRQoL. It means recommended levels of physical activity were associated with a significant increase in HRQoL and vice versa. Similar associations between physical activity and HRQoL were recorded in studies conducted in Spain [26], the UK and elsewhere [12,48]. The probable reason could be regular physical activity enhances the sense of control, physical fitness and functioning [24,49,50]. Additionally, physical activity is associated with considerable mental stimulation and improvement in psychological health [49]. Perhaps, respondents who met the recommended level of physical activity in the current study might have gained some physical and psychological benefits associated with physical activity as manifested in the higher PCS, MCS, SF-6D and SF-36 scores compared to those who did not meet the recommended level of physical activity. Although this finding does not infer causality, it provides yet another strong evidence on the possible impact of physical activity on HRQoL. --- Strength and limitations The main strength of this study is the large sample size and longitudinal nature of the study. This study utilizes 247,457 person-year observations using the most recent 19 waves of the HILDA survey spanning the period (2002-2020) to examine the association between disability and physical activity with HRQoL among adults in Australia. Despite these strengths, there are some limitations of this study. First, because the current study used unbalanced longitudinal datasets for the analysis, the findings only suggest an association between disability and physical activity with HRQoL, and inferences on causal relationships cannot be made based on the findings. However, the consistency of the current findings across different measures of HRQoL supports the need for further studies into the causal relationships between disability and physical activity with HRQoL using balanced longitudinal data. Second, previous studies reported that different forms of disability have a different impact on HRQoL [44]. However, in the present study, disability was not classified into forms or types, and therefore, the influence of different types of disability on physical activity or HRQoL could not be ascertained. Also, because the level of physical activity was self-reported, there is a possibility of social desirability bias which could affect the interpretation of the study findings. Additionally, one significant confounding variable in the association between physical activity and HRQoL is chronic disease [12]. However, this was not controlled for in the present study, limiting the interpretation of the study findings. --- Policy and public health implications This study builds on existing knowledge about the relationship between disability and physical activity with HRQoL. The findings highlight the importance of physical activity as a public health strategy to improve the quality of life among persons with disabilities. Therefore, stakeholders need to design and implement intervention programs that will increase participation in physical activities among adults. Such intervention programs should be targeted at raising awareness of the potential benefit of physical activity to adults. Additionally, certain types of physical activities may not be appropriate for certain types of disabilities, limiting participation or endangering health. Hence, engaging health professionals in determining the appropriate type and amount of physical activity could enhance participation and ensure safety [21]. --- Conclusion This study provides further evidence on the association between disability and physical activity with HRQoL using 19 waves longitudinal data from the HILDA survey. The findings revealed that disability negatively contributed to HRQoL, but increasing physical activity levels were associated with significant improvement in HRQoL. Therefore, there is a need to enhance public health intervention programs such as educational campaigns and engaging health professionals to promote physical activity. This could increase participation and thereby improve HRQoL. However, to what extent a different pattern of physical activity involvement is associated with better HRQoL and what pattern of physiotherapy will be more fruitful is beyond the scope of this paper. This aspect can be a further research option to be explored by the scholars. paper, however, are those of the authors and should not be attributed to the Australian Government, DSS, or any of DSS contractors or partners. DOI: 10.26193/OFRKRH, ADA Dataverse, V2." --- Availability of data and materials The data used for the study were collected by the Melbourne Institute of Applied Economic and Social Research. There are some restrictions on accessing this data and it is not available to the public. Those interested in accessing this data should contact the Melbourne --- Supporting information --- S1 Appendix. (DOCX) --- Author Contributions Conceptualization: Syed Afroz Keramat. --- Data curation:

Any form of long-term physical or mental impairment might negatively influence healthrelated quality of life (HRQoL). HRQoL, as an independent concept, covers a wide range of characteristics that includes physical, mental, social, and spiritual functions. People with disabilities are continuously exposed to multiple barriers that deteriorate their HRQoL. It also creates impairment in performing physical activities. However, experts opine regular physical exercise as an intervention to help disabled people. This research aims to investigate the association between disability and physical activity with HRQoL among the adult population in Australia.A retrospective cohort study.This study utilized the most recent 19 waves of data (2002-2020) from the nationally representative Household, Income and Labour Dynamics in Australia (HILDA) survey. Component summary scores such as physical component summary (PCS) and mental component summary (MCS), and SF-6D utility scores were utilized to measure HRQoL. Randomeffects GLS regression technique was fitted to estimate the association between disability

Introduction There has been a plethora of research utilizing research epistemology as a conceptual tool to explore how knowledge has been produced and/or reproduced in higher education and its linkages to hidden global geopolitics and historical forces. Engaging the self in the process of doing research portrays the researcher's ontology and epistemology subtly. It lends something profoundly beyond the merely static, enclosed insider's perspective of the researcher and has shifted attention toward the researcher's self as the primary instrument of inquiry and, thus, the best source of knowledge about the social world (Bednarz, 1985). Correspondingly, it permits the richness and complexity of everyday life portrayed through complex, symbolic language and personal narratives (Foley, 2002). Similarly, Wall (2006), in her article on autoethnography, argues "an individual is best situated to describe his or her own experience more accurately than anyone else." Several scholars have spoken of the importance of situating the "I" narrative; turning the researcher into a subject of representation; and using autoethnography as a useful alternative self-inquiry line of research to challenge the dominant, longstanding, powerful positivism in traditional research (Jackson & Mazzei, 2008;Pitard, 2017;Tilley-Lubbs & Bénard, 2016). In another landscape, Canagarajah and Silberstein (2012) mobilizes postcolonial perspectives and autoethnographic inquiry into English language acquisition and the diaspora's identities. This body of research on ethnography and engaging the researcher self 1 3 as a research inquiry has added a significant dimension to this paper. And yet, unpacking the researcher's epistemology and ontology is never an easy task. This burden appears to be doubled when the researcher has crossed the borders and lived and worked abroad for a long period of time. "Educators working in international contexts encounter these ontological and epistemological borders daily and are brought to grapple with the role of Otherness in their scholarly practices," writes Kester (2021). In a similar vein, Bhabha (1987), upon deconstructing a diaspora's identities, stresses the importance of understanding the secret art of invisibleness to portray the absence of the identity of these diasporas. Unfortunately, their lives are located in the in-betweenness where their sense of who they are and which country they belong to seem to be blurry, and they are not yet entirely subscribed to either the host country or the country of their origin. This in-betweenness/third space generates two indefinite "moments of being"-identities. As a result, the invisibleness of the diaspora's identity, argues Bhabha (1987), is nailed by segregating two indefinite "moments of being" into a hybrid form. Their incommensurable differences between their core identities (their sense of self) are signified throughout this repetition process, between which the missing person/the Otherness is identified and thus appended with its significant (cultural) meaning. Often, these diasporas appear to struggle with two coexisting identities-the Self/the Otherness-day in and day out without having a clear idea which one they subscribe to (1987). Again, Bhabha's proposition on the diaspora's struggle of being Self-versus Otherness intersects with and is indeed mirrored in what Kester (2021) warns is the ontological and epistemological boundaries of Otherness in the scholars' lived experiences and research practices. Undoubtedly, Bhabha's prolific work has contributed significantly to postcolonial studies on the black diaspora's identity and subjectivity. This foregrounds the core of subsequent work on hybridity, postcolonial identities, and subjectivities. However, his work did not seem to interpolate the specificity and particularity of geographical location, which allows richness and depths of narrating postcolonial lived experiences and the subtle colonized mentality, as well as the contradictory mix of feelings (e.g., fantasy, seduction, resistance, oppression, and agonies featured by a plethora of postcolonial scholars such as Chen (2010), (Nguyen & Lehy, 2015). Additionally, Bhabha adequately addresses the totalization of hegemonic global theory. For example, Kuan-Hsing Chen (2010) examines the tension between the colonizer and the colonized subjects in East Asian countries. The scholar problematizes the Self-Other dichotomy by indicating that although accepted as one of the most popular postcolonial conceptual tools, the Self/Other binary-often used to address the differences between the Self (the colonized) and Other (the colonizer)-is inherently slippery. It delineates the continuation of colonialism, irrespective of its geographical location, and challenges the traditional, Western-centric ways of interpreting postcolonial subjectivity and identities. The dichotomy of Self/Other is not often perceived as easily as it appears. Nor is it as crystal-clear as is commonly speculated in the research literature, warns Chen (2010). This paper is foregrounded in the postcolonial work on Self/Other, as aforementioned, and/or the dichotomy of Self/ Other and the structure of feelings of the colonized [desire, fantasy, ambivalence, agony, and resistance, which will be elaborated in depth in the subsequent sections]. Further, it features an autoethnography research approach by narrating two paralleled and intersecting personal journeys of two academics who were formerly international PhD students in Australia and Canada, respectively. Nhai was an international PhD student in an Australian university and, thereafter, a globally mobile educator and part of the Vietnamese diaspora in Australia. It portrays in depth how she, a global educator, juggled at the edge of in-betweenness, that is, the East/West ways of thinking and doing, struggled to redefine her being invisible Otherness in research practices, and overcame the predetermined conditions of knowledge production dominated by Western centricity. Yeow-Tong was an international PhD student at a Canadian university and-similar to Nhai-was a globally mobile educator and a part of the Singaporean diaspora in Australia. He critically reflected and historicized his educational and intellectual experience and decolonizing journey, with passing references to his struggle of being Otherness in the discursive fields in the History of Education, comparative education, and Asian Studies. The paper aims to answer two key questions: What types of ontological and epistemological transformations might educators experience during long-term periods abroad? and How might these transformations initiate decolonial moves in regard to educational pedagogy, policy, and practice? Toward unpacking our answers to these questions and demonstrating our personal lived experiences through autoethnography texts in this paper, we are inclined to alert novice researchers to the danger of being locked into Western colonized "imaginaries" and a compliant research imagination, as warned by Kenway and Fahey (2008). This compliant research imagination traps the researchers into deploying secondary imagination, which is purely "reproductive, imitative, or combination imagination" (Kenway & Fahey, 2008, p. 9). This particular type of research imagination does not assist the researchers in thinking beyond the box and identifying their relationship in authority with knowledge. Therefore, our journey of shifting from a compliant research imagination toward a defiant one is akin to the journey of decolonizing our research ontology and more challengingly transforming our research epistemology in our everyday practices. --- Autoethnography as a gateway to unpack researchers' ontology and epistemology Initially, the Oxford Advanced Learner's Dictionary defined ontology as a branch of philosophy or the science of what is. It attempts to clarify or explain the nature of existence. Similarly, Crotty (1998, p. 10) defines ontology as "the study of being." Ontology deals with the structure of reality as such. Additionally, epistemology, a prominent theoretical perspective, is viewed as a way of looking at the world and making sense of it (Crotty, 1998, p. 8). It is constituted of knowledge, and it embodies a certain understanding of what is entailed in knowing, that is, how we know what we know. Echoing the intellectual work of Hamlyn (1995) and Maynard (1994), Crotty (1998) equates epistemology with the essence of knowledge, its possibilities, its scope, and its general basis. It serves as a philosophical basis for identifying what types of knowledge are possible and in what ways we can assure that they are sufficient and legitimate. Both ontology and epistemology are fundamental and thus conditional to shaping a robust theoretical perspective in social research. Crotty's work on ontology and epistemology is significant in this research. It foregrounds ourselves as an object of inquiry in this research to gain insights into an understanding of ourselves (who we are-our identities) and what we know (our ontology) and critically identifies the types of knowledge we own and their hidden linkages to postcolonialism and our structure of feelings attached to these knowledges. In addition to conceptualizing epistemology and ontology, we adopt autoethnography as a dominant research approach. It ascribes ethnography as a process and a product. First, according to Ellis et al. (2011), autoethnography is regarded as a research approach and writing in which the author narrates in depth personal experiences systematically to make sense of cultural experiences. This research approach stems from autobiography, in which the researcher retroactively and selectively writes about past experiences, namely, epiphanies-the moments which hold significant meanings fundamental to a person's life. Additionally, in ethnography, a researcher studies relational practices, common values and beliefs, and shared experiences to assist both cultural insiders -those belonging to a culture -and outsiders, those who are considered strangers to that culture. Thus, an autoethnographic researcher often narrates, both retrospectively and scrupulously, the epiphanies rooted in a particular culture through being a member of this culture and/or having a specific cultural identity (ibid.). Viewed in this manner, ethnography is equated with a process. Also, ethnography is considered a product when it plows a thick description of a culture and facilitates and improves and deepens understanding of a culture for both insiders and outsiders while portraying a robust narration of personal experiences. Essentially, throughout this process, ethnographers move back and forth between the first/second person to the third person in telling the stories and in their ethnographic texts (Ellis et al. 2011). In a similar vein, in his prolific work entitled "Critical Ethnography: The Reflexive Turn," Foley critically writes that "the act of writing itself becomes a way of being and knowing" (2002, p. 475). Following Foley's line of argument, engaging the self in the process of doing research and thereby writing vividly depicts the researcher's ontology-what we know as well as epistemology, which is how we know what we know (Pitard, 2017). Specifically, shifting the focus to themselves and turning their self into an object of inquiry, the researcher investigates in depth their existence, their being (who they are), and what they know (their knowledge) through observing and narrating their lived experiences and social realities. This is indeed an inside-out process leading to the journey of exploring the dimensionalities of the researcher's being or their ontology. More importantly, the researcher's self-embeds the various, subtle ways in which it becomes an act of writing about self. Moreover, autoethnography permits the richness and complexity of everyday life through the lens of "complex, symbolic language and dramatic, personal stories" (Foley, 2002, p. 475). Toward interpreting Pitard's synthesis of epistemology, it becomes clear that ethnographers deploy everyday life and connotative language, which is much more robust, embodied, and situated in a particular sociocultural historical context. In this paper, the scholars deploy this language to induce a richer narration of the researcher's personal lived experiences and thereby assist in interpreting the complexity of these experiences and the hidden links of their knowledge to global geopolitics. They ironically identify the types of knowledge they own and uncover which ones are globally legitimated while others are marginalized. Moving beyond epistemology, these researchers use critical ethnography and narration to describe how their research imagination has been colonized-for instance, in this paper, throughout the PhD journeys of Nhai and (Yeow-Tong)-the journey of reshaping their defiant research imagination. Taking Foley's synthesis as the departure of this research, our point is to provide critical accounts of our personal stories of two diasporic academics (Nhai and Yeow-Tong) living and working permanently in Australia. This autoethnography is expected to lend something profoundly beyond the merely static, enclosed insider's perspective. This ethnographic line of inquiry reveals the two secret moments of being: as both insiders of their cultures, be they Vietnamese and Singaporean, and outsiders in the Australian context, as well as in their research practices and knowledge construction. In doing so, both diasporic scholars turn themselves into an object and an instrument of inquiry. Bednarz (1985) echoes this argument, emphasizing that the researcher self should be seen as the primary instrument of inquiry and, thus, the best source of knowledge about the social world. Autoethnography validates the values of the researchers as being self-referential, which is not inducible to culturally bounded and theoretically detached native informants. Rather, it serves as a catalyst for a transcultural, reflexive research subject who engages in "a reflexive move of understanding themselves as agents and subjects of transculturation, and of imagining fieldwork as a site where transculturation occurs" (Butz & Besio, 2009, p. 1663). Nhai and Yeow-Tong located themselves in a continuum of being both agents of signification (academics) who strive selfconsciously to understand themselves as an important part of what they are signifying and objects of signification in which they involve themselves as authors in public acts of self-representation. Apart from that, narrating personal experience becomes seen as one of the major lines of our research inquiry. The act of self-narration, defined by Denzin (1989), describes the representational practice where social scientists operate their dual identities-their academic and personal selves-to tell autobiographical stories about aspects of their experience in daily life (Butz & Besio, 2009, p. 1665). Here, we, submitting to self-narration, utilize different circumstances to understand the wider social and cultural phenomena occurring in both our home countries (Vietnam and Singapore) and the host countries (Australia and Canada), which involve but exceed ourselves in portraying our ontologies and epistemologies in research practices. Situated in these particular contexts, our personal narrative writing becomes a representational strategy that incorporates affection and emotion into our analysis-to echo Butz and Besio's phrases. Following these scholars' synthesis, we radically move from being agents who are already incarnated with an array of specific cultures and social practices to being an object of signification which requires us to distance from ourselves and the surrounding and turn them into objects of critical inquiry and analysis. Casting on our personal experiences is then similar to dancing within and between spaces of a researcher and the researched, allowing us to turn the twilight on both being an objectification and subjectification of signification, a storyteller and a protagonist of our research project. This marks such a candid moment where the "cultural Other" has been detected and, consequently, detached from the researcher self and becomes visible for analysis. Additionally, our personal experience is framed as a "contextual given" in which, as Clandinin and Connelly (1994) note, personal stories are of significance. It is because these personal stories carry the duality of "raw sensation" and the cultural form-a cluster of social construction or conventions associated with the existing patterns of activities-which surpass the personal and social history. Positioning ourselves as diasporic scholars in the specific contexts of Australia and/or Canada and utilizing the lived experiences as a major standpoint of reference in research design, data collection, and data analysis, we aim to manifest the raw sensation of our stories via the first-hand, vivid, and emotional life experiences accompanied by a unique structure of feelings, emotions, affection (to be discussed shortly). More importantly, these stories embody the cultural forms in a particular society in which we live and work. French sociologist Pierre Bourdieu (Foley, 2002) urges researchers to be vigilant against the ways in which the practices and discourses of their own discipline secretly influence how they think and write (epistemology). Notably, an ethnographic study conducted by Woolgar andLatour (1978, cited in Foley, 2002) on a biomechanical laboratory uncovers the overlapping and crisscrosses of being a physical scientist and an ethnographer in the politics of the lab and their discipline expertise. These scholars conclude that "in this type of reflexivity, the author also consciously situates her representational practices within the disciplines of past knowledge constructions. Such an interpretive move makes transparent the socially constructed, historically situated nature of the authors' facts, thus the partiality of their truth claims" (Foley, 2002, p. 476). This example also resonates with our personal experiences of living and working in our disciplines and how we struggle with these nebulous boundaries of ontologies and epistemologies in research practices in Australia. However, drawing our research solely on autoethnography cannot fully serve our purposes in this paper partly because it poses the dangers of locking ourselves in the Western conceptual framework of autoethnography dominated by Western practices. Additionally, we are prone to doing injustice to the complexity of our research, that is, the socioeconomic and historical contexts in which we grew up and the one in which we live and work. Importantly, we become caught in the relentless struggle to find a research voice in this well-established education and comparative history in Australia, and above all, how we can construct a defiant research imagination instead of a compliant one. There emerges postcolonial thinking on Self/Other and Asia as Method in the forthcoming section to assist us in navigating this challenging research journey and getting closer to a defiant research imagination. --- Self/other in postcolonial thinking Toward disentangling researchers' ontology and epistemology, we find postcolonial thinking on the Self/Other dichotomy and/or binary highly influential because it offers a powerful conceptual framework to interpret self and identity. --- 3 Postcolonial lens into the Self/Other attempts to understand the ways in which the colonized and the colonizer represent themselves via the lens of the binary/dichotomy of Self/ Other. Self refers to the colonized subject; other denotes the colonizer. Akin to the reciprocity between Yin and Yang in Chinese culture, the Self and Other conditions are thus conditional to one another. The Self cannot be defined without being referenced to the Otherness and vice versa. Within the context of our paper, Self is also used to refer to the globally mobile Asian diasporic scholars [Nhai and Yeow-Tong], whereas Otherness is closely linked to their Western counterparts. Postcolonialism contextualizes the colonizer's perception of self and lends an exceptional lens into unraveling its identity by depicting the subtle, daily lived experiences of the postcolonial subject that co-construct the system of feelings and track their identity trajectories. Bhabha's powerful work Interrogating Identity validates the postcolonial Self/Other and the journey of shaping postcolonial identity. Locating his identity analysis within the postmodern context, Bhabha speaks of postcolonial identity and the problem of frame. The scholar argues that "the space of representation, where the image-missing person, invisible eye, Oriental stereotype-is confronted with its difference, its Other" (1987, p. 5). Following Bhabha's line of argument, differences exist in this dichotomy between the stereotyped Oriental Self/the Invisible and the Other [the Western]. Therefore, seizing an identity names the invisible with a representation of the self by disrupting the stability of the ego. Self is elucidated in the sameness of image and identity: the secret art of the invisible has altered the terms of our recognition of the "person," Bhabha (1987) emphasizes. The scholar urges us to critically capture the secret art of invisibleness to grasp the absence of identity. This, argues the author, is accomplished by splitting two moments of being in the hybrid form, their incommensurable differences signified in the repetition process, between which space and time the evil eye or the missing person, called Bhabha, is appended with its (cultural) meaning. --- Hybridity Bhabha extends his argument to include the notion of symbolic consciousness, the one that provides the sign of identity, its depth, its unity, and its integrity: the dimension of doubling. He constantly speaks of the specialization of the subject, occluded in the misleading perspective of what he calls the "third dimension" of the mimetic frame or visual image of identity. Alternatively, this third dimension is equated with the notion of hybridity, the in-betweenness state of being in which the postcolonial subject is subscribed to neither. Bhabha's configuration of "doubling logic/logic of hybridity" has laid the cornerstone for further postcolonial theory to be developed on postcolonial identity and self. His work is significant for our research but inadequate to allow us to interpose the implicit forces of the specificity, the particularity of location and the moment, and the totalization of the hegemonic global theory (Nguyen & Lehy, 2015;Phan, 2008;Zhang et al., 2015) in identifying the colonial mentality and the structures of feelings alongside the epistemology and ontologies of these postcolonial subjects. Postcolonial study is fundamental to the understanding and interpretation of postcolonial subjects and identities. However, it has been challenged. For instance, Kuan-Hsing Chen (2010) advances one step beyond the postcolonial paradigm to the field of Inter-Asia cultural studies, examining the tension between the colonizer and the colonized subjects in East Asian countries. This scholar problematizes the Self-Other dichotomy. Despite being recognized as one of the most popular postcolonial conceptual tools, Self/Other appears inherently treacherous. Colonial residuals subdue any geographical location and time and call into question for understanding, thereby interpreting postcolonial subjectivity and identities. Both dichotomy and resistance should not be overlooked; there are no clear boundaries between these two notions, as Chen critically remarks (ibid) and as illustrated in the epiphanies of Nhai and (Yeow-Tong) as follows. --- Nhai's multi-layered colonial mentality and desire for Western credentials and knowledge Nhai's personal story features her multi-layered colonial mentality and desire for Western credentials and knowledge. Her story is situated within the historical context and her personal family background, both of which decisively influence how she discursively constructed Vietnamese higher education and her choice of PhD research topic. She makes a critical point that the macro and micro contexts-in which she was born and grew up-are fundamental lenses through which she shapes her ways of being and seeing the world [ontology and epistemology precisely]. Her personal epiphany starts with a comparatively difficult childhood through which she struggled with financial hardship and was obsessed with her whole family's burgeoning dream of traveling interprovincially to pursue higher education and obtain credentials to improve their quality of life. That the people she knew in her village with university qualifications enjoyed a comfortable life sent a strong message to her, awoke her strong internal desire for education, and inspired her to strive tirelessly for academic accomplishments. She writes. I witnessed my parents' lack of education and their struggles against life hardships. I saw meritocratic values subscribed to the exam-oriented education system in Vietnam where university entrance examination had long been regarded as a golden key for school graduates to unlock their future. As indicated elsewhere (Nguyen, 2011(Nguyen,, 2019;;Nguyen & Tran, 2018, 2019;Nguyen et al. 2019), Vietnamese society's mentality and values were heavily influenced by Chinese Confucian culture. This is largely because Vietnam had undergone nearly one thousand years under Chinese colonization; consequently, Confucian's values and its meritocracy had been imprinted in Vietnamese society, they were embraced and converted into an action motto for every single family and individual to strive for academic success (London, 2006;Marginson, 2011;Nguyen et al., 2009;Nguyen, 2011Nguyen,, 2019)). However, Nhai's journey did not stop short of that. Growing up in the northern province of Vietnam, her education was heavily influenced by Russia despite her not studying Russian in primary school. When she entered Year 6 in middle high school, she bravely took up English as her major subject and continued this subject as her specialization in a gifted high school in Thai Binh province. This decision changed her life forever. At that time, Russian enjoyed nationwide popularity because it was taught in almost all schools in North Vietnam, along with other languages, such as Chinese, French, Japanese, and English (Nguyen et al. 2019). The second milestone occurred when the socioeconomic changes at the macro level occurred, shortly after she was born. After a couple of decades under the United States' economic embargo imposed on Vietnam when it defeated the United States and reunited the North and the South, Vietnam widely opened its door to the world in 1986. Its timely economic reforms called "<unk>i m<unk>i" in this year, followed by the normalization of the diplomatic relationship between Vietnam and the United States and the collapse of the Soviet bloc in Eastern Europe, also in 1990s, attracted massive foreign direct investment. This flood of foreign currency and investment postulated a magic touch on the national economy and boosted the nation's GPD growth to 8% per year (Glewwe & Nguyen, 2002). However, the downside of rapid, hot economic growth widened the wealth gap between the rich and the poor and accelerated the disparity between urban and rural areas (Glewwe et al., 2002). Foreign companies' presence in the country induced a surging demand for English-speaking white-collar professionals and upward social mobility for those fluent in English, accompanied by comparatively high social status and lucrative incomes (Boyden, 2013). The zeal for English language proficiency and the socially wide craze for English language study. Possessing English language certificates and/or credentials uplifted the English language's status as the most prominent foreign language taught in the mainstream Vietnamese curriculum and schools, contrasted with the nationwide fading enthusiasm for Russian and French (Bui & Nguyen, 2016, Nguyen, 2012). They correspondingly fueled a yearning for English and/or Western credentials. Although her genuine passion was for Vietnamese literature and math, Nhai attended a gifted high school in her province, where she pursued English as her major and later on obtained undergraduate and postgraduate degrees in English language education. --- Yeow-Tong's colonized mind Yeow-Tong's intellectual journey is perhaps best likened to that of a colonized mind in the process of decolonization. He reflects and historicizes on his educational and intellectual journey, ending with a critique of the usefulness of Chen's work in framing his experiences. Yeow-Tong shares his insights into how his mind was colonized: "I was born and raised in Singapore, a former British colony that became independent in 1965, but remained a member of the British Commonwealth." The "colonial hangover," as historian Loh (1998) calls it, is visible and ubiquitous. Unlike most colonies that disavowed their colonial past, British colonization is somewhat valorized (Chia, 2015a(Chia,, 2015b;;Loh, 1998). The post-independence Singapore leaders regarded colonialism as "the modernizing force which had transformed the non-Western world" (Sum, 1991, p. 31). Through colonial rule, "originally primitive and backward economies were developed through technological, professional, administrative expertise provided by Europeans" (Lee, 1968). This valorization of colonialism is in contrast with the other ex-colonies' antipathy toward colonial rule. Indeed, Singapore lauded her colonial legacy. According to founding Prime Minister Lee Kuan Yew: We deem ourselves to be among the fortunate few who can afford to be proud of their past, with no desire to rewrite or touch up the truth. It is a short history, 150 years, but long enough for us to value our association with the British people. (Lee, 1968) The progressive legacy wrought by colonialism, as viewed by Singapore's leaders, fit in with the modernizing ethos in post-independence Singapore. Political and economic survival was the prevailing national sentiment and ideology (Tan, 1998). History, particularly the pre-colonial past, was seen as hindering progress; as such, it could not be a source of direction for a modern technological society (Nair, 1983). Rajaratnam, Singapore's first foreign minister, contended that propagating a Singaporean history before 1819 might alienate members of the multicultural fabric of Singapore (Chan and Haq, 1987). The postcolonial Singaporean government thus regarded Sir Thomas Stamford Raffles, an administrator of the English East India Company, as the "founder" of Modern Singapore. The arrival of the British to Singapore in 1819 became regarded as the start of Singapore's modern history, and "the pre-colonial past became [portrayed as] a prehistoric dark age" (Loh, 1996, p. 3). This perceived irrelevance of history by the government and the public was reflected in the low priority given to the teaching of history (Chia, 2015a(Chia,, 2015b)). Mathematics, science, and technical studies, among others, were deemed "useful subjects" in producing a "technically proficient workforce" to fulfill the needs of Singapore's industrialization and economic development (Goh & Gopinathan, 2005, p. 210). This emphasis on mathematics and science for nation building is not unique to Singapore. What is somewhat unique to Singapore is the valorization and appropriation of coloniality for the purposes of economic development and nation building. Education, particularly schooling, was crucial to the quest for modernity via industrialization (Chia, 2015a(Chia,, 2015b)). This was the context where Yeow-Tong received his schooling. He writes. I was interested in history and the humanities from young and struggled especially with maths. I recall some of my relatives questioning my choice of studying humanities rather than the sciences, which reflects the low status of humanities in Singapore. So, I felt "Othered" at an early age. Yet I also accepted this colonial ethos of modernity at the same time in my embrace of the positivistic view of historiography. I studied for my undergraduate degree at the National University of Singapore, and graduated with Honors in history. Back then, I accepted the Rankean view of history of eigentlich gewesen-as it really was, and privileged the archives as the main source of historical truth." I also fully agreed with the view of G. R. Elton (1967), a twentieth-century proponent of Rankean historiography: The task of history is to understand the past, and if the past is to be understood it must be given full respect in its own right. And unless it is properly understood, any use of it in the present must be suspect and can be dangerous. (pp. 47-48) He further contends that "the study of history is a search for truth" (ibid., 51) and that it is tied in with the effort at making history scientific. That is not to say that I wasn't exposed to postcolonial approaches to historiography during my undergraduate studies. It's more that colonial and positivistic historiography appealed more to me then. --- Fantasy, ambivalence, agony, and resistance Postcolonial researchers, explains Chen, tend to hold up the Self/Other dichotomy as a handy tool with which to sculpt differences between the colonized and the colonizers, without being aware that difference is merely a convenient strategic tool of the colonizer used to educate the colonized. Nevertheless, it intensifies racism, identity discrimination, nation, and cultural traditions (Bhabha, 1994;Chen, 2010). Chen indicates one paradox: resistance deliberately reproduces dominance. Oppression and resistance are usually locked within an "unconscious system of representation," shaping the cultural imaginary of the colonized and colonizers. They set conditions for shaping the world of complex sentiments involving both oppression and seduction (2010, p. 111) as if the "cultural imaginary" bleeds into the psyche; controls human subjectivity; and, more treacherously, conditions the unconscious representation of the colonized. This world of paradoxical sentiments leads to the secret formation of the "structure of feelings" that, instead of problematizing the existing problems of the Self-Other dichotomy, intensifies, outlives, and augments the disorganized and new form of colonialism in postcolonial countries. Similarly, Bhabha (1994) unravels the pathology of "ambivalence," where the hybridity of desire and resistance resides in the psyche of the colonized subject. He reiterates that desire and oppression throw colonized subjects into a state of emotional chaos and that these sentiments are central to constructing their subjectivity and identities. Additionally, autoethnography is a strategic tool not just for ontological, epistemological, and methodological implications but also fundamentally for political self-positioning in the academic field, where the power inequality between the Global North and Global South scholars is observed. Nhai's voice rises from the position of a young academic from a developing country, namely, Vietnam, dialoguing with the dominant white academia. Particularly, she produces a self-representation that intervenes with the ethnographic and the dominant universal academic discourses about her exotic Other status. Additionally, drawing on Mary Louise Pratt (1992), the postcolonial critic, she would argue that ethnographic texts have become an effective means for controlling the construction of self-representation not only of European academia to the subjugated others but also of those marginalized subalterns in reaction against the metropolitan representation. Through autoethnography, Butz andBesio (2009, p. 1667) provide insights into the researcher placing his/her "self" into the social context in which autoethnography is a source and outcome of transcultural identity formation laced with the complex intermingling of the dominant and the oppressed. Nhai's memories were thrown back in 2006 which were still vivid to her when she had first-hand experiences in Western education and started being aware of her research ontology. She recalled.

Epistemology has been recognized as a useful conceptual tool to explore how knowledge has been produced and/or reproduced in higher education research and its linkages to hidden global geopolitics and historical forces. The topic has attracted considerable attention in the literature, particularly that of scholars in the

i's voice rises from the position of a young academic from a developing country, namely, Vietnam, dialoguing with the dominant white academia. Particularly, she produces a self-representation that intervenes with the ethnographic and the dominant universal academic discourses about her exotic Other status. Additionally, drawing on Mary Louise Pratt (1992), the postcolonial critic, she would argue that ethnographic texts have become an effective means for controlling the construction of self-representation not only of European academia to the subjugated others but also of those marginalized subalterns in reaction against the metropolitan representation. Through autoethnography, Butz andBesio (2009, p. 1667) provide insights into the researcher placing his/her "self" into the social context in which autoethnography is a source and outcome of transcultural identity formation laced with the complex intermingling of the dominant and the oppressed. Nhai's memories were thrown back in 2006 which were still vivid to her when she had first-hand experiences in Western education and started being aware of her research ontology. She recalled. It was the year when I won the RMIT postgraduate scholarship in Educational Leadership and Manage-ment. I became an international offshore Vietnamese student. It was the first time ever in my life I had an opportunity to study in a Western university and it was hard to imagine how honored I felt at that time. A new journey commenced two months after the scholarship letter of offer. The campus where I studied was located right in the hub of Hanoi, not as spacious as my previous university campus but enough to sense the differences at once: classrooms were exceptionally designed to feel the gapless between the lecturer and students, equipped with projectors, laptops, whiteboards, etc. My lecturers were all English native speakers, exceptionally friendly and open-minded, which was not far from what I imagined. The infrastructure was all impressive: thousands of electronic journals, databases, e-books, and e-lectures. All of the subjects were all new, exciting and basically Western oriented. Heaps of novel knowledge and experiences were poured into my world with overwhelming emotions. These resonate a robust structure of feeling associated with 'privileges', 'fantasy' and 'desire' for Western education and credentials". Meanwhile, my classmates experienced this scholarship program differently. The majority of them had already studied overseas in prestigious Australian universities, so they indicated a thin interest in this program. There were stark differences, as they narrated, between onshore and offshore programs and between high-ranked universities and those of low rank. These contradictory experiences haunted me. My understanding of international education started becoming fractured as I experienced the agonies of being seen as'substandard' and ambiguously 'partially Otherness' albeit my being an international student in an Englishspeaking campus right in my country. This feeling is substantially echoed in my research on international offshore students' identities in Australian transnational education (Nguyen, 2013). My enthusiasm and fantasy began wearing out. This line of thought reverberates well with my PhD journey in which I started crossing the border for the Australian Leadership Award which I won in order to pursue a doctoral degree program at Monash University, Australia. However, being an international offshore postgraduate meant totally different in Australia. It became clear to me now why my ex-classmates in the branch campus in Vietnam were not interested in the program at all. The first experience held me back when I first attended a stimulating seminar in RMIT Melbourne. However, I first tasted agonistic feelings and a sense of being inferior when one of the conference topics focused on transnational education and the corresponding quality assurance issues. I came to realize that transnational education in academic discourse appears to be associated with somewhat negative discourse (McBurnie, 2007). I still recalled the moment of introducing myself as an offshore student and sensed the surprise of academic staff in the Melbourne-based campus. It carved out deep, fanatical, cursed feelings of being marginalized and stereotyped as an international offshore student. Butz and Besio's autoethnography thesis validates Nhai's personal experiences of being an international offshore student in Vietnam and then in Australia. Autoethnography is at times deployed by researchers to portray their transcultural self-representation in the apparatus of the colonized-the groups at the margins of authorized knowledge (Butz & Besio, 2009). The repatriation of autoethnographic texts is strategically important for her research approach and output because it assists her in making sense of and subsequently interpreting the self-identification processes and representational strategies in the Vietnamese and Australian contexts. More specifically, the erection of autoethnography from below offers invaluable insights into what Butz and Besio (ibid, p. 1668) term the "epistemological characteristics" of their subjects' self-narrations, encompassing what they say and how they perform for researchers in research interaction. It becomes clear that Nhai's structure of feelings and self-identification indicate her colonized ontological and epistemological characteristics when narrating her colonized self. They expose vividly the fragile, amorphous postcolonial identity emerging from this context reminiscent of what she describes as "deep, fanatical, cursed feelings of being marginalized and stereotyped as an international offshore student." The vocabulary of emotions and feelings as such underpins a complexity of the colonized mentality, feelings, emotions and an agonic taste of being marginalized and undermined by the status of being an international offshore student in Australia. --- Yeow-Tong's being Otherness in everyday life and academia Unlike Nhai's structure of mixed feelings, colonized mentality, and marginalization, Yeow-Tong experienced the status of being "Otherness" in his everyday life in Canada. His epiphany recalls the experience of being a racial minority in Toronto, Canada. In other words, he was racialized as being Asian. He identifies its linkages to the history of anti-Asian migrants in Canada and other countries in the late nineteenth century. Unfortunately, the "Yellow-Peril" remained and emerged during the COVID-19 pandemic, exposing the centuries-long structural racism and anti-Asian mentality in Western countries. Moreover, he was trapped in being "Otherness,"," marginalized, and had a faint idea about which field he belonged to: History of Education, comparative and international education, or Asian Studies. He analogously recalls his experience. Going over to Toronto, I experienced what it meant to be a minority for the first time in my life. Through the readings and interactions with other students and people I met, I began to be conscious of my Chinese privilege back in Singapore. Being an ethnic Chinese in Singapore, I belonged to the 'racialized' majority. Despite the Singapore state's purported multiracial aspiration, the reality was that the Chinese enjoyed implicit and explicit privilege, something that I didn't realize and took for granted. The categorization of the different ethnic groups of Singapore into neat and essentialized Chinese, Indian, Malay, Eurasian and Others was a product of British colonization that was carried over post-independence in Singapore. Another realization was the awareness of the entanglements of racism, colonialism, and imperialism. The history of racism was intertwined with colonialism. In former the white settler colonies, this manifested in the dispossession and cultural genocide of the Indigenous populations, as well as virulent anti-Asian racism. This came historically in the form of "Yellow-Peril" and anti-Asian immigrant from the late 19 th century in the US, Canada, Australia and New Zealand that was only dismantled after the Second World War. While the legal structures of anti-Asian racism have been dismantled, the invisible structural racism endures. But in another way, White Supremacy which is tied up in coloniality and imperialism, remains undismantled. The anti-Asian racism and other racism during the ongoing COVID-19 pandemic is a poignant reminder that systemic and structural racism have not been fully addressed, and that anti-racism education remains weak. Before the more obvious COVID anti-Asian racism, I was involved in the struggle against anti-Asian racism in 2011. This was in the form of the Too Asian campaign in Toronto (and Canada), which arose from a "Too Asian" article from a premiere Canadian news magazine that depicts an unfavorable and stereotypical view and image of Asians versus the normative whites (For a more nuanced and comprehensive discussion, see Coloma, 2013). I was conscientized on racism through helping to organize a town hall meeting and deputations to the City Council through my involvement with the Chinese Canadian National Council Toronto Chapter. I have written elsewhere (Chia, 2012) on my experiences of Otherness in the fields of History of Education, Comparative and International Education, and Asian Studies. History of Education remains rather parochial and Eurocentric, even though there are efforts on transnational histories of education. On the other hand, there appears to be "the sacrifice or almost total abandonment of the historical dimension in comparative educational research" (Kazamias, 2009, p. 155). As for Asian Studies, research and studies in education remain peripheral in this field. Kenway and Fahey (2008) critique compliant research imagination, which often tends to deploy disciplined, established research techniques and concepts. They argue that compliant research imagination rests on a global hegemonic "ontology of determinacy" and appears to block social imaginaries where meanings are predetermined and consistent and linear with the established disciplines. Consequently, these scholars urge for a genuine recognition of the hidden nature of the global power/knowledge situated in the praxis of knowledge and truth. It is what they call the destabilization of such positivistic assurance, nurturing the "ethical acute angles inquiry," or what they term "the philosopher in the researcher" (Kenway & Fahey, 2008, p. 25). As philosophers, researchers are pushed toward a defiant global research imagination encompassing a set of "probing, challenging and provoking sensibility." --- Decolonizing research imagination Although stemming from the core concept of reflexivity discussed widely in ethnography, the concept of defiant research imagination suggested by Kenway and Fahey advances critical ethnography. On the one hand, reflexivity discussed by Butz and Besio (2009) articulates the self-signification of the researcher in their research project, turning themselves into an integral reference point of what they are signifying in ways that they locate themselves in the web of relations with people and the worlds [they are studying], the fields of power underlying these relationships, the situatedness, and the partiality of the academic knowledge and the partiality of the truth they claim. On the other hand, this concept appears to be naive in the complexity of postcolonialism and its coat-tail remaining in colonized countries. If not for the defiant research imagination and its repatriation of epistemic virtues, comprised historicity, reflexivity, relationality, positionality, and criticality, novice researchers would hardly make sense of the field and its complexities; the hidden global forces; and the geopolitical and global disruptures that actually write and rewrite our lived experiences, otology, epistemology, and beyond. The discussion of a defiant research imagination suggests a philosophical (or epistemological) and ontological stance of a novice researcher. Nhai wants to advance this argument by examining the context of her research context, Vietnam. She argues that a defiant research imagination intersects with a relentless vigilance against the risks of being "internally colonized" by all subtle variations of neocolonialism. For intellectuals in the postcolonial period, the risks of encroaching on the practices of thought on nationalism, civilizationism, and nativism (Chen, 2010) are almost visibly dangerous. As aforementioned, neocolonialism simultaneously creates resentment and "desire" among the colonized. The literature from postcolonial countries may often encroach on the nationalist discourse against the West without recognizing that nationalism is a handy but dangerous tool deployed by colonialists to connect ethnocentrism and racism. Neocolonialism has implicitly continued its colonial project under even the intangible coverage of "cultural imaginary" so successfully that it has become the psyche, the human subjectivity, and the identification of the colonized. We illustrate this as follows: The project of neocolonialism in the world explicates the jeopardy of cultural imaginaries seeded by colonialists in colonized countries. Drawing on the work of Edward Said titled Culture and Imperialism (1993), Chen points to the paralleling concept of "cultural forms and structures of feeling" and cultural imaginary as a displaced form of intellectual and psychic dominance. Said maintains that imperialism conditions the whole set of cultural forms and structures of feeling. Chen, agreeing with Said, emphasizes that these forms and structures are actually the space of cultural imaginary. Chen contends. Cultural imaginary is, once again, a result of the encounter between colonialism and local historical and cultural resources. Through discursive articulation, cultural imaginary is disseminated to different social fields, shaping the imagination of both olonized and olonized subjects. Operating on the terrain of popularity, the cultural imaginary structures the system of ideology, links the concrete experiences of daily life, and forms the direction and boundary of the psychological space. Its discursive saturates popular subjects, official discourse, and anticolonial discourse" (2010, p. 111). Chen problematizes existing academic discourse as being the direct result of cultural imaginary despite its neutrality. So popular is the binary of "Self" and "Other" that it has become the dominant frame of academic discourse and, therefore, falls prey to the "unconscious system of representation." Similar to the Althusserian's concept of ideology, the cultural imaginary, according to Chen, refers to "an operating space within social formation, in which the imaginary perception of the Other and self-understanding are articulated. In this domain the structure of sentiment is the link and mediator between the colonizer and the colonized. It is the domain of cultural imaginary that the psychoanalytic tradition of decolonization opened up by Fanon becomes a constitutive part of place-based global ethnography" (Chen, 2010, p. 111). Therefore, we revisit the primary purpose of this paper: decolonizing research imagination. We posit that the urge for researchers, especially novices, is to build a defiant research imagination. Pertinent to this task is to decolonize our research imagination. Chen writes....to decolonize the colonial cultural imaginary as to free colonizing and colonized subjects from the limits imposed by colonial history is an important task for politically committed cultural studies. As practitioners of cultural studies, we are the articulating agents and linking points of decolonization; our research and discursive practices can become critical forces pushing the incomplete project of decolonization forward. At the very least, we must decolonize ourselves. (2010, p. 113) Nhai's case indicates that decolonizing her research imagination is accompanied by her journey of uprooting her complex, multi-layered colonial mentalities and, thereby, cultural imaginary. Being cognizant of her Vietnamese origin located within the complex colonial heritages of Vietnam's history, she struggled in the "in-betweenness," wondering which part of her academic and personal identity alongside her cultural imaginary prevails: Vietnamese or Western. She recalls. English gets me into its world, becoming a central part of my self-representation. Equally, being trained in Western education, it is now hard for me to draw a boundary whether my way of thinking and seeing is either Vietnamese or Western. Is this a curse or a privilege? It was not until the stage of data analysis and discussion [of my PhD thesis] that I came to fully understand the complexity of my research setting and participants. Even being confined to modernist and postmodernist research approaches turned out to be all-pervasive but superficial and handicapped in lending me an insight into the interpretation of international offshore student identity. Not being able to move beyond the bounded, positivistic, linear view of the place troubled me. The local specificities and the complexities of Vietnam history, most of which were, more or less directly, navigated toward the colonial experiences-under the colony of Chinese, French, Japanese, and most recently American. They were equally tricky. So were the postcolonial project and imagination as they co-existed in the mask of cultural, political and economic globalization. In Hanoi, Vietnam where my research is located, traces of globalization were visible in every corner of the city crawling into all spheres of life: from the smallest unit of production to educational services as well as the emergence of international schools and universities. All that said, unique specificities of local setting in my research embed multiple layers of power relationships and the global geography of knowledge still exerted its powerful impacts on the daily life of the local people. Therefore, understanding the identity formation of Vietnamese students in Australian offshore degree programs in Vietnam was head-spinning. Western theoretical framework, its conceptual tools and its research rigors, all the stuff I had pulled out from reading research textbooks, blocked possible interpretations and created 'dead rigors' preventing me from looking beyond the boundary of power and knowledge. I failed to make sense of data, findings and the 'transgressive imagination' which I could hardly scratch the hidden interconnectivities between international offshore student identity formation and the impacts of Western education." (Nhai's personal reflection) Nhai's personal journey of decolonizing her research imagination resonates the epistemic virtue of what Rizvi terms historicity, reflexivity, relationality, positionality, andcriticality (2006a, 2006b). Rather than surfing the glossy globalization, Rizvi warns that researchers should focus on the contexts of time, space, and power and to questions such as "for whom, when and how?" Similarly, citing Castoriadis, Kenway and Fahey view that "undecidability concerning the subjective and objective contributions to the 'encounter' we call knowledge; the fact that this knowledge itself has a history and the ontological import of this fact" (Curtis, 1997, cited in Kenway & Fahey, 2008, p. 26). This argument corroborates Betz and Besio's proposition (p. 1667) and underscores that "if researchers attend carefully to the flows of power, information, signification, and identity that occur in an expanded field, they may come to understand their objects of research less in spatially bounded and temporally static terms, and more in terms of flows, assemblages, networks, and other associated ontological formations. These are the sorts of ontological move." Chen accentuates a somewhat comparable argument, calling for a process of decolonization functioning at various levels of social formation. Decolonization should no longer be confined to fighting for national independence but "any form of colonization, then we have to recognize both neocolonialism, and globalization are structure continuations and extensions of colonialism; and that colonialism is not yet a legacy but remains active in geocolonial sites on the levels of identification and cultural imaginary and it continually reconfigures itself amid changing historical processes to reshape the colonial cultural imaginary" (Chen, 2010, p. 112, emphasis added). --- Yeow-Tong's ongoing decolonizing journey In the process of decolonization, Chen (2010) argues for multiple modalities of decolonizing cultural imaginary or research imagination in the words of Kenway and Fahey (2008). These should not be limited to the objective structure of historical moments but relentlessly, at the micro level, our daily practices such as action, subjectivity, and a plane of thought. At the macro level, we must be mindful of cultural forms of expression and, more generally, how society is instituted and how the global political economy is explicitly and implicitly structured. More critically, researchers should segregate colonizing and colonized subjects from the shadow of history. To decolonize cultural imaginary is to map out the dots among the complex global network and shifting and multiplying points of reference. In this paper, Yeow-Tong's epiphanies indicate that he has undergone the process of decolonization throughout his undergraduate study in Singapore and his PhD study in Canada. He was surprised when challenged by an undergraduate political science tutor about his naive interpretation of British colonists. This momentum alerted him to his limited, one-dimensional way of knowledge and, thus, reading and interpreting British colonialism. By multiplying his frame of reference, Yeow-Tong admitted that using Chen's Asia as Method as a reference point against which he touted the implicit forces of colonial legacies and postcolonial impacts parasite in his research imagination and his way of knowing the world is useful. As a result, he experiences such transformative ontological and epistemological moves. Yeow-Tong nostalgically shares. My first postcolonial encounter was at a political science tutorial during my undergrad. The tutor was a South Asian academic, and the course was on International Political Systems I think. I recall commenting that the British were benign colonialists compared to the other Europeans. Upon hearing my ignorant remark, the professor went red in the face and banged on the table, challenging how I could say the British were benign when they chopped off the fingers of the Indian weavers to ensure that there would be no competition to their cotton trade. It was only after my doctoral studies at the Ontario Institute for Studies in Education (OISE) at the University of Toronto that I discovered about the violence that the British did in Africa, India and to the Indigenous communities in the settler colonies like Canada, Australia and New Zealand. While de jure independence and de-colonization took place after the Second World War, cultural and economic colonization and imperialism remained embedded. I also began to read and reflect more into postcolonial and postmodern his-toriography and theories through the graduate courses at OISE. Chen's (2010) notion of Asia as Method is useful in framing my experiences of Otherness in my own educational and intellectual journey in regards to my approach to historiography. It is also useful in critiquing, explaining, and uncovering the invisible legacies of colonialism that persists in Singapore, and that I used to unquestionably accept. Chen's work is particularly useful in excavating the inherent colonial structures in History of Education and even Asian Studies as well. However, Chen is somewhat silent on the forming and consciousness of the racialized Other, and the historic entanglements and relationships between Race and Imperialism. I hope that my own experiences can contribute to more thinking, interrogating, and theorizing on the role and place of Race in Asia as Method. Yeow-Tong's insights into decolonizing his research imagination confirm Chen's synthesis of decolonization (2010). Chen emphasizes the importance of deconstructing, decentering, and disarticulating novel imaginations. As a result, researchers can explore what he calls "a more democratic future direction" by shifting away from colonial bonds, multiplying and shifting existing sites and objects of identification. By reading Chen's work, we are no longer confined to the binary/dichotomy of the West and the rest and local versus global sites. By contrast, the transgression of nation-state boundaries should be extended beyond regional and intercontinental sites. These include Vietnam as a Method and Singapore as a Method, inherent in this paper. Most notably, akin to Foley's proposal (2002) and Butz and Besio's (2009) proposition of moving back and forth between subjectification/agent and objectification of signification, we multiply objects of identification and transform our subjectivities. Through our imaginings of Vietnam, Singapore, Australia, and Canada, we expand our frames of reference across our horizons, multiply our perspectives and augment our subjectivities. It is here where the decolonization of our research imagination occurs and marks a new journey of self-transformation toward shaping a defiant research imagination. --- Conclusion This article has responded to two emerging research questions: What sorts of ontological and epistemological transformations might educators experience during long-term periods abroad? and How might these transformations initiate decolonial moves in regard to educational pedagogy, policy and practice? Through the conceptual lens of autoethnography, postcolonialism, and Asia as Method, the paper narrates the lived experiences of two diasporic academics, Nhai and Yeow-Tong. Nhai experiences the subtle structure of feelings of the colonized subjects encompassing fantasy, ambivalence, agony, and resistance, whereas Yeow-Tong's experience discloses the process of being colonized in his mentality, racialized, "Othered,'' or marginalized in his life and academia in Canada and Australia. Both scholars have experienced a painful process of decolonizing their research imagination as they have become acutely aware of the danger of being confined to the Western colonized imaginaries. Subsequently, they are likely to fall prey to deploying naively Western knowledge (ontology) and a way of knowing (epistemology) in their research -what Homi Bhabha alerts as a mimicry -the intake of the colonizer's culture into the colonized culture. And most dangerously, Western colonized imaginaries manifest the complex structure of feelings, as in Nhai's case, and the colonial mentality, as in the cases of Nhai and Yeow-Tong. This recalls what Kenway and Fahey (2008) warn of: a compliant research imagination in which researchers tend to advocate such a positivistic assurance and a simplistic, mimicking, derivative, or compromised imagination determined solely in Western research. This compliant research imagination has curtailed the ability of the researchers to move beyond their existing knowledge and predetermined ways of acquiring knowledge to track down the hidden linkage between "their own relationship in authority with knowledge and 'being determined' by conventional practices of thought" -to reiterate our thesis in the introduction. Shifting ourselves from a compliant research imagination toward a defiant research imagination should be understood as the journey of continuously and tirelessly decolonizing our ontology and epistemology in our everyday practices for novice researchers. In this journey of decolonization, echoing Chen's proposal (2010), researchers should recognize that cultural imaginary contemplates colonialism in many ways because it connects structure and agency in historical materialism and geographical-historical materialism-both of which focus on modes and relations of production. Clearly, cultural imaginary plays a key role in uprooting the global hidden connectivities, global forces, and postcolonial illusory ties between the colonized and the afar imperial/colonizer. Chen reaffirms that "without the analytical category of cultural imaginary, the specificity of the international relations of production between the colony and the imperial center cannot be adequately addressed" and emphasizes the intersection between political economy and cultural studies, noting that "to bring the notion of cultural imaginary to the center of geocolonial historical materialism is to produce the dialectic between political economy and cultural studies" (Chen, 2010, p. 110). Decolonizing research imagination requires that the focus be expanded to the objective structure of historical movements; deliberate action and knowledge (ontology); subjectivity; ways of thinking (epistemology); subtle, novel plight of thoughts; cultural forms of expressions, and macro level constituents, such as social institutions and the structure of the global economy. To summarize our argument, we borrow Chen's words to conclude this paper. As practitioners of cultural [and also educational] studies, we are articulating agents and linking points of decolonization; our research and discursive practices can become critical forces pushing the incomplete project of decolonization forward. At the very least, we must strive to decolonize ourselves (Chen, 2010, pp. 112-113). --- Declarations Competing interest The authors of this journal article declare that the paper has neither received funding nor has any financial or nonfinancial interests directly or non-directly related to this work submitted for publication. --- Ethical approval The paper fulfills the ethical standards for self-study research. Therefore, it neither needs informed consent of the human participants nor a statement on the welfare of animals. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Epistemology has been recognized as a useful conceptual tool to explore how knowledge has been produced and/or reproduced in higher education research and its linkages to hidden global geopolitics and historical forces. The topic has attracted considerable attention in the literature, particularly that of scholars in the

Introduction This impact is felt so clearly in all levels of society even though those who are most affected are the lower middle class. Therefore, to overcome problems that occur in society, the Government of Indonesia issued policies such as Large-Scale Social Restrictions (PSBB) and the Implementation of Restrictions on Community Activities (PPKM). To keep the Indonesian people able to survive during the COVID-19 pandemic, especially from an economic perspective, one of these policies is the provision of Social Assistance or (BANSOS). In practice, it has basically been explained in various policies and decisions both at the central and regional levels. One of them is Regulation of the Minister of Social Affairs No. 5 of 2021 concerning the implementation of the distribution of social assistance, it is stated in article 15 that data collection is carried out by Integrated Social Welfare Data (DTKS) according to decisions taken by the Minister of Social Affairs every year. This data collection will be checked and finalized by the District/City Social Services which will also be assisted by District and Subdistrict data (Riyanto, 2021). To carry out this program there is also a unit that specifically functions as a bridge or liaison between the government and the community, the unit is called Social Assistance Facilitator. With this unit, it is hoped that it will become a link between the community and the government in an effective, efficient and transparent manner. Social assistance is a program that has been implemented by the Government of Indonesia for a long time to improve the welfare of its people, this can be seen in the formation of Integrated Social Welfare Data (DTKS) as outlined in Minister of Social Affairs Regulation number 5 of 2019 concerning integrated social welfare data management. Through this regulation integrated data management is expanded not only to data on the poor but also to include other social welfare data, namely social assistance data, Social Welfare Services Requirement Data (PPKS), and Social Welfare Potential and Resources data (PSKS) (Ministry of Social Data, 2020). Thus the data collected by DTKS will always be the basis for distributing social assistance to the community, therefore DTKS changes data at least 4 times a year, namely January, April, July, and October (DTKS Ministry of Social Affairs, 2020). During the pandemic, the Indonesian Government's welfare program in the form of groceries and cash was needed by the community, this was because these incentives could make people survive amid the COVID-19 pandemic. To realize this, the Government of Indonesia established a program called the Social Safety Net (JPS). In this program, there is at least 7 assistance in the form of programs and incentives from the Government under the responsibility of the Ministry of Social Affairs, namely (1) Family Hope Program (PKH), (2) Cash Social Assistance, (3) Direct Village Fund Cash Assistance (BLT Dana Desa), (4) Basic Food Social Assistance (BSS) for the Jakarta Bogor Depok Tangerang and Bekasi (Jabodetabek) Region, (5) Pre-employment cards, (6) Basic food cards, and (7) Electricity subsidies (Noerkaisar, 2020). However, social assistance policies, especially during the COVID-19 pandemic, did not work properly, and some people even complained about the implementation of this policy. One of the cities that feels this way is Makassar City, where the phenomena that occur in Makassar City regarding the distribution of social assistance are very bad. According to media reports, namely Sonora.id, the data of many people who will receive social assistance during this pandemic are fictitious and not real. This certainly affects the effectiveness of the process of distributing social assistance to beneficiaries of social assistance, besides that this problem has been going on for a long time and has not been repaired. In addition to data collection problems which are the biggest factor in the ineffective distribution of social assistance in Makassar, management problems are also a very bad thing. This is based on the mechanism and Standard Operating Procedures (SOP) for providing assistance has been slow. Supposedly, distribution does not need to wait for administration or adjust to existing SOPs. So that this problem has an impact on the contents of social assistance, especially basic foodstuffs which have expired and are not suitable for public consumption, therefore the contents of these basic food items have to be thrown away which is the same as detrimental to the state. The restlessness of the people of Makassar City regarding social assistance was also caused by delays in distribution to the community. According to Kompas.com, social assistance, such as groceries, has experienced distribution delays of up to two months. This certainly has an effect on the problems mentioned above, namely the contents of the basic necessities are no longer suitable for consumption. This problem is also felt by the people in Mariso District, Makassar City where the distribution of social assistance is not carried out every month and even some people have only received social assistance from the government for almost a year. The community also did not get clarity from the implementor who served as a provider of social assistance services and did not consistently go to the field to check social assistance problems that occurred in the community. So that the community does not know and do not understand the flow and mechanism of the distribution of social assistance. Coupled with problems regarding supervision and control which are often not carried out, especially members of the Regional People's Representative Council (DPRD) of Makassar City. Their absence is one of the factors causing many problems regarding Social Assistance, especially in its distribution. Members of the Makassar City DPRD are individuals chosen by their constituents who are in the electoral district (electoral area), so basically they know best which characteristics of their community are entitled to receive and which are not entitled. Thus the DPRD's function as oversight should be carried out and the social assistance policy in Makassar City can run effectively and on target because it is regularly controlled and escorted. Social assistance assistants as one of the implementers are in the spotlight of the community due to their minimal presence and contribution as a bridge between the government and the community. One well-known case occurred in Mariso District, Makassar City. In this case, the social assistance assistants abused their authority by taking funds from the beneficiaries they assisted, and according to some people, their ATM cards were held or controlled by their assistants several months before the aid funds were disbursed. Because of that, some people were very disappointed because as soon as the government announced the aid funds to be distributed, some of their ATM cards were empty, and once confirmed by the companion, they instead responded with various kinds of reasons that were irresponsible. This phenomenon occurs in almost all of Mariso District, one of the cases that occurred was in the Bontorannu Village, the difference is that the beneficiaries of social assistance do not dare to complain about this problem. Andi Faiz, one of the people in the Bontorannu Village, explained that the problem of reducing the amount of social assistance by certain individuals is commonplace and has occurred several times (Personal communication, 1 March 2022). Thus the community has made sense of this and it has become an open secret for the people in Mariso District, especially for the government's welfare program. However, during the COVID-19 pandemic, where the situation had quite a significant impact, especially on the economic aspects and people's welfare, the community was quite sensitive and made resistance if problems occurred that threatened their rights and welfare. Various problems that occur in social assistance programs, make people angry and protest actions as a form of disappointment with the procedures of social assistance policies. One of those who did this was the community in Mariso District, Makassar City, even the phenomenon of this protest action had an impact on social assistance policies, especially in terms of data collection and distribution mechanisms. From the various problems mentioned above, this research would like to provide an overview of the process of implementing social assistance programs in Mariso District, Makassar City during the COVID-19 pandemic by focusing on the community as the main stakeholder in this policy who carried out protest actions. For this reason, this research will describe how effective the implementation of the distribution of social assistance to the community is by conducting observations and in-depth interviews with all actors procuring social assistance in Mariso District. Furthermore, in this study, researchers will focus on the 7 social assistance programs that are part of JPS, only 3 programs are the focus of this research, namely the Family Hope Program (PKH), Direct Cash Assistance (BLT), and Basic Food Cards. This is because the three types of assistance are the most frequently distributed types of social assistance to the community in the Mariso District. Thus the main focus of this research is to provide an overview of the protest actions carried out by the community in Mariso District which were affected by social assistance policies, especially in the mechanism of data collection and distribution. In addition, this research will also explain the dynamics experienced by the community, and how social assistance problems make the people in Mariso District protest against the COVID-19 social assistance policy. Furthermore, to add information so that it is validated and also accurate, this research also looks at other stakeholders such as the Makassar City Social Service, the Head of the Camat in Mariso District, and RT/RW. From the various literatures that have been described above, the researcher divided into 2 groups with the intent and purpose to differentiate the literature study and also as 2 aspects that became the basis for researchers to conduct research with the same case. From the literature that has been described, it can be understood that there have been many studies on social assistance with various perspectives and approaches. In addition, the problems studied also vary, ranging from policies to implementers of these policies. Therefore in this study, researchers will also do the same case but the focus of the approach and point of view will be different. This can be seen starting from the approach, the researcher will use a political science approach with his point of view focusing on people who are protesting against the COVID-19 social assistance policy. Furthermore, this research will also analyze the causes and effects of protests carried out by the community, why this happened and how this collective movement can influence the policy of social assistance for COVID-19. Thus, in terms of place, time and analysis, the results will be different from previous research, even though this research is in the same case and research object. From the various pieces of literature that have been described above, the researcher divided into 2 groups with the intent and purpose to differentiate the literature study and also as 2 aspects that became the basis for researchers to conduct research with the same case. From the literature that has been described, it can be understood that there have been many studies on social assistance with various perspectives and approaches. In addition, the problems studied also vary, ranging from policies to implementers of these policies. Therefore in this study, researchers will also do the same case but the focus of the approach and point of view will be different. This can be seen starting from the approach, the researcher will use a political science approach with his point of view focusing on people who are protesting against the COVID-19 social assistance policy. Furthermore, this research will also analyze the causes and effects of protests carried out by the community, why this happened, and how this collective movement can influence the policy of social assistance for COVID-19. Thus, in terms of place, time, and analysis, the results will be different from previous research, even though this research is in the same case and research object. The purpose of this study is to examine and provide an overview of the implementation of social assistance policies in Mariso District, Makassar City. By focusing on collective movements carried out by the community, namely protests against social assistance policies. In addition, this research will also focus on the community as the main stakeholder in the discussion of this research, so that it will be clear the role and struggle of the community to defend the right to social assistance that must be received as an incentive from the government during the COVID-19 pandemic and how this collective movement can change the social assistance policy in particular from the aspect of distribution and data collection mechanisms. This research has significance as an additional discourse in the study of political science, especially regarding urban politics, with the community as the main stakeholder in social assistance policies for COVID-19. In addition to adding to the academic side, this research is also expected to be a reference and insight to the general public about social assistance programs in the COVID-19 pandemic era, where this research can describe the actual conditions for people who receive social assistance COVID-19 to become learning in addressing and acting towards public policies issued by the government. With this research, researchers hope to help people who receive social assistance gain insight into this program so that in the future they are not easily manipulated by those who want to benefit from this program. And finally, this research can be a reference for political science students who are interested in urban political discourse, especially regarding public policy with aspects of community welfare, in order to enrich other Political Science studies. --- Methods Research on social assistance for the people in Makassar City will use qualitative research methods. According to Craswell, qualitative method research is research that focuses on exploring and understanding the meaning of individuals or groups in certain social problems (Creswell, 2014). Research using qualitative methods will focus on group and individual problems where researchers will explore in depth and detail to find out the interpretation of the object under study on a social problem. This research will use one of the existing designs in the qualitative method, namely case studies. According to Craswell, case study research is qualitative research in which the researcher develops an in-depth analysis of a case such as a program, event, activity, process, or individual or community group. Cases are limited by time and activity, and researchers collect detailed information using various data collection procedures over a continuous period (Creswell, 2014). This research will use primary and secondary data sources. Primary sources were obtained by conducting interviews with all informants online (Zoom Meeting/Google Meeting, Phone Calls, and Whatsapp) or offline (face-to-face interviews). Secondary data will be used as a support and complement to primary data obtained by researchers. To obtain secondary data, researchers will seek and obtain information through literature studies, and previous research that addresses the same topic. In addition, researchers will use various news sources both offline and online related to the research topic they wish to study. Furthermore, this research will use purposive/based-on-criteria data collection techniques, namely informants who are selected based on certain criteria by the research. The selected informants are expected by researchers to be able to represent each particular category (Margaret & Ardiansa, 2014). The criteria for selecting informants for this study were those who were involved in all aspects of social assistance (Bansos). Parties that will be used as primary sources in this research are the government and society. The government will be represented by the Makassar City Social Service, the sub-district head in Mariso sub-district, the head of the sub-district head in Bontorannu, Panambungan and Mariso sub-districts and the Social Assistance Unit in Mariso sub-district, while the community will be represented by RT/RW and the community receiving social assistance. Researchers took informants from the government because they wanted to know the process of distributing social assistance, the data collection process, the relationship and the role between the Social Service, Camat, Lurah and Social Assistance Assistants as political actors who are responsible for this program and distribute social assistance to the community. For the perspective of recipients of social assistance, researchers will take informants from RT/RW as parties who know the conditions of the community on a small scale and how their relationships and roles are with other stakeholders who are responsible for the provision and distribution of social assistance to the community. Communities as recipients of social assistance are used as informants because they want to know how far social assistance is being used amid the COVID-19 pandemic, the problems and distribution faced by the community in obtaining social assistance from the government. Selection of informant criteria for this study, the authors used the Purpose Sampling technique. The Purpose Sampling technique is a technique for selecting informants with certain considerations or criteria, for example the person is considered to know best about what we expect (Sugiyono, 2018). The reason for using the Purpose Sampling technique is that researchers see that the informants mentioned above are the entities that know best about the phenomenon the author wants to research, namely social assistance. Furthermore, by selecting informants, researchers will know the process of social assistance starting from the procurement process to distribution to the community, this can be known if there are informants from the procurement party (government) and recipients (community). In addition, with this technique, researchers will clearly know the role of the political actors who are responsible for procuring social assistance in Mariso District, especially for social assistance assistants in procuring social assistance. Furthermore, this researcher will find out how the relationship patterns are built, especially between social assistance assistants who are responsible for distributing social assistance as a bridge between the government and the community. So it is hoped that the information that will be obtained by the author regarding the phenomenon under study can be comprehensive, clear and detailed from both the government and the community. The data analysis that will be used by the author in this study will refer to the book written by Creswell. In the book there are at least 6 steps in conducting data analysis, namely First, the researcher will prepare and process the data, then organize it into different types by looking at the information sources. Second, the researcher rereads the results of the data to translate back the information obtained through the informant. Third, coding by organizing words that contain the meaning of a data. Fourth, the coding results describe the presentation of information according to categories. Fifth, the researcher will interpret the findings that have been divided into several categories into detailed narrative forms. Finally, the researcher will interpret the data to find out whether the results found justify previous studies or obtain new research results that do not match the results of previous studies (Creswell, 2014). These analysis steps are useful for both text and image data. Based on the framework of the flow of thought, the researcher intends to explain how the process of distributing social assistance and what kind of impact both procedurally and practically has on the people who receive social assistance. The flow of thought in this research began with the holding of COVID-19 social assistance for the people of Makassar City, but in terms of implementation, many things did not meet the expectations of the community and even tended to harm the people of Makassar City, especially in Mariso District. One of the things that happened was the abuse of authority by social assistance assistants. This phenomenon occurs due to the absence of strong oversight and control from both the government and the community itself, so that the access they have, such as access to information, distribution, or authority they have, is misused for their interests. Thus there are many impacts caused by the behavior of social assistance assistants such as: 1) delays in the distribution of social assistance to the community, 2) Social assistance funds are reduced as they should and 3) there are protests by the community at the Social Service as --- The government social program during the Covid-19 Pandemic in Makassar There is a form of abuse power in the procedural practice There are some substantial issues, i.e., technical and nontechnical. --- Consequences --- Distribution delay Reduced materials Social protest a result of dissatisfaction with performance implemented by implementers. By looking at the phenomena that occur, especially social assistance in Mariso District, researchers have several hypotheses for this study, namely: 1) There is the abuse of authority by social assistance assistants as a result of weak oversight by the Government and the community over the implementing unit of this policy. 2) The phenomenon of social assistance in Makassar also occurs because the organizers of this policy are still incompetent and still stuttering so the implementation is still not in line with the expectations of the people of Makassar City. --- Results and Discussion In the previous chapter it was explained that this research focuses on 3 types of social assistance distributed by the City Government of Makassar in Mariso District, namely the Family Hope Program, Direct Cash Assistance, and Non-Cash Food Assistance (BNPT). Therefore, this sub-chapter will explain clearly the three types of social assistance, starting from the origins of these policies to the policy stage that oversees the three social assistance. --- Different Social Assistance Programs by The Government The Hopeful Family Program or commonly abbreviated as PKH is one of the social assistance programs that has existed since it was first launched in 2007. According to the Ministry of Social TNP2K, PKH is a social protection program through the provision of cash assistance to Very Poor Families (KSM), who have pregnant women, postpartum, or breastfeeding; or toddlers and preschoolers; or have children who are still attending elementary, junior high and high school equivalents; children aged 15-18 who have not completed basic education (TNP2K, 2014). The purpose of establishing PKH social assistance is to break the poverty chain by providing incentives to the poor and needy. But in general, this PKH aims to improve the quality of human resources and change the behavior of relatively small PKH participants. Efforts to improve welfare and break the intergenerational poverty chain are not supported. This goal is also to try to accelerate the Millennium Development Goals (MDGs) (Murah, 2016). However, there are also specific objectives in this program, namely 1) Improving the health quality of RTSM/KSM; 2) Increasing the education level of RTSM/KSM children; 3) Improving access and quality of education and health services, especially for RTSM/KSM children (Cheap, 2016, p. 122). This assistance program consists of various components of assistance which are divided into several types. Further details will be explained through a brief description below (Ministry of Social Affairs, 2019): A. Social support for each household 1) Regular : IDR 550.000/Family/Year 2) With the PKH : IDR 1.000.000/Family/Year B. Bantuan Komponen untuk setiap jiwa dalam Keluarga PKH 1) Ibu Hamil : IDR 2.400.000 2) Anak Usia Dini : IDR 2.400.000 3) SD : IDR 900.000 4) SMP : IDR 1.500.000 5) SMA : IDR 2.000.000 6) Diffable : IDR 2.400.000 7) Elderly : IDR 2.400.000 The mechanism for procuring PKH social assistance has several stages which have been stipulated in the Decree of the Director General of Social Protection and Security Number 02/03/OT.02.01/12/2020 Concerning Technical Guidelines for the Distribution of Non-Cash Social Assistance for the 2021 Family Hope Program. In this stage it begins from the first stage of planning where this process begins to determine how much revenue for this social assistance comes from the Integrated Social Welfare Data (DTKS). Second, Socialization and Education are carried out by special social assistance assistants for PKH to beneficiary communities. The third distribution of KKS or ATM will be used by the recipient community if social assistance is disbursed. The fourth is the distribution of assistance and withdrawal of PKH social assistance funds which are carried out at ATMs that have collaborated with the Ministry of Social Affairs. Fifth Reconciliation of results of the distribution of PKH social assistance and Sixth Monitoring, Evaluation, and Reporting of Social Assistance. For more details, the following is a picture of the distribution flow of PKH social assistance. --- Different social assistance programs by the government In the previous chapter, it was explained about the implementation of social assistance in Mariso District, Makassar City starting from the stages, the number of beneficiaries to the types of social assistance distributed to the community. For this chapter, the author will explain the problems that arose during the process of distributing social assistance in Mariso District, Makassar City. In addition, this chapter will also explain in more detail the results of the interviews that have been conducted by researchers so that it will be clear what all forms of aspirations, complaints, and opinions regarding the social assistance program in Mariso District and the events experienced by the community during the social assistance program took place in during the COVID-19 pandemic. Furthermore, this chapter will explain about stakeholders who have power and interest, whether to use these two things to influence each other so that phenomena that have been determined by higher power or vice versa occur. Likewise regarding the interests of each stakeholder in this social assistance policy. When a program or policy is to be implemented, all elements involved in this program must work well together and carry out their functions and duties properly, so that there is synergy between all parties involved. In the context of the distribution of social assistance in Makassar City, especially in Mariso District, the synergy between stakeholders is still not good enough so in several cases mistakes have occurred which have resulted in the social assistance policy process not being maximized. Why is it that, the implementers do not synergize with each other, starting from social assistance assistants, RT/RW, to the Government itself (Lurah, Camat, and Social Services)? Of all these stakeholders, coordination is not synergistic with one another, so it spreads to other issues as previously mentioned namely Information, Communication, and Data Collection. Apart from that, there were also several matters relating to the implementor who acted not by the existing rules and regulations, resulting in several problems in the procurement of social assistance in Mariso District, Makassar City. The two behaviors of social assistance assistants in the Panambungan Village that are of concern to the community are that all recipients of social assistance must spend their money on the spot. This is done so that the business can run smoothly while according to the provisions of the funds provided by the community can be spent according to the needs of the community itself. Thus it can be said that the social assistance assistant also carries out coercive actions on the community and is biased toward interests. In addition, there are also forms of coercion and intimidation carried out by this social assistance assistant, namely they will carry out blocking actions if the community does not obey what is ordered by the social assistance assistant. Because of this, many people ultimately obey the words of the social assistance assistant so that the ATM which is the access to get social assistance is not blocked by the social assistance assistant (Interview with Chaeruddin Dg Talle, 2022). For funds that have been withdrawn, basically, it has been carried out from 2019 to 2021 with an amount of IDR 9,327,000. This action was carried out before the community protested against this social assistance companion. The recapitulation results are as follows: --- Collective Action Protest Through The Stakeholder Mapping Lense In this study, the community is categorized as a stakeholder subject. In the power versus interest grid analysis, the people, in this case, are stakeholders who have high interest but tend to have little power. What happened in the case of Mariso District where the community was able to change social assistance policies is a unique phenomenon. This is due to the existence of collective action carried out by the community affected by the unfavorable behaviors carried out by the implementor, in fact it succeeded in changing this situation so that it could benefit the community. In the power versus interest grid analysis popularized by Eden and Ackermann, it is stated that every stakeholder who plays a role in social assistance policies can change the program by using the power they each have. But in this context, people who are categorized as subjects do not have power. However, by taking action against the Social Service, Kelurahan and Mariso Sub-District, they were able to change the policy. According to researchers what happened in the incident in Mariso District to social assistance programs is inseparable from the existence of the COVID-19 pandemic. Where in this situation all people are affected both economically, health and welfare of each of them. Social assistance during the COVID-19 pandemic can basically help the community to survive in this pandemic situation. But in reality the program was politicized by several implementers which resulted in the program not running as it should. Moreover, economically the people in Mariso District are areas that are categorized as urban poor. So it is not surprising that the community is protesting because social assistance, which is one of the hopes for survival in the COVID-19 pandemic situation, is actually being used by irresponsible individuals. In the power versus interest grid analysis, it is explained that when a policy change occurs, there will be a process of influencing and being influenced among related stakeholders. In this case, the Office of Social Affairs, Kelurahan and Kecamatan as one of the stakeholders who can influence other stakeholders because of their very high interest and power. However, in reality the people who form coalitions with the mass media are assisted by community leaders who are quite influential in their area. So that what should influence is influenced, in this case it is the Office of Social Affairs as the one responsible for immediately evaluating and making changes to social assistance policies. In the Problem-Frame Stakeholder Map analysis, it is stated that coalition stakeholders will take action to influence each other and even express their interests through various behaviors, such as what to oppose or support. As mentioned in this analysis there are 4 categories namely strong and weak opposition as well as strong and weak support. The phenomenon of protest actions carried out by the community in Mariso District, where the collective movement was able to change social assistance policies in terms of distribution and data collection was the result of the hard work of the community to demand their rights and justice, one of the ways was by forming a coalition with the mass media to get support and be able to spread incidents of abuse of authority from implementers of social assistance policies to all people of Makassar city. In this case, it is clear that the community opposes and acts as an opposition to this social assistance policy, because the people in Mariso District feel disappointed with the implementation of social assistance policies. At first the community was categorized as week opposition, this was because the people who carried out the protest did not receive more attention, especially to implementers who carried out social assistance policies such as the Social Service. But when the community formed a coalition with the mass media and there were also community leaders who voiced the aspirations and complaints of the community, so that what was not heard before became heard by other stakeholders and even changed social assistance policies in accordance with the demands of the people who staged the protest. In other words, the people who were previously referred to as week opposition (weak opposition) have become strong opposition by forming a coalition with the mass media. In addition, this analysis also explains that subjects who have weak power will be taken into account if they form a coalition with other stakeholders, where in this case the community does this by hooking up with the mass media so they can spread this event and put pressure on other stakeholders. For analysis, the Policy Implementation Strategy Development Grid functions for stakeholders, in this case the community, to carry out various strategies so that they can influence social assistance policies, especially those that occur in Mariso District. As is well known, community protests are a form of strategy or effort to influence social assistance policies. Where in effect, this collective action has produced results by changing the distribution and data collection mechanisms of social assistance policies. Therefore this Policy Implementation Strategy Development Grid analysis will provide an explanation of the Mariso District community protest action as a form of strategy to influence social assistance policies. For more details, this analysis presents a table that can explain the success of the protest action as a form of resistance strategy against social assistance policies in Mariso District. As previously explained, the main focus in this research is the community as the main stakeholder in social assistance policies in Mariso District. Previously it has been identified that the community is a subject stakeholder who has high interest but has power. In addition, the community in this policy is the opposition party (opposing), namely those who oppose social assistance policies and changes must be made that emphasize the rights and interests of the community as the target of this policy. In the analysis of the Implementation Strategy Development Grid it is explained that there are 7 things that become the basis for Stakeholders to take action to influence and be influenced in a policy. Interest: researchers identify it as social assistance, this is because the community is an affected entity and social assistance is a form of incentive from the government to be able to survive the COVID-19 pandemic. Resources: As an entity that receives social assistance, the resources in implementing its strategy are social assistance recipient communities. This is because they are victims of the abuse of authority by the implementer, so that the fate and suffering of the beneficiary communities have the same taste as other communities. Channel: Basically the protest action was carried out by visiting the local Kelurahan and Kecamatan offices, but the results had no impact on social assistance policies. So that people use Mass Media as a channel to carry out protest actions so that they can raise what is being fought for to be known by the wider community, especially in Makassar City. Thus, when the community knows about this incident and everyone supports what the people in Mariso District are doing, there will be pressure on other stakeholders, in this case the Social Services, District and Village Offices, to fulfill the aspirations and demands of the people who are protesting. Possibility of Participation: The protest action carried out by the people of Mariso District had an effect on other communities, so that the participation was quite large, especially since the protest was accompanied by a community leader. Level of Influence: Protest actions carried out by the community have a very large influence, moreover the community has formed a coalition with the mass media so that the effects are felt by all the people of Makassar City and other stakeholders. --- Conclusions Based on the discussion and analysis of the Social Assistance Program in Mariso District, Makassar City in previous chapters, this research can conclude what has been done by researchers. This research was conducted based on research questions that had been determined and formulated in the previous chapter, namely Chapter 1 Introduction, namely: "Why can the Community Protest Action in Mariso District, Makassar City change the mechanism, data collection and distribution of COVID-19 social assistance?". This question is a question based on the protests carried out by the community in Mariso District against the implementation of social assistance policies in Makassar City. So that the impact caused by this event has affected the social assistance itself, especially the aspect of the distribution mechanism. Implications: The impact caused by this protest action is a change in the mechanism for distribution and data collection on social assistance policies, due to the pressure from the protests and the news coverage carried out by the mass media. Action: The purpose of carrying out this protest action is to demand a change in social assistance policies, especially in terms of distribution and data collection. This is because these 2 aspects have received great attention from the community as a result of these 2 aspects not going well during the implementation of social assistance policies in Mariso District. The protest actions carried out by the community did not run smoothly at first. This is due to the power relations faced by the community towards implementers, especially for social assistance assistants. Where in this case, there is an element of threat and coercion if the community as recipients of assistance acts excessively and can threaten the position of social assistance assistants. Thus the protest actions carried out by the community did not have an impact on the situation, especially in the ongoing process of implementing social assistance policies. However, the people who received responses such as threats and coercion from the Social Assistance Facilitators took other methods so that they could be heard by the government of Makassar City. This is because social assistance is one of the incentives given to people affected by the COVID-19 pandemic. Therefore, the people held protests again, no longer to the social assistance assistants but to the Kelurahan, Sub-District to the Makassar City Social Service. Apart from that, in this protest action, the community also formed a coalition with the mass media in order to disseminate the situation in Mariso District with the aim that the people of Makassar City could find out what was happening in the implementation process in Mariso District. Moreover, this protest action also presented a community leader named Chaeruddin Dg Tale as a leader in the collective movement, so that the protest action process was carried out synergistically, systematically so that the message conveyed could be conveyed properly to the government of Makassar City. The theory used, namely

This paper analyzed the Makassar government's public policy during the COVID-19 pandemic, namely the social assistance program. In this study, the perspective of stakeholders is taken, in which in this study the community is the main stakeholder. In addition, there are also other stakeholders such as the Social Service, District, sub District, Social Assistance Assistants. This research will explain the implementation of social assistance policies in Mariso District, Makassar and how the community responds to this policy. In addition, in this study, there were protests carried out by social assistance recipient communities in Mariso District, Makassar as a form of disappointment with the implementation of the Social Assistance policy in Mariso District, which proved successful enough to put pressure on so that aspirations and input could be realized and the government evaluated social assistance programs. COVID-19. This research conduct qualitative methods with data collection techniques using interviews with informants, in this case are the stakeholders. This study also uses the Stakeholder Mapping theory which was popularized by Eden, Ackermann and Bryson. This study uses 3 analyzes in this theory, namely 1) Power versus interest grid, 2) Problem-frame stakeholders map and 3) Policy implementation mapping. The Power versus interest grid is used by researchers to see and analyze from the side of interest and power for the community as the main Stakeholder in this research. The Problemframe stakeholders map is used by researchers to see how the conditions of stakeholders, in this case, are the community. How does the community solve problems in this social assistance program and what actions are taken by the community to solve these problems. Policy implementation mapping is used by researchers to describe the strategies carried out by the community to influence social assistance policies, especially in Mariso District, Makassar.

especially in the ongoing process of implementing social assistance policies. However, the people who received responses such as threats and coercion from the Social Assistance Facilitators took other methods so that they could be heard by the government of Makassar City. This is because social assistance is one of the incentives given to people affected by the COVID-19 pandemic. Therefore, the people held protests again, no longer to the social assistance assistants but to the Kelurahan, Sub-District to the Makassar City Social Service. Apart from that, in this protest action, the community also formed a coalition with the mass media in order to disseminate the situation in Mariso District with the aim that the people of Makassar City could find out what was happening in the implementation process in Mariso District. Moreover, this protest action also presented a community leader named Chaeruddin Dg Tale as a leader in the collective movement, so that the protest action process was carried out synergistically, systematically so that the message conveyed could be conveyed properly to the government of Makassar City. The theory used, namely Stakeholder Mapping, can be used to analyze the phenomena studied by researchers, namely community protests against social assistance policies, where the community is the main stakeholder in this policy. The analysis in this theory is 1) Power versus Interest Grid, 2) Problem-Frame Stakeholders Map and 3) Policy Implementation Mapping is able to explain the protests carried out by the community and also the impact of these protests. The researcher uses the power versus interest grid analysis to see what kind of stakeholder the community belongs to and the researcher identifies it as the stakeholder subject. Where these stakeholders have high interest but have low power, so that it can be said in this social assistance policy that the community becomes a stakeholder who has very high interest but their strength as one of the stakeholders is not that great. What is unique in the results of this study is that people who are categorized as subject stakeholders can change social assistance policies, which should be done by stakeholders with higher power. But in reality the community is able to change social assistance policies by forming coalitions with several parties such as the mass media and using community leaders in carrying out protest actions so that their goals can be conveyed properly to the Makassar City government. As previously explained, the Mariso District community protest action was successful and social assistance policies were changed, especially in the distribution and data collection mechanisms. Finally, the analysis of the Policy Implementation Strategy Development Grid functions as an analysis of stakeholders, in this case the community, to carry out various strategies so that they can influence social assistance policies, especially those that occur in Mariso District. This analysis has 7 bases where each base has a function to see how the strategy is and how the effect will be caused by the strategy. 1) The interest in this case is that the community has an interest in social assistance so that it can be carried out immediately in accordance with its original purpose, which is to help people affected by the COVID-19 pandemic. 2) Resources, in this context are social assistance recipient communities. This is because all people in Mariso District who receive social assistance have the same fate, namely to become victims of abuse of authority by irresponsible implementers. 3) Channel, in the phenomenon studied, the community uses access to carry out protest actions through several channels, such as visiting the Kelurahan, Sub-District to the Social Service. Communities also use the mass media as partners in carrying out protest actions so that they can have a broad impact and be felt by the implementers who are responsible for social assistance policies. 4) The possibility of participation can be said to be quite large because most people who receive social assistance become victims of irresponsible behavior by implementers. Moreover, in this strategy the community is led by a community leader named Chaeruddin Dg Tale so that this protest action can be synergistic, systematic and the messages conveyed are well conveyed to stakeholders who are responsible for social assistance policies in Mariso District. 5) The level of influence caused by this protest action was very large, especially when the community formed a coalition with the mass media, the news spread throughout Makassar City. 6) The implication or effect caused by this protest action is a change in the mechanism for distribution and data collection. 7) Lastly is action, where the protest action aims to change policies whose implementation is felt to be inappropriate, especially in the distribution and data collection aspects. So the strategy used to change this is to carry out protest actions and demand changes that lead to equity and justice for the community as recipients of social assistance. --- Informed Consent Statement Written and verbal informed consent has been obtained from the participant(s) to publish this paper. --- Data Availability Statement Data will be provided by the author by request. --- Ethical Review Board Statement Not applicable. --- Conflicts of Interest The author declares no conflict of interest.

This paper analyzed the Makassar government's public policy during the COVID-19 pandemic, namely the social assistance program. In this study, the perspective of stakeholders is taken, in which in this study the community is the main stakeholder. In addition, there are also other stakeholders such as the Social Service, District, sub District, Social Assistance Assistants. This research will explain the implementation of social assistance policies in Mariso District, Makassar and how the community responds to this policy. In addition, in this study, there were protests carried out by social assistance recipient communities in Mariso District, Makassar as a form of disappointment with the implementation of the Social Assistance policy in Mariso District, which proved successful enough to put pressure on so that aspirations and input could be realized and the government evaluated social assistance programs. COVID-19. This research conduct qualitative methods with data collection techniques using interviews with informants, in this case are the stakeholders. This study also uses the Stakeholder Mapping theory which was popularized by Eden, Ackermann and Bryson. This study uses 3 analyzes in this theory, namely 1) Power versus interest grid, 2) Problem-frame stakeholders map and 3) Policy implementation mapping. The Power versus interest grid is used by researchers to see and analyze from the side of interest and power for the community as the main Stakeholder in this research. The Problemframe stakeholders map is used by researchers to see how the conditions of stakeholders, in this case, are the community. How does the community solve problems in this social assistance program and what actions are taken by the community to solve these problems. Policy implementation mapping is used by researchers to describe the strategies carried out by the community to influence social assistance policies, especially in Mariso District, Makassar.

Introduction: Work-Life balance is a concept which acts as the juncture of both differentiation and overlap between work and life. The concept of life here over the years has been understood with various constructions. The components that have been understood to conceptualize life are personal, social, familial and others. The academic construct of work-life balance is a bidirectional one; which essentially translates to that work can interfere with life, and life can interfere with work. Locomotive Pilots is a term that is used as a designation for the individuals who work in the Indian Railways and operate the locomotives which in turn power the trains. The problem is that there is significant work load on the running staff of the railway network, the loo-pilot is an example of such running staff. The themes obtained from the review of literature display that loco-pilots perform an extremely demanding job in terms of work output and efficiency. These jobs require support from the family as well as often result in outcomes of lack of balance and/or neglect towards the family. (Ranjan & Prasad, 2013) (Ranjan & Prasad, 2014) There is direct conceptualization of very frequent travel outstation or base in terms of frequency which also can be for a long time. The job entails associated with tasks requiring continuous monitoring, tasks requiring fine motor skills, and tasks undertaken in hot and humid environments. Shift work for Loco-Pilots is often associated with two occupational stressors: working unsocial hours; and fatigue. (Pradhan, Pattnaik, Panda, & Panda, 2015) These stressors may induce lack of efficiency thus may lead to increased workplace accidents and injuries. Furthermore, excessive fatigue, family and social life disruption may have implications on lower job satisfaction, motivation, and employee well-being. --- Methodology: The research design is descriptive by nature and the tools of questionnaire and semi structured interview have been used to collect data for quantitative and qualitative respectively. 19 respondents who correspond with the designation Loco-Pilot were the participants of the study thus it is a small sample study. The sampling for this study was conducted purposively. The data was collected by visiting the crew lobby with the necessary permissions. The ethical considerations of informed consent and anonymity were put into place. Since, the quantitative could only highlight the findings thus to describe the experiences the qualitative component was also incorporated and narratives were documented. --- Results: The profile of respondents depicted that 12 respondents are married with 1 Child, 5 respondents are married with 2 children, 1 Unmarried, and 1 Widowed with 1 Child (during the interview it came about that his wife passed during the Pandemic). It also needs to be considered that respondents are Loco-Pilots which is a designation and is obtained with increasing years of service thus age also increases proportionally with some exceptions. The insights from the data can interpreted that most of the respondents that is 13 (68.4%) believed that work-life Balance was not maintained, 4 (21.1%) respondents were not sure, and 2 (10.5%) respondents believed work-life balance was being maintained. The respondents mentioned that how it was difficult to provide specific fixed family time because there is the absence of the fixed schedule. The schedule runs according to the crew management system roster and the schedule of train that one operates on a given day which would enable their schedule their time of being at home, departure, and arrival from and at home respectively. The data depicted in the above-mentioned tables provides the insight that 11 Respondents find Calendar Festivals as well as Recreational Activities to be Not Satisfactory whereas rest are distributed between less satisfactory and average. The understanding that can be conceptualized is that the loco-pilots do not get calendar holidays and recreational activities are also less because of the schedule that possess and it is about getting most rest to tackle the fatigue as well as starting the next shift well rested is vital from the perspective of the locomotive pilot. Furthermore, it is not that recreational activities are not being organized but the continuous scheduling of crew limits the access to the recreational activity like sports (for example cricket, football, volleyball). The correlations drawn between variables of Work and Family Life Balance, Recreational Activities, Calendar Holidays and Family Time display that the variables are correlated. The significant correlations that can be depicted from the data are between Recreational Activities and Calendar Festivals with a correlation coefficient of.602 (moderate) and p-value of.008 at 0.01 level and the variables of Work and Family Balance and Calendar Festivals display a correlation coefficient of.839 (strong) and p-value of.000 at 0.01 level. These can both be interpreted as statistically significant which further establishes the argument. As mentioned earlier, stress is common in any individual's life but it is not always from the same sources. --- Frequency --- Calendar Festival It is essential to understand that among respondents who are loco-pilots there arises a need to categorize for conceptual clarity. Thus, the conceptualization of occupational sources and personal sources need to be introduced into the discussion. The occupational sources would include components like nature of shift duty, responsibility of shift duty, bad weather which may have an adverse impact while on duty and others. The personal sources of the stress would associate the personal life vis-à-vis family, health of self and family, parenting, education and establishment of children, and others. The data that has been depicted in Table 4 essentially displays the distribution of the responses regarding the variable of Sources of Personal Stress. 15 respondents mentioned Family, 3 Respondents mentioned Finance, and the remaining respondent mentioned Health, although there were other options which have not featured in the responses. One of the respondents mentioned, "I have been working for 25 years but still work-life balance has not been obtained. The attempt is to juggle between job, household work that one is supposed to do, and spending leisure time with family at best. The workload is essentially high because there is an acute shortage of loco-pilots because the designation is obtained based on seniority and regular recruitment at the level, regular promotions and other factors influence the presence of loco-pilot. Mostly, major festival on Durga Puja and Chhath Puja there are special trains that operate to meet the demand of passenger movement thus our frequency of duty also increases, spending time with family on festivals is a problem." Another narrative that was documented from a respondent stated that, "I hardly can participate in household work. The only contribution is that when I get link rest at base I go to bank and do the necessary work that is to be done. I have only to been to my daughter's school Kendriya Vidyalaya once during admission and after that my wife has had to take over paying school fees, to the regular drop and pick-up, to attending keeping track of her studies, marks, and attending parent teacher meetings." The analysis of the narratives which been documented display that there is direct first-person perspective that how there are different aspects and domains of social and familial life which need to prioritized but not at the cost of each other. There has been the mention of education of children and it is extremely important that there is a role of both parents in it which in this case is extremely difficult to obtain citing the nature, frequency associated workload, and outstation movement. The respondents need to maintain an integrated approach towards it. --- Discussion and Conclusion: There is a felt need to balance and integrate family needs and career requirements. The ability to balance between workplace's needs and personal life's needs is perceived as an important issue among employees globally. The lack of balance can lead to implications like stress, burnout, depression, and lower work contributions. The combination of work and family demands often leads to time pressure, stress, and conflict. (Sanne, 2008) (Srinivas & Reddy, 2013) The respondents are directly trying to manoeuvre the work deliverables, schedule at work which is one of the major reasons for disruption since it flexible and not predictable in terms of both frequency as well as the clock. The respondents do not function ass per conventional clock hours, it is the railway clock which essentially is 24*7. The factors which play a role in scheduling are the nature of trip, the destination, the type of train (mail/express/superfast/premium) and others. Although, there are several factors directly impact the scheduling like an outlier, weather, railway traffic, delays and others are example of these unpredictable factors. The intersection with family needs to be understood as that there are significant areas life children's education wherein both parents are key stakeholders and respondents have mentioned it as a theme in the narratives which they are concerned about because there is a thought that it gets neglected. Also, the discussion of the major finding needs to be understood as railways do not operate as per calendar thus there is the absence of calendar holidays. The intersection is that the family does function as per calendar holidays and spending time with family becomes an issue. Furthermore, vacations for loco-pilots are difficult because it can be planned but leaves for the said days cannot be planned because of link diagram of scheduling that one is functioning upon. The special trains that are operated during specific festivals which have more calendar holidays as mentioned in the narratives increase the frequency of duty of the loco-pilot thus does not have the chance to go on vacation with the family and often ends up missing the original festival because of being outstation with the special trains. The management is conducting programmes for recreational purposes, to increase motivation, but the argument stands that it cannot be substituted in place of work-life balance. Thus, while summarizing it can be argued that work-family life balance for locomotive pilots is an area of concern and there is scope for structured systematic research in the future. --- Conflict of Interest: None

The concept of occupation has become specific specialized, and competitive with time. Locomotive Pilots (Loco-Pilots) are one such specific group tasked with operating the Locomotives in Indian Railways which power and manoeuvre the trains. The themes from the limited literature available in the Indian context (which is mostly quantitative) talks about occupational stress, fatigue, noise induced hearing loss among others. The social life of locomotive pilots is an area which has been problematized that there is lack of balance due to work but can be described further in detail. The objective to document and discuss the balance between work, social life, and family life of loco-pilots. Methodology: The research design is descriptive and the tools of questionnaire and semi structured interview have been used to collect data for quantitative and qualitative respectively. The sampling has been conducted purposively. The ethical considerations of informed consent and anonymity were put into place. Results: There is lack of specific time schedule attached to this job which converts to the absence of specific fixed family time. Further, there are no calendar holidays in their occupation which becomes the concern of leaves not matching the calendar festivals. Also, the calendar festivals enhance the frequency of shift duty (festival special trains) thus lack of leave opportunity. The respondents also mentioned that they miss being a stakeholder in children's education which is another highlight. The occupation poses as a direct challenge wherein the occupational factors tend to affect the social and familial programmes.

Introduction: An eveningness chronotype is generally associated with reduced sleep continuity and quality, as well as social jetlag. Changes in hormones and menstrual phase similarly impact sleep, although research on the chronobiological effects of these changes are equivocal. This study aimed to examine the role of menstrual cycle in daily self-report and actigraphy-assessed sleep in two consecutive menstrual cycles. Methods: Participants (n=51; 43% Caucasian), 18-35 years (23.67<unk>4.68) completed actigraphy and daily sleep diaries over two menstrual cycles (m days=51.29). Four menstrual phases were identified via dates of menstrual bleeding and urinary ovulation testing: perimenstrual (<unk>3 days of bleeding), mid-follicular, periovulatory, and mid-luteal. Relationships between menstrual phase and sleep parameters were estimated using multistep hierarchical linear modeling. Subjective and objective measures yielded the following sleep variables: Total Wake Time (TWTsub and TWTobj), Sleep Efficiency (SEsub and SEobj), and mid-sleep point (MSP). Participants completed the Morning-Eveningness Questionnaire (MEQ) at baseline. Results: Mean cycle length was 28.61 days<unk>2.69. Age was significantly associated with TWTobj (r=-.32, p <unk>.001); SEobj (r=.34, p <unk>.001), and MSP (r=-.42, p <unk>.001) such that older participants had shorter TWT, higher SE, and earlier MSP. TWTobj was 4-7 minutes lower during the mid-follicular (61.54<unk>3.37) and mid-luteal phases (63.11<unk>3.29) compared to the perimenstrual phase (67.54<unk>3.37; p <unk>.001). SEobj was higher in the mid-luteal phase (82.50<unk>0.79) vs. the perimenstrual phase (80.71<unk>0.82, p =.006). Perimenstrual women reported 8-16 minutes longer awake (TWTsub=52.23<unk>5.01, p <unk>.001) and had 1-3% reduction in SEsub (89.70<unk>0.10, p <unk>.001). MEQ negatively predicted TWTobj (p=.004) and SEobj (p=.003), but did not vary across menstrual phase. In morning-type individuals, TST was significantly higher in the periovulatory (b =1.81, p=.01) and mid-luteal phases (b=2.03, p<unk>.001) compared to the perimenstrual phase. --- Conclusion: With increasing age, women experienced reduced time awake, higher sleep efficiency, and earlier sleep timing. Eveningness predicted greater total wake time and lower sleep efficiency. With menstrual phase considered, disturbed sleep was highest in the perimenstrual phase and women reporting a stronger preference for eveningness reported shorter TST during the perimenstrual phase. These findings highlight the importance of considering the menstrual cycle in the sleep health of

Introduction: Studies have highlighted the detrimental impact of family conflict and the beneficial effects of family cohesion on insomnia. Given the Latinx cultural value of familism, which emphasizes the centrality of close, warm family relationships, the quality of family relationships may be an especially important risk or protective factor of insomnia among Latinas. Additionally, a high adherence to marianismo, the constellation of Latinx female gender expectations, may amplify the effects of family relationships on insomnia because it emphasizes the woman's responsibility in maintaining harmonious family relationships. Our aims were to (a)examine the association between family conflict, family cohesion, and insomnia severity and (b) test the moderating effects of marianismo among Latinas. Methods: Using a subsample of cross-sectional data from Latinas participating in the Hispanic Community Health Study/ Study of Latinos(HCHS/SOL) Sociocultural and Sueño ancillary studies(n=604), we conducted weighted, linear regression analyses to test the association among family conflict(Conflict), family cohesion(Cohesion), and insomnia severity(IS). Adjusted models controlled for age, marital status, education, and English/Spanish language preference. A final adjustment was made for depressive symptoms. We conducted moderation analyses(marianismo*Conflict; marianismo*Cohesion) in minimally and fully adjusted models. Conflict was measured using the Family Cultural Conflict subscale of the Hispanic Stress Inventory. Cohesion was measured using a subscale of the Family Environment Scale. Marianismo was operationalized as adherence to the family pillar subscale of the Bem Sex Role Inventory. We used the Insomnia Severity Index to measure IS. Results: Participants were Mage 41.38(SD=13.41). Most women were married(44.74%), earned >high school diploma(39.71%), and preferred to speak Spanish(76.03%). The mean IS score was 8.02(SD=6.76). Conflict was not statistically significantly associated with IS(SE=0.05, p>.05). One SD increase in Cohesion was associated with a 0.10 decrease in IS in minimally adjusted models(SE=0.05, p=0.04), but was not statistically significant after adjusting for depressive symptoms. Marianismo did not moderate these associations. Conclusion: Greater cohesion emerged as a robust predictor of reduced insomnia severity in one of the first large-scale studies examining the effects of sociocultural factors on Latinas' sleep. If replicated using longitudinal data, findings suggest that developing family-based interventions amplifying cohesion, rather than decreasing conflict, may be more beneficial for reducing insomnia among Latinas. Support (if any):

INTRODUCTION The notion of life quality comprises various elements, such as: material goods, safety, including economic security, health, membership of certain social groups, and environment. Each of these elements can be considered in the objective context, but evaluation of life quality depends on the subjective level of fulfilling the needs in each of these domains. The applied methods of survey and interpretation of results concerning the discussed phenomenon vary among particular branches of science. In spite of various research tools, no single definition of life quality has been drawn up to-date, and problems with the meaning result from the multi-aspect character of this concept [1,2]. Nevertheless, quality of life is largely a subjective value and depends substantially on the mental state, personality, or system of values of a given person. One of the factors influencing human life in our civilisation is professional work which is the basis of a person's existence [3]. The outcome of work is not only creation of material goods but also the shaping of life quality. Professional work contributes to well-being and, according to the authors, is the basis of self-identity, especially for middle-aged people [4,5]. In the system of values of a contemporary human, professional work has considerable significance as the basic form of activity for an adult, a measure of achievements, security and quality of life [3,6]. On the other hand, lack of work is one of the reasons for deteriorated mental condition associated with new demands and the need to adapt to this situation. Unemployment changes previous relations with the environment, cuts-off the advantages connected with professional work, frequently alters the position in the family and among friends, and influences one's views on ethics, religion or politics [7,8]. Research on life quality of people who have lost their jobs due to various reasons, or have never been employed, demonstrates that their life is not the same as the life of working people. This is a completely different way of functioning, connected with another system of values and possibilities. Thus, it seems that the phenomena of unemployment and an insufficient number of nurses and midwives in Poland are basically shaped by issues connected with the broadly understood quality of life of people pursuing these professions. Research on the life quality of medical staff frequently takes into account the physical aspect, related to efficiency of basic physiological functions. An increasing number of patients who are elderly or need intensive care, as well as work in a forced position or at night, negatively influence the physical state of medical employees [9][10][11][12][13]. Deficits in this area cause characteristic symptoms in the emotional sphere, such as mood changes, anxiety, proneness to depression, over-sensitivity and lack of self-control [14]. The presented study focuses on the psychological and social aspects, due to the specific character of the work, of nurses and midwives who are exposed to imbalances in these domains. Apart from the detrimental physical factors, nurses and midwives are susceptible to tiredness, sleep disturbances and stress [15]. Constant availability, bearing responsibility for the health and life of patients, as well as stress connected with witnessing death and suffering, enhance negative feelings. Consequently, physical workload is accompanied by mental strain exerting a direct influence on the psychosocial domain of life quality. --- OBJECTIVE This study attempts to explain differences in the subjective evaluation of the psychological and social aspects of quality of life in the group of nurses and midwives. --- MATERIALS AND METHOD Examined group and selection. The general examined population comprised nurses and midwives from the Lublin province in eastern Poland. The sampling frame was based on reports of the Main Chamber of Nurses and Midwives and on registers of the Regional Labour Office in Lublin. In order to select the examined group and to enhance its representative character, random stratified-systematic sampling was applied. Stratified sampling was used to select health care centres and Labour Offices, whereas systematic sampling was applied to determine the number of respondents in particular institutions. The selection encompassed a total of 1,200 nurses, who were professionally-active or unemployed nurses and midwives from the city of Lublin, and the following towns in Lublin Province: Pu<unk>awy, <unk>widnik, Hrubieszów, Lubartów, Zamo<unk>, Kra<unk>nik, Parczew, W<unk>odawa, Radzy<unk> Podlaski, Janów Lubelski, Che<unk>m, <unk>uków, Mi<unk>dzyrzec Podlaski and <unk>czna. The research had the character of diagnostic survey. The respondents received anonymous questionnaires and were asked to fill them in and send them to a given address. On the basis of the returned questionnaires, 620 respondents (315 nurses and 305 midwives) were qualified for the study; the remaining questionnaires were not sent back or had significant gaps. Among the 315 nurses, 144 were professionally-active, while among the 305 midwives -157 were professionally-active. In the group of nurses there were only 6 men (1.9%) and in the group of midwives -just 2 men (0.7%). Due to such a small share of males, no statistical analysis in relation to gender was carried out. The study was approved by the Bioethical Commission at the Medical University of Lublin (Permit No. KE024/71/2016). Measurement tool. The applied research tool was generic questionnaire WHOQOL-100 [16], supplemented with a set of demographic questions. In the introduction to the questionnaire, the respondents were familiarised with the purpose of the study and asked to complete the questionnaire thoroughly, and were guaranteed anonymity. The first part of the questionnaire contained questions for creating a profile of the overall quality of life, general health and 6 domains of life quality: • physical (pain, discomfort, sleep, rest, energy, tiredness); • psychological/mental (appearance, self-confidence, positive and negative feelings, perception of one's own body, self-esteem); • social (social support, personal relationships, sexual activity); • environment (security, material resources, access to health care, access to information, spare time); • independence (dependence on medication, work/learning ability, mobility); • spiritual (importance of faith and religion in life, significance of faith in dealing with problems). The independent variable was a respondent's declaration as a working or an unemployed person. Dependent variables which could modify the relation: quality of life -occupational status were: age, marital status, place of residence and education. Overall quality of life was also evaluated. Raw scores of the examined individuals were presented on a scale of 4-20 (irrespective of overall quality of life measured on a scale of 1-5). --- Statistical analysis. The results of the research were statistically analysed with SPSS software. The choice of the statistical methods used in the study was conditioned by the kind of data contained in the questionnaire. Descriptive statistics were calculated for quantitative variables, while parametric Student's t-test for independent variables was used to test the significance of differences between average values, with checking of equality of variances by Levene's test. For analysis of dependences of qualitative features, multifield Tables and non-parametric Chi-square test were used (if necessary -calculated with Yates' correction), as well as Fisher's exact test. The outcomes of tests p<unk>.05 were regarded as statistically significant. Furthermore, at interpretation of extended frequency Tables the Parteo principle was taken into account, also known as the 20:80 rule, according to which 20% of the respondents represented 80% of the examined phenomenon. --- RESULTS The average age in the examined group of nurses was 42.6 (for the unemployed nurses -33.8), whereas in the group of midwives it was 41.2 (for the unemployed midwives -30.4). There was a noticeable majority of younger people in the group of unemployed nurses (age 26-35) and midwives (age [18][19][20][21][22][23][24][25][26][27][28][29][30]. Both in the group of nurses and midwives, most people were in a relationship, lived in towns and had secondary education (Tab. 1). The analysis demonstrates that overall quality of life was evaluated as satisfactory by the respondents both in the group of nurses and midwives. It is worth noting that unemployed midwives rated this variable higher (M=14.29) than working midwives (M=13.55). In the case of working nurses, the situation was the opposite (Tabs. 2, 4). Furthermore, the mental and social domains were evaluated more favourably by unemployed midwives (M=12.85; M=13.17) than by nurses from the same group (M=12.73; M=12.74). The evaluations assigned by the respondents to particular domains of life quality were similar. However, those who were professionally-inactive made slightly better evaluations in comparison with those who were working. Professionally-active nurses evaluated the mental domain less favourably (M=12.33) in comparison with unemployed nurses (M=12.73), and the difference in average values was statistically significant (p=.043) (Tabs. 2, 3). In the group of midwives there were considerable differences in each discussed domain. Unemployed respondents evaluated overall quality of life (M=14.29; p=.005) and mental domain (M=12.85; p=.009) more favourably. The social domain was evaluated lower by professionally-active midwives (M=12.73; p=.022) (Tabs. 4, 5). Moreover, the analysis of other domains, not included in this study, showed statistically significant differences in the physical domain (p=.01) and the independence level (p=.005) in relation to the group of unemployed nurses -higher evaluations. In the case of unemployed midwives, there were statistically significant correlations in higher evaluation of environment (p=.000) and independence (p=.001) domains. --- DISCUSSION It is generally believed that unemployment has an adverse effect on the quality of life and health, and is a factor undermining self-esteem and self-confidence [17][18][19]. Nevertheless, the presented study demonstrates that evaluation of overall quality of life and its particular domains varied considerably in the groups of nurses and midwives, depending on their occupational status. It is also worth noting the paradoxically higher quality of life in the mental and social domains among unemployed nurses and midwives. In this case, the hypothesis about work as a beneficial factor is not confirmed. As shown by the descriptive analysis, the majority of the unemployed people (70.8% of nurses and 55.4% of midwives) were in a relationship; therefore, the high evaluation of life quality may result from greater support received by the unemployed from family and friends and, as a consequence, certain types of protective behaviour. However, research by Gholami does not confirm this assumption [20]. Furthermore, positive evaluation of life quality by the unemployed may result from their satisfaction with having spare time and considerable freedom, or high self-esteem [18]. This was not confirmed by the study, revealing worse overall quality of life and the mental domain in working nurses, due to depression and other health concerns [15,20,21]. Quality of life significantly correlates with the subjective condition of physical and mental health. Positive evaluation of the latter domain facilitates coping with stress at work, protects from emotional exhaustion and contributes to a positive attitude. On the other hand, negative feelings in the physical domain undermine mental health [22]. A person's quality of life is always a subjective feature, largely dependent on the person's mental state, personality traits, preferences and system of values. The mental domain exerts enormous influence on an individual's functioning within society. It seems that employment should improve evaluation of life quality in this domain and unemployment should have the opposite effect. However, according to the current study, evaluation of life quality in the mental domain was lower in the group of working nurses and midwives than among those who were unemployed. The above-mentioned outcomes are not reflected in the results of research indicating worse mental health in unemployed people [18,23]. The character of work in health care is associated with high exposure to occupational stress [24,25]. Emotional demands are especially significant, such as the need to cope with negative feelings resulting from everyday contact with illnesses, difficult situations of life, and sometimes with death of patients. These factors can significantly decrease evaluation of life quality in the mental domain. Nevertheless, literature on the subject offers a psychological profile of an unemployed person: of low self-esteem, dissatisfied with his or her situation, but with a positive goal of finding a job. [4,20,21]. Therefore, it can be supposed that since the majority of unemployed respondents are young people, below the age of 35 (52% of nurses and 58.1% of midwives), they evaluate quality of life in the mental domain less favourably [21,27]. However, the situation is exactly the opposite, which may result from higher adaptation abilities of young people and their conviction that current unemployment status has only a temporary character. On the basis of the results of research in occupational psychology, it can be claimed that the broadly understood quality of interpersonal relations at work is an important factor in satisfaction with work and good mental and physical condition of an employee. Certainly, the strength of this correlation depends on the type of work. The specific features of the professions of a nurse and a midwife include the relations with colleagues, doctors and superiors. The positive influence of colleagues and superiors is especially important for mental and physical well-being. The situation of unemployment alters the sphere of social contacts [1,4]. An unemployed person no longer feels wanted and his or her social role changes. The situation of unemployment typically brings stress, insecurity, aggression, depression or apathy, which largely influences social relations [28]. However, the outcomes of research in the group of nurses reveal that those who were working evaluated life quality in the social domain lower than those who were unemployed. Similarly, in the group of midwives, life quality in the social domain was rated lower by employed midwives and higher by the unemployed. The research conducted by Ergun also demonstrates that this domain is rated significantly lower by professionally-active nurses [26,29]. The above-mentioned differences may result from overlapping of the mental and social domains which transfers psychical tiredness onto social relations and, consequently, risk of alienation [29], especially among single people [30]. Therefore, social support seems to be crucial, especially at work. This includes: feedback, advice and instructions improving effects of work, and praise. According to Ratajczak, such social support from superiors and colleagues is a factor highly conducive to a sense of satisfaction with work and life [31]. The authors' research seems to show that in the Polish realities, social support at work in the group of nurses and midwives is insufficient. On the other hand, the outcomes of the NEXT programme research indicate that in the professional environment of nurses in Poland the condition of interpersonal relations and social support can be regarded as satisfactory, in comparison with other examined countries [32]. Juxtaposition of the authors' results with outcomes achieved by other researchers was not easy due to few studies comparing the two groups -of professionally-active and inactive people. This study attempted to discover the motives for the paradoxically higher evaluation of life quality in a group of unemployed people. Nevertheless, in order to determine the real reasons, it is necessary to continue the research, taking into account methods of qualitative evaluation. --- CONCLUSIONS 1. Paradoxically, unemployed respondents made typically more positive evaluations of the examined phenomenon. 2. Employment is not a factor positively influencing quality of life and its psychosocial dimension. 3. Higher evaluation of life quality among unemployed respondents may result from the buffering impact of social support.

Objective. The objective of the study was to explain differences in the subjective evaluation of the psychological and social aspects of quality of life in a group of working and unemployed nurses and midwives. Materials and method. The survey was conducted in a group of 620 professionally-active and inactive people (315 nurses and 305 midwives), selected by random stratified-systematic sampling. The tool used to gather empirical material was the standardized questionnaire WHOQoL-100. Results. Professionally-active nurses evaluated the mental domain less favourably (M=12.33), compared with unemployed nurses (M=12.73), and the difference between average values was statistically significant (p=.043). It is also worth noting that in the group of midwives there were significant differences in each discussed domain. The unemployed respondents evaluated more positively the overall quality of life (M=14.29; p=.005) and the mental domain (M=12.85; p=.009), while the social domain was evaluated less favourably by the professionally-active midwives (M=12.73; p=.022). Conclusions. Paradoxically, those who were unemployed made slightly more positive evaluations in comparison with the professionally active. Professional work is not a factor preferably affecting the quality of life and its psychosocial dimension. The higher quality of life of the unemployed respondents may result from the buffering impact of social support.

Introduction Over the course of 2020, the numbers of COVID-19 cases rose, fell, and re-surged in many Western nations. This reflected the ineffectiveness in 2020 of many Western nations to 'flatten the curve' (Fig 3), amid substantial heterogeneity of infection levels and public and government responses. Groups repeatedly gathered unprotected in 2020, despite the public health recommendations against it [1]. More understanding is needed on the acceptability of different behavioral transmission interruption strategies in context with their effectiveness [2,3]. With important lessons for future policy, the events of 2020 reflect a familiar challenge, in that the more successful a preventative strategy is (e.g. slowing an epidemic like COVID- 19), the more public demand there is to relax those successful efforts before the threat has actually passed [4][5][6]. This recalls the 'Icarus paradox', or failure brought about by the same strategy that led to initial success [7]. Successful preventative public health measures can facilitate the illusion that they were unnecessary in the first place. A virus such as COVID-19 is partly invisible as it is not only contagious without obvious symptoms [8] but inadequate testing of populations [9] meant that undocumented infections likely outnumbered documented infections by an order of magnitude [8][9][10][11][12]. These factors (along with mixed public messaging [13]) led to underestimated risk perceptions of the virus, which for many people were overshadowed by more transparent concerns, such as financial constraints [14,15]. While the 'Icarus paradox' has been investigated in epidemiology and community medicine studies, the complexity lies in the multiple drivers of behavioural change, including information and social learning [16][17][18][19]. Ideally, decisions would be determined by their intrinsic payoffs within their socio-ecological environment [20]. In the real world, decisions are made by people who combine observational learning, which produces noisy information, and social learning, which diffuses that information to others [21,22]. The transparency of learning is a crucial parameter [23]; the less transparent the payoffs are, the more noise and heterogeneity enters into the behavoral dynamics [24,25]. While humans are motivated to avoid cues associated with pathogens, through emotions such as fear or disgust [26], COVID-19 and similar viruses display few cues in asymptomatic cases [27]. If the pathogen is less visible than the behaviors of peers, avoidance behaviors will be less effective at preventing the pathogen's spread. In this situation, most people would underestimate the threat based on personal observations of infected individuals. Hence, while general social distancing would be more protective than avoiding/isolating only those individuals with obvious symptoms, its benefits may be less transparent than its economic and psychological costs [15,28,29]. This suggests that drivers of social distancing include two dynamic factors: observable risks and observable behaviors. The risk of infection may not become apparent until the epidemic has become widespread. At the same time, social distancing that is more visible (e.g., maskwearing or conspicuous lack of people in public spaces) may be adopted through social influence and conformity even before its benefits are widely observed [17,30]. Subsequently, as the true benefits become more transparent to the public, individual cost-benefit decisions can support the behavior, in place of social conformity. Here we frame the impact of the 'Icarus paradox' as dependent on information and timing, incorporating differential age-based cohorts impacts to reflect both increased influence from peers [31] and the well-publicized age-stratified risks from infection [32]. At what point do individuals observe enough infections around them to adopt preventative behavior as their own cost/benefit decision? Before this point, in the absence of government directives, social norms may be needed to encourage protective behaviors as people are not yet observing many infections. We expect that early in an outbreak, the link between protective behaviors and being uninfected will not yet be transparent. As infection prevalence increases, and the benefits become more obvious to individuals, social learning becomes less necessary to facilitate preventative behaviors. We believe new insights are offered by modelling the interacting effects of noisy information and social learning on behavior. We take the approach of discrete behavioral choice with social influence [33][34][35][36], where we model decisions as based on a separable combination of two components: observational and social learning. Importantly, the underlying physical contact network through which a disease might spread [37][38][39][40][41], which can be mitigated by physical distancing, are different than the social learning pathways of information, behaviors, or beliefs [18,41]. Social learning can take place via a variety of media and daily communicative activities, whether physically close or distant. --- Model In order to model observational and social learning, we combine aspects of quantal response models [42,43], which use a probabilistic (logit) choice function that allows errors in payoff estimation, with social learning of variable transparency [33,44,45]. Our model falls within the family of binary decision models with "positive externalities," meaning that the probability that one individual will choose a certain behavior will increase with the relative number of others choosing that same behavior [34,[46][47][48]. The difference with our model lies in the feedback between these externalities (social learning) with disease dynamics (observational learning). As the dynamics are complex, we use an agent-based model (ABM) that explores two related dynamics: good protective behaviors reduce the transmission of the disease, whereas observing other infected individuals encourages (through observational learning) the adoption of protective behaviors. The aim is to tease apart the timing and impact of these different mechanisms for influencing individual behavioral choices over the course of an outbreak. --- Observational learning The individual observational learning component is governed by the payoff difference between options, based on information people receive or observe to form beliefs about their health risks [17,18,41,49,50]. For example, the perceived utility of social distancing likely increases as more illnesses are observed. In a country like the U.S., where social distancing is complicated by numerous factors both political and socioeconomic [15,51], we see nevertheless that the number of cases predicts a measure of social distancing such as mask-wearing. As shown in Fig 1a, the relationship between mask-wearing [52] and infections per square mile (from the second week of July 2020) is sigmoidal. This is consistent with typical formulations of discrete choice theory or quantal response theory, the probability that an agent chooses choice i at time t is proportional to e kU i <unk>t<unk> <unk> i <unk>t<unk>, where <unk> is the transparency of choice and U i (t) is the intrinsic utility of the choice, and i (t) is a noise term [33,34,42,53]. Normalized across all choices, the sigmoid is shaped by two parameters. One parameter for this is the point at which one option has a higher utility than the other, U i > U j : we call this the 'inflection point', <unk>. In our model, this inflection point represents the level of viral infections people perceive (assumed proportional to the number of infections in the age cohort) that signals the positive utility of social distancing in reducing infection risk. This average inflection point is a convenient modeling assumption; in reality there would be a distribution among the population as well as an 'identification problem' in detailing how a group's average behaviour influences its individuals [54,55]. The second parameter for the observational learning component is transparency of choice, <unk>, which governs the steepness of the sigmoid curve: the higher the transparency of choice, the steeper the shape becomes, i.e. the smaller the variance in selecting the highest utility, U. In the real world, transparency might range from a clear, government-issued stay-home order (transparent), to seeing another person coughing, to a cacophony of conflicting media messages (non-transparent). Although these are quite different sources of information, they ultimately feed into an individual's estimate of their own risk. To a first approximation, this risk estimate from observational learning amounts to the infection rate around the person adjusted for the person's age. We represent this as follows. Given I a, the proportion of infected individuals in the cohort, a, the probability for an individual i to switch from 'non-adherent' status, NA, to 'adherent' status, A, is defined as: P<unk>a; NA! A<unk> 1 1 <unk> e <unk> k<unk>I a <unk> n<unk>1<unk> where <unk> represents the transparency of choice-determining the steepness of the sigmoid curves-and <unk> defines the point at which the individual has a 50% probability to switch to adherent status, A. The influence of <unk> and <unk>, respectively, on the probability of adoption, P, is illustrated in Fig 2. In reverse, the probability for an individual to switch back from adherent to non-adherent behavior, given the fraction of the age cohort who are not infected, (1 -I a ), is: P<unk>a; A! NA<unk> 1 1 <unk> e <unk> k r <unk>1<unk> I a <unk> n r <unk>2<unk> where <unk> r is inflection point for reverting to NA behavior (and can be different from <unk>) and <unk> r the steepness of the curve use to calculate the probability of switch back to NA decision (and can also be different from <unk>). --- Social learning Social interactions play an important "role in mediating the spread of social contagions that impact health outcomes," [41]. Here we treat social distancing and related protective behaviors as'simple' [41] contagions: copying what others do (e.g., wear a mask upon seeing someone else wear one). For our aggregated scale of modeling, we assume social influence operates 'as if' each person copies a currently healthy person, randomly encountered in the population, within a certain social or physical distance. The effect of the frequency of copied behaviors is stochastic, where probability of selecting option i at a time t is proportional to its current frequency or popularity, p i,t [33,34,54]. We also assume that social learning of simple behaviors (as opposed to complex skills learned over years) is biased by similarity, in that agents copy others within their cohort (a cohort could be age, political affiliation, etc). For convenience, this assumption conflates two observations, that: (a) cohorts tend already to share similar beliefs and preferences, derived from both ontogeny and broadly shared socio-economic landscape during early years of development [56][57][58][59][60][61][62], and (b) conformity tends to be age-dependent with cohort-biased social learning [63]. --- Agent-Based Model (ABM) The ABM (Fig 1b, Algorithms 1 and 2) consists of agents who are involved in two inter-related processes, the contagion of a disease in SIR fashion [64], and the spread of protective behaviors through a combination of individual and social learning. Agents move in a grid, with a normally-distributed range of speeds. The ABM is initialized with 500 agents and one infected agent. Within this space, an infected agent can infect an uninfected agent that is not socially. At the same time, agents of similar age are observing the levels of infection as well as protective behaviors, and adjusting their behaviors according to the observational and social learning rules described in Eq 1. --- Algorithm 1: Main Algorithm Data: N: number of of agents, t step : number of time steps, P <unk>b<unk>: vector with the probability of infection for different behaviors, b d: the distance between two agents under which the disease can be transmitted, i 0 : the number of initial infections, p: the probability of observational learning, r: radius within which individual can learn socially <unk>: transparency (steepness of the sigmoid), <unk>: inflexion point of the sigmoid, <unk> r : steepness of the reversion sigmoid, <unk> r : inflexion point of the reversion sigmoid, The algorithm of the ABM (Algorithms 1 and 2) relies on two main functions, one (genera-tePopulation) that generates the initial population of agents and the other (selectModel) that allows agents to copy the behavior of another agent, who must be both non-infected and within the same cohort, within radius r of the agent. Table 1 summarises its adjustable parameters. Result Simulations were run with the parameters in Table 1, with the population initialised as described by the Algorithm 2. Some parameters were fixed (N, d i, i 0 ). Initial behaviors were all non-adherent to start each simulation. The speeds were sampled from a normal distribution S N <unk>1; 0:2<unk> and recovery times were sampled from a uniform distribution R * U(8, 14) <unk> 24. The parameters were selected such that, overall, agents encounter a mean of 12 individuals per 24 time steps, such that each time step represents one hour. The recovery times in the SIR model were thus calculated to represent 8 to 14 days as a reasonable approximation for COVID-19 [65]. To explore the impact of learning on the disease outcomes over the course of an outbreak, we ran three sets of models. We first ran two baseline conditions in which individual behavior is held constant as either non-adherent (worst case scenario) or adherent (best case scenario) over the course of the simulation. We subsequently ran the models with the parameters described in Table 1 after initializing the population following Algorithm 2. In all, we ran 826,892 simulations and recorded the number of infected agents at each time step in each simulation. Algorithm 2: Generate a population of agents To summarize our simulations in a way that captures the 'flattening the curve', we focused on two metrics: (a) the maximum number of infected people I max, and (b) the time to reach this maximum <unk>. As in Fig 3, the 'flat' curve has lower I max and larger <unk>. Across all simulations, we recorded the largest and smallest maximum total infections among all the runs, as max (I max ) and min(I max ), respectively, as well as the longest and shortest times to reach the max, as max(<unk>) and min(<unk>), respectively. Since these dimensions will tend to be inversely correlated, we defined a metric, <unk>(s), for a set of simulations s summarizing both: d<unk>s<unk> 1<unk>4 1 2 1 <unk> t <unk> min<unk>t<unk> Dt <unk> I max <unk> min<unk>I max <unk> DI max <unk>3<unk> where <unk>I max = [max(I max ) -min(I max )] and <unk> = [max(<unk>) -min(<unk>)], from all simulations. Whereas our results below involve the simulation just described, we also explored three alternative scenarios, described in the S1 Text. In the first scenario individuals could copy any other individual via social learning, rather only those seen to be healthy. In the second scenario, part or all of the initial population already adhere to social distancing. The third scenario allows learning only after a certain number of time steps. The results yielded by those three alternative scenarios are given in the S1 Text but do not differ from the one presented in the next section. --- Results and discussion Our simulations produced meaningfully different outcomes that varied in the success of 'flattening the curve' (Fig 4,left). This reflects the expected patterns of outbreak curves under the impact of social distancing. Our simulations reveal multiple possible outcomes of behavioral mitigation, from 'flat' infection curves to full, unchecked outbreaks (Fig 4, right), some of which are direct illustration of the Icarus paradox. Which learning parameters yielded the 'flattest' curve? The simulations reveal a mix of parameters underlying the best preventative outcomes. Among the simulated outbreaks in which <unk> were minimized-what we call the 'best' outcome-the transparency and inflection points (<unk> r and <unk> r ) for reversion to non-protective behavior needed to be more constrained than the respective parameters (<unk> and <unk>) for choosing protective behavior. terior distributions of <unk> versus <unk> (adopting protective behaviors) and of <unk> r versus <unk> r (reversion back) on the left and right, respectively. Note particularly that the parameter regions flip-flop between adopting and reverting back. In other words, for the 'best' outcome, it is better to have low <unk> for adopting protective behaviors but then high <unk> for reverting back to non-protective behavior (see the cross-sectional distributions along the axes of each bi-variate plot in Fig 5,lower row). At the same time, for the 'best' outcome <unk> can be virtually any value for switching to protective behaviors, but needs to be quite high for reverting back. This exemplifies the 'Icarus' paradox: when preventive actions triggered by environmental cues bring about improvements that subsequently trigger premature relaxation of those preventative behaviors. As a qualitative interpretation of the asymmetric effects of <unk>, the desired 'flat' curve is achieved through low transparency of choice in adopting the protective behavior, but high transparency about whether to revert back. Qualitatively the same is true of the inflection point, <unk>, which needs to be low in adopting the behavior but high in reverting back, in order to yield a 'flat' infection curve. These results suggest the 'best' outcomes involved a 'ratchet' effect: a low, fuzzy barrier to adopt the behavior but a high, sharp (transparent) barrier to revert back. Our results imply that combined observational and social learning can drive successful mitigation strategies (Fig 4), even with differential, age-based disease risk. In an 'Icarus' scenario, where an initially successful strategy can lead to its own failure, the timing of these forms of learning are crucial. Those simulations yielding a flat curve generally required either low transparency of choice, low inflection point for adopting the behavior, and/or high inflection point Comparing the mean trajectories of SIR model where agents do not learn and instead continue in their initial behavior, with trajectories generated by simulations.Red curve: all agents are non-adherent to social distancing and stick to this behavior. Blue curve: all agents adhere to social distancing. Dashed red line: mean trajectory of the 1, 000 worst simulations. Blue dashed line: mean trajectory of simulations run with the parameters selected in the 1, 000 best simulations with regard to <unk>. Vertical gray line: status after 150 time steps. Right: Distribution of 826, 892 simulations given two different metrics: the maximum number of infected people (y-axis) and the time to reach this maximum (x-axis). The colors represent different class of the simulations ranked given <unk>, the metric defined in Eq 3. https://doi.org/10.1371/journal.pone.0262505.g004 for reversion back to non-protective behavior-in other words, a reluctance to give up the protective behavior is more important than a low threshold to acquire it (Fig 5). While it is not surprising that strong maintenance of risk-averse behaviors would protect a population, the low, fuzzy barrier to adopt these behaviours is notable and shows parallels to theory on the diffusion of innovations [48,67,68]. The challenge is that the risk needs to sufficiently observable to the populations that need to undertake meaningful chance. Hence protective behaviors may be not be adopted until infection rates are very high, especially if most symptomatically infected individuals are not be publicly visible (e.g., remaining at home or in hospital, or else segregated by age). For this reason, low transparency of choice-such as poor or conflicting information -can 'jump-start' adoption of protective behaviors by stretching out the inflection into a range, such The two-dimensional areas represent the 70% and 90% HDR (High Density Region) i.e., the smallest areas within which respectively 70% and 90% of the parameters combination fall (for the mathematical definition of HDR and how they can be represented see [66]. Lighter colors represent the 90% HDR whereas darker represent the 70% HDR. The top row represents the value for those parameters that minimize (in blue) or maximize (in red) the number of infected people at time step 150. The bottom row shows the parameters that minimize (in blue) or maximize (in red) <unk> (as defined in Eq 3) at the end of the simulation (1500 time steps). Marginal posteriors for each parameter are drawn in the margin. https://doi.org/10.1371/journal.pone.0262505.g005 that some individuals'mis-estimate' infection risks as enough to trigger their decision (see Fig 5). However, this result relies on the breadth of the distribution of responses to low transparency, rather than an alternative case in which either leadership or social norms cause low transparency to lead to greater average hesitancy to take any action [69]. Social learning dynamics are crucial, as "copying recent success" is often highly adaptive [70]. If symptoms/prevalence of a disease are transparent, copying healthy individuals ('success') should increase protective behaviors. Because COVID-19 can be asymptomatic, however, infected individuals may seem healthy, such that non-protective behaviors can be copied even through a "copy success" strategy. This lack of transparency may critically compromise learning-only strategies for successful disease risk containment. By being aware of this effect, policies could be better crafted to forestall eventual rejection and thereby remain more effective in the longer term. These effects may be heightened among young people, for whom COVID-19 infection is more frequently asymptomatic [27] and who are also socially influenced by peers in their cohort [63]. Hence, while lower fatality risk from COVID-19 may help explain why some groups of young people rejected social distancing early in the U.S. outbreak [1], another important dynamic has likely been social conformity and lack of transparency about infections among their peers. One limitation in our simulations is that we employed a broad definition of observational learning, as agents estimate infection rates with some degree of precision (transparency). Observational learning is heterogeneous; at any given moment, each person observes different information and a different segment of the population. The real world encompasses myriad information sources, individual experiences, and biases. Also, information from media will have a different effect on decision-making than having friends and family become ill [71]. Individuals who follow stay-home protocols have different interactions than those who interact in public spaces. Taken together, these processes affect the transparency of how observably protective behaviors relate to disease risks. These considerations are particularly relevant for mitigating pandemic spread where strong governmental control is not possible. When individual choice is the driving factor in protective behaviors, cohort effects become important since different demographic segments of societies are likely to be more initially risk-averse than others. In terms of age cohorts, for example, older individuals may be early adopters of adherent behaviors because news reports of mortality rates in older populations create a psychological burden of fear. By contrast, younger and/ or more economically limited individuals may delay switching to behavioral adherence, doing so only when they feel their circumstances allow it. In such cases, the socioeconomic and demographic representation of a population may be the critical drivers in determining whether individual behaviors, guided by learning, can be relied upon to effectively achieve outbreak mitigation by adherence to social distancing. In our models, we have also assumed that choices are rational and focused only on epidemiological risk. Human decision-making is never fully rational, especially during period of stress [72]. Further, we have here explored only one potential route of social learning, in which individuals simply copy the behaviors of perceived healthy individuals. More nuanced approaches may emphasize preferentially copying people who share your beliefs, alignment with deeplyheld beliefs or values, and other social learning strategies [41,[73][74][75]. Similarly, we have construed frequency of contact within a spatial radius to be the only medium for social derivation of learning. In reality, of course, individuals have many means of arriving at their sense of what other people are doing, including unique personal experiences and personal choice of media, however complicated or accurate [41,[76][77][78]. This raises many interesting questions, such as the different effect of centralized versus diverse media, for example. Given our parsimonious starting point, future expansion and testing of our models can address these potentially important features of social groups. We also focused on public health measures that could be quickly adopted, in the initial case where sweeping lockdowns are not politically feasible. Our model examines the initial transient coupled dynamics directly following the introduction/emergence of a novel pathogen threat. The model proposed here focuses exclusively on the first, major wave of infections. While our contribution has been to couple the social and individual responses, we note that even in an asocial awareness model, a pandemic peak can become a prolonged plateau rather than a sharp peak, if individual transmission decreases in response to awareness of the disease at a population level [16,79,80]. The past two years have witnessed multiple surges of COVID-19 in many countries, including the U.S., for a diverse range of socio-political reasons [81]. Our base model presented here -focused on a single coherent, population-level response-would not, on its own, explain the observed secondary waves of COVID-19. In 2020-2021, different municipalities quickly diverged in their response to COVID-19 risks; lockdowns lasted different durations of time [79], political discourse became divisive [81], and later new strains such as Delta altered the disease epidemiology. In a mathematical model, one way to induce a second wave is to introduce a step function, representative of a centralized decision to remove lockdowns (i.e. increase spread) when public support for closure drops below a certain threshold. [82] introduce such a model, focused on centralized decisions such as school closures, that also includes social learning dynamics underlying these centralized "on-off" decisions. Since our model is based on individual, rather than centralized, decisions, this step-change instigating a second wave would not occur in our base model without more complex modifications, although this would be a valuable topic for future research. In particular, we anticipate future work where studies build on our work to investigate the various reactions that could occur as outbreaks progress. Future exploration of the model could integrate these aspects, by adding asymptomatic individuals, the apparition of new variants, more complex population structure and the possibility for recovered individuals to be infected again after a certain time. We could then explore which social learning features can mitigate subsequent waves. Understanding how the timing and dynamics of different types of learning affect individual behavior over the course of an outbreak, as disease prevalence changes the transparency of benefits of protective behaviors, while those behaviors become more visible as they proliferate. Social learning can help boost protective behaviors, but not until the number of infections has brought about those behaviors initially through observation-driven decision making. For diseases such as COVID-19, in which age-based differences in observability and risk complicate age cohort-based learning, it may be particularly important to understand the dynamics of observability over time. These insights translate directly into concrete recommendations for how to communicate protective health policies. Our results indicate that social influencers can be recruited from different demographic cohorts to help model protective behaviors in populations. The effect may be most poignant when certain cohorts have become jaded by or resistant to public health efforts-the point our simulations indicate can drastically shift the course of an outbreak. Further, a shift away from messages of communal support (e.g. "We're all in this togetherH) to messages that more closely reflect cheer-leading (e.g. "It's working, people!") might meaningfully alter adoption and/or maintenance of protective behaviors. Making protective behaviors publicly visible among different cohorts should help to sustain those increases by social influence, and help attenuate the ensuing complacency and reversion to non-protective behavior. Policy makers who incorporate this perspective of social learning can formulate more effective policies to anticipate the potential self-defeating effects of initially successful public protective behaviors in a disease outbreak. Each distribution represent the parameter distribution of simulations for which the metric <unk> is ranked below different level, from top to bottom: 10, 000;5, 000;2, 500;1, 000. The 2d areas represent the High Density Regions, ie the smallest regions within which falls a certain percentage of the distribution of the parameters our selected simulation. The lighter areas represent the area within which all the simulations are distributed and darker areas represent regions for smaller HDR. (TIFF) S1 File. Data and code. All data generated or analysed during this study are included in this published article (and its Supporting Information files). The code used to implement, run and analyse models is in R3.5 [83] and available at: https://github.com/simoncarrignon/slsir. --- Supporting information S1 --- All code used to generate the data is accessible here: http://github. com/simoncarrignon/slsir, compiled vignette is available here: https://simoncarrignon.github.io/ slsir/vignettes/paperPLOSONE.html and pre-run simulations results here: https://osf.io/fxjh4/. --- Author Contributions

The global pandemic of COVID-19 revealed the dynamic heterogeneity in how individuals respond to infection risks, government orders, and community-specific social norms. Here we demonstrate how both individual observation and social learning are likely to shape behavioral, and therefore epidemiological, dynamics over time. Efforts to delay and reduce infections can compromise their own success, especially when disease risk and social learning interact within sub-populations, as when people observe others who are (a) infected and/or (b) socially distancing to protect themselves from infection. Simulating socially-learning agents who observe effects of a contagious virus, our modelling results are consistent with with 2020 data on mask-wearing in the U.S. and also concur with general observations of cohort induced differences in reactions to public health recommendations. We show how shifting reliance on types of learning affect the course of an outbreak, and could therefore factor into policy-based interventions incorporating age-based cohort differences in response behavior.

I. INTRODUCTION The family has been recognised as a significant social institution throughout history, serving as a safe haven for its members, particularly children. However, despite its role as a sanctuary, family units have frequently become the site of unpleasant occurrences, notably violence against children. Of these occurrences, sexual violence is among the most egregious. A vast body of evidence links domestic violence to a broad spectrum of sexual violence, which indicates that violence against children is a pervasive phenomenon globally. According to a report published by UNICEF, 257 million to 133 million children bear witness to domestic violence in their families every year (Dalal, 2008). Moreover, a study conducted in 2015 reveals that more than one billion children aged between 1 year and 17 years have experienced physical, emotional and sexual violence (Hillis et al., 2016). A comprehensive range of behaviours falls under the umbrella of sexual violence against children, ranging from physical and direct sexual contact (such as rape or oral sex) to non-penetrative acts, including masturbation, kissing, touching and rubbing the child's body. In addition, non-contact activities, such as soliciting children to create or view sexual content or watch sexual acts, encouraging inappropriate sexual behaviour and grooming children for abuse, are also considered forms of violence against children. Research demonstrates that children are at least twice as likely to be victims of violence from family members as from strangers (Henting, 1978). Moreover, an estimated 13% of individuals who experience rape are assaulted during childhood and within familial contexts (Stoltenborgh et al., 2015). The issue of sexual harassment has garnered the interest of scholars since the 1980s, given its pervasiveness and far-reaching consequences (Grubb & Turner, 2012). Sexual violence elicits significantly greater attention compared to other forms of violence due to the extensive harm inflicted upon the victim. When such harm is perpetrated by close relatives or within the family unit, the magnitude of the damage is compounded. Often shrouded in silence, such aberrant behaviour is infrequently disclosed. --- @ Exploring the Contexts of Child Sexual Abuse Within Families: A Field Study on the Taboo of Incestuous Adultery in Iran Meanwhile, the Iranian Government's disapproval of sex education in schools and other education systems, using ideological justifications, is contrary to the practice in many countries and is recognised in international documents. Sexual education helps raise children's awareness of sex and teaches them selfcare methods and techniques. The lack of systematic access to this education in Iran and the resulting lack of skills and knowledge leave children vulnerable to abuse and violence. On the one hand, the prevalence of violence against children, particularly sexual violence, is increasing, and, on the other hand, the lack of effective support, the absence of sex education in schools and other organisations and the social stigma associated with this phenomenon create an environment where victims are hesitant to report the abuse they have suffered. Addressing this issue has become increasingly important, especially since the victims of sexual violence are often silenced and left unsupported. Iranian society's tendency to stigmatise victims of sexual violence has contributed to the problem. Victims often fear judgment and ostracization, and, as a result, they avoid seeking help. It is critical to provide education about sexual violence, including its consequences and how to prevent it. Creating a safe and inclusive environment for victims to come forward and report incidents is also essential. Such measures must be introduced on both the governmental and non-governmental levels to ensure that children are protected and supported in the face of sexual abuse. Furthermore, it is vital to recognise the importance of sex education and the role it plays in preventing sexual violence. Through these measures, we can begin to address the issue of child sexual abuse and make Iranian society a safer and more equitable place for all. At the macro level, crafting and implementing policies and legislation are crucial to combat and mitigate this phenomenon. It is essential for any policies and laws to be rooted in research, knowledge and expertise generated in this field, to ensure their efficacy. Given the prevalence of sexual violence in the family environment and its severe impact on individuals who have experienced it, particularly children, addressing this issue becomes even more crucial. Numerous studies have investigated the various types of violence and the groups most susceptible to it; however, there is still a significant gap in our understanding of the experiences of children, particularly young girls, who have been subjected to sexual violence within their own homes. Therefore, the aim of this study is to examine sexual violence against children in the context of the family environment. This form of violence encompasses a broad range of actions, including physical contact, rape and exposure to sexual images. A thorough understanding of the underlying causes, lived experiences and outcomes of this phenomenon would enable policymakers and experts in this field to develop appropriate policies and effective interventions to prevent and address this issue in a proactive manner. Such measures should be based on comprehensive research and knowledge that can inform and guide effective policymaking and law enforcement at all levels. Research such as this serves as a crucial starting point for reflection, recognition and, ultimately, policymaking in response to the issue of sexual harassment. It is imperative for governments to give serious attention to this issue, as sexual abuse not only violates a child's sanctity, dignity and self-esteem during childhood, but also it affects the child in other periods of life and can perpetuate the cycle. Thus, sound policies must be developed based on scientific findings, the expertise of specialists and the experiences of those who have suffered abuse. Otherwise, sexual harassment may persist and victims and survivors may even face punishment. Of course, the responsibility for preventing sexual harassment is not solely on governments, as they may lack sufficient capacities in this area. It is necessary to educate and inform society and to provide suitable platforms, particularly for non-governmental organisations, to participate in various ways related to this traumatic issue. Many organisations have first-hand experience dealing with these abuses -with victims, their families and even perpetrators. For these reasons, this article will be divided into two parts. The first part will investigate the causes and bases of sexual violence against children in the Iranian family structure, utilising a qualitative design and field research. The second part will examine the structural, institutional and individual consequences of sexual violence at the macro and intermediate levels, drawing on expert opinions and analyses. The following question will guide the study: What are the social, economic and legal foundations on which sexual abuse and violence against children in Iranian families are built? By answering this question, the author hopes to shed light on the complex nature of sexual violence against children and provide insight into the necessary policies and interventions needed to prevent and address this issue. --- II. RESEARCH METHODOLOGY Sexual harassment has been a pervasive and persistent problem in human societies throughout history. Despite this, it remains a challenging phenomenon for scientific investigation. The difficulty in accessing a sample from people who are unwilling to cooperate with researchers is a significant obstacle to studying sexual harassment. This issue is further compounded by the fact that sexual harassment is often considered taboo and therefore victims are often reluctant to speak about their experiences. To better understand this phenomenon, it is necessary to employ unconventional methods of investigation. This problem is particularly acute in traditional societies such as Iran, where sexual harassment is shrouded in secrecy. Despite the challenges, the damage caused by sexual harassment cannot be ignored. Effective policies are needed to combat this phenomenon. These policies must be sensitive to the various forms of sexual harassment and include practical solutions for addressing this issue. To effectively understand and formulate a theory on sexual harassment, it is crucial to rely on real and empirical evidence and data. Additionally, gaining the trust of both victims and perpetrators and understanding their perceptions and experiences are also essential. Qualitative methods, specifically the Grounded Theory approach, can provide researchers with the necessary techniques and tools to investigate contextual factors, causal conditions, experiences, strategies and consequences of sexual violence against children. Therefore, this research is conducted using Grounded Theory, which can result in the development of a theory or contextual model of the studied phenomenon. This research aims to investigate individuals who have experienced any form of sexual abuse during their childhood, specifically those who were abused under the age of 18. The study involves a sample of 452 individuals who were selected using a combination of snowball and purposeful-sampling methods. Purposeful sampling allows for the inclusion of individuals with special experiences or knowledge relevant to the research. Data was collected using semi-structured interviews and analysed using the Strauss and Corbin coding process. --- III. RESEARCH REVIEW The phenomenon of sexual harassment has been a topic of interest for researchers since the 1980s, due to its prevalence and wide-ranging effects (Grubb & Turner, 2012). Sexual violence is especially concerning as it causes severe harm to the victim, and when it occurs within a family or between people who are related or close to the victim, the damage can be even greater. Unfortunately, this type of abuse often remains undisclosed. Even in cases where it is reported, it can be difficult to believe and prove due to societal views of the family as a safe and loving environment (Zarei, 2016). Sexual violence against children encompasses a wide range of acts including physical contact, sexual penetration (such as rape or oral sex) and non-penetrative acts such as masturbation, kissing, rubbing and touching of the child's body. Additionally, it includes non-contact activities like encouraging children to engage in inappropriate sexual behaviour, grooming them for abuse, and producing or viewing sexual images. Research has revealed that children are twice as likely to be victimised by family members or acquaintances as by strangers (Hunting, 1978). Approximately 13% of individuals who have been raped experienced the abuse during childhood, within a familial environment (Stoltenburg et al., 2015). Enduring traumatic experiences such as rape and sexual abuse during childhood has long-term psychological and social consequences, including memory problems, behavioural disorders such as domestic violence (Dube et al., 2005), and depression (Chen et al., 2010). A prominent theory of child sexual abuse posits that those who have been victimised as children are more likely to become perpetrators of sexual abuse in the future (Glasser et al., 2001). Additionally, several studies show that experiencing rape during childhood is a significant factor in committing sexual violence and rape in adolescence and adulthood (Babchishin et al., 2011). --- IV. CAUSES OF SEXUAL ABUSE OF CHILDREN IN THE FAMILY The sexual abuse of children is caused by a complex interplay of economic, social and legal factors. Not only do these factors contribute to the occurrence of child sexual abuse, but also, they contribute to the mechanisms that perpetuate and intensify the problem and its consequences. Violence is often a result of deprivation, which can then lead to the sexual abuse of children. Cultural and social structures can further exacerbate the issue by causing the victim to fear rejection and criminalisation, which may result in denial of the abuse and a failure to report the abuser. Without appropriate policies and social, economic and legal support for victims, the cycle of sexual abuse of children will continue to escalate. This dialectical relationship between social institutions at the macro, medium and micro levels of society create and perpetuates crises. In the following sections, we will discuss the main causes and factors underlying this issue. --- A. Economic Causes Studies in this field reveal that the economic factor is crucial in the genesis and perpetuation of the sexual abuse of children. Economic factors such as poverty, unemployment, type of occupation and housing contribute to the prevalence of violence and sexual harassment. The economic dimension is associated with fulfilling the basic needs of the family, and any disruption in this regard, such as inadequate income, can trigger problems. Poverty often leads to child neglect, when families struggle to meet the basic needs of their children and provide adequate care for them. Consequently, the children's development and social skills are hindered. As they grow up, they may lack proper communication skills and find it difficult to form healthy relationships with the opposite sex. Due to financial constraints, they may not have access to legitimate channels for satisfying their needs, leading them to resort to violent means. Moreover, poverty may also affect parents' awareness of appropriate parenting skills. Additionally, poverty can result in people residing in disorganised neighbourhoods and areas that lack proper infrastructure. These areas are often characterised by factors such as high population density, residential instability, inadequate security measures and breakdowns in the social capacity of residents to manage their environments. As a result, the likelihood of various crimes, including violence and rape, increases. In societies like Iran, where poverty is often associated with other negative phenomena such as inequality, inefficiency and addiction, there are specific areas with structural vulnerabilities to sexual harassment. The type of housing can also have an impact on child sexual abuse in cases of poverty. Poor households often live in small dwellings where the lower-floor area of the house causes children to hear their parents engaging in sexual activities or all family members may have to sleep together in the same room at night. This increases the risk of sexual assault and rape. The economic aspect of deprivation has an impact on both individual and social self-awareness. In recent decades, the monetisation of the educational system has been accelerating in Iranian society. As economic problems and disruptions intensify, more groups in society are being excluded from education, as well as cultural and artistic opportunities. One of the consequences of this is a lack of self-care skills and an inability to properly care for children and teenagers within the family institution. From the findings of this research, it can be inferred that the low socioeconomic status of parents, indicated by their level of education and housing situation, is a significant factor in child sexual abuse. This highlights the correlation between economic deprivation and other forms of deprivation when economic hardship impacts the level of social awareness and the quality of social interactions. Poverty can also lead to a situation where a divorced mother is compelled to enter into a marriage, she does not desire, solely for the sake of having a provider and meeting her expenses. Such households are at high risk of child sexual abuse. Families affected by deprivation, both economic and non-economic, may experience negative emotions such as fear and guilt; hold beliefs related to honour, dignity and social approval; and suppress their needs due to a reward-and-punishment system. In extreme cases, they may even force the abused child to marry to restore their reputation. --- B. Socio-Cultural Causes The cultural context is a significant factor in creating an environment conducive to sexual violence. A patriarchal subculture endows men with the audacity and authority to perpetrate sexual violence within their familial relationships, while notions of respect, honour and shame inhibit them from addressing such situations. In Iran, where socialisation and education institutions contribute to the culture of denial and secrecy, discussions about sexuality are prohibited and deemed taboo. This is reinforced through religious discourse. The provision of sexual education requires collaboration between various institutions. These include the family, schools, media, religious institutions, governments, and policy-making bodies that allocate budgets for such education. Effective and comprehensive sexual-education programmes require coordination among these institutions. In Iranian society, however, institutional interaction faces obstacles due to overlapping roles, conflicts of interest and negative attitudes towards one another. Consequently, sexual education has been neglected. The presence of opposing views and dualistic attitudes has also contributed to the failure of sexual education in Iranian society. Social attitudes are a major impediment to sex education in Iranian society, stemming from the socialisation process. Cultural values of shame, guilt, dishonour, and fear are deeply ingrained in Iranian culture and hinder discussions about sexuality, which is considered taboo and is therefore stigmatised. Consequently, victims of sexual harassment are prone to keeping it a secret, allowing perpetrators to continue their abuse. The initial step in planning and implementing policies for sex education is acknowledging the existence of the problem. The lack of trust in sex education by parents, coaches and teachers in Iran's education environment, along with the failure to teach children self-care measures, has led to unpleasant incidents. At a structural level, one of the primary reasons for the absence of sexual education for children is the conservative and ideological nature of policy-making institutions. In Iranian society, religion holds considerable influence over policy-making institutions, with many officials and policymakers being clerics. The Islamic perspective on sexuality is negative, and this religious discourse, by dominating the legal, social and cultural structures, has legitimised the suppression of sexuality and the lack of discussion and education about it. As a result, systematic sex education is non-existent in society, and responsible institutions often impede the efforts of individuals who feel accountable in this field. In addition to education, supporting victims is crucial. When a child experiences sexual abuse, it is important for support institutions to provide assistance in various ways. However, there are significant challenges to providing effective support in crisis centres. Due to the extensive nature of the problem and the numerous systematic limitations and obstacles faced by intervening and supporting institutions, the current interventions do not function well. The gender of an individual is significant in determining the nature and extent of sexual harassment in a culture that perpetuates sexism. Research indicates that women are more likely to experience sexual harassment from their intimate partners than men. This disparity highlights the impact of traditional biases, attitudes and gender stereotypes in education and socialisation, which can perpetuate discrimination and unequal treatment. --- C. Legal Causes The insufficiencies of the criminal justice system along with the absence of policies, programmes and executive assurances of protection measures for victims of sexual violence are among the legal problems in Iran. Prior to the enactment of the Law on the Protection of Children and Adolescents in 2020, there was no particular legislation safeguarding children who had been sexually abused, punishing perpetrators or ensuring protection to prevent them from reoffending. The Islamic Penal Code was the foundation for addressing such incidents, but the passage of this law addressed some of the gaps in this area. The legal system's failure to punish sexual abusers is legitimised by a discourse that stems from the patriarchal culture dominating society and is based on gender discrimination. Additionally, economic factors often result in the punishment for sexual harassment being reduced to a mere fine, reinforcing this cultural discourse. This failure to adequately punish sexual abusers often leads to repeated occurrences of sexual abuse, including instances of adultery and incest. After reviewing the opinions of the participants in the study, three main themes were identified: insufficient legal protections, the lack of enforcement of existing laws and the influence of patriarchy in legal systems. Some participants argue that there are no specific laws protecting sexually abused children or addressing sexual abuse in general. 1 In practice, there are inadequate procedures and mechanisms in place to enforce existing laws and ensure their effectiveness. Iranian law has a fundamental problem regarding the age of childhood. Various ages are determined in Iranian law, such as the age of marriage, the age of commencing work, the age of puberty and the age of criminal responsibility. Additionally, legislators use three terms, namely 'child','minor' and 'adolescent', to refer to the period of childhood, indicating a lack of consensus in this regard. The lack of a clear distinction between these periods has led to new difficulties in the matter of sexual harassment. The Islamic Penal Code defines a 'child' as a person under the age of 15. Article 221 states that adultery is sexual intercourse between an unmarried man and woman, and if one or both parties are minors, the minor(s) will not be punished, but will receive protective and educational measures. Article 224 lists death as a punishment for adultery in cases such as adultery with relatives. Article 91 states that adultery must be proven by the testimony of four righteous men or three righteous men and two righteous women, and, if proven, the punishment may be either flogging or stoning. However, this law has several problems; for example, it sets the age of childhood at 15 years, whereas many international conventions of which Iran is a member define childhood as ending at 18 years of age. Additionally, imposing the death penalty is not only ineffective in preventing sexual crimes, but also violates human dignity, and restorative justice should be implemented instead. Finally, historical evidence reveals that sometimes child victims of sexual abuse are wrongly accused of adultery. The Law on the Protection of Children and Adolescents does not address the issue of adultery explicitly, but covers topics such as sexual abuse, prostitution, obscenity, imminent danger and pornography, wherein any child abuse in these cases will result in intervention. However, the law's definition of 'childhood' is vague, and it includes the age of religious maturity, which is nine for girls and 15 for boys, reflecting gender discrimination. The definition of 'teenager' is 'any person under 18 who has reached legal maturity'. The law's foundation in Sharia law raises fundamental issues, and there is ambiguity regarding the precise definition of 'childhood' in various areas. Article 2 states that 'this law applies to all persons under 18 years of age', but the age of childhood is not precisely defined, leading to confusion. --- D. Family Causes Factors such as familial disorder, authoritarianism and isolation, or weakness in terms of marital and familial bonds can accelerate sexual violence or child sexual abuse at the family level. Disorganised and dysfunctional families can take various forms. Based on structure, the main types of disordered families identified in this study include patriarchal and religious families, divorced families, families with one guardian absent due to death or separation, families with guardians in prison, large and extended families, families lacking a suitable guardian, families with stepparents and step-siblings, families with a deceased mother and a stepfather, families with a polygamous father, and step-siblings with age differences. 2While families are often safe havens, they can also be dangerous for children due to violence and sexual abuse. Sexual abuse can occur in any type of family, including religious families. In fact, the suppression of feelings and needs often imposed by religious texts and restrictions can lead to a degree of sexual stimulation and even sexual abuse. Religious families may institutionalise feelings of guilt and shame, which can lead victims of sexual abuse to feel these emotions and blame themselves. Gender roles are often strictly divided in religious families, with the father or man being the owner of everything, including family members and assets. Children and other family members may not have the right to protest against him, and any dissent may result in punishment. These factors, along with others such as disordered and dysfunctional family structures, can contribute to the occurrence of sexual violence and child sexual abuse within families. Although a family may be free from certain harms such as addiction, divorce and bad parenting, it may not necessarily be balanced. Some families are structured in ways that are either too strict or involved or too permissive and distant, which can lead to a suppression or imbalance of people's feelings and needs. Such imbalances may lead to sexual harassment and adultery. Extended families with large numbers of members can also contribute to the risk of abuse. In some cases, impoverished parents may have more children in anticipation of having support in their old age. However, these households often lack the resources to meet the basic needs of their children, and the increased number of dependents further strains the family's resources. Additionally, without a specific plan or strategy for raising their children, many of these families may leave their children neglected and vulnerable to abuse. On the other hand, having a large number of family members can also act as a protective factor and serve as a support system for the children. It is crucial to consider the family dynamic between abusers and child victims in cases of sexual abuse. Abusers within the family can perpetrate different forms of sexual harassment -one category being incestuous. Incest involves a deep connection between the child and the abuser, who may be a family member such as a father, mother, brother or sister. Given that these individuals are sources of support and security for children, experiencing abuse from them can be particularly traumatic and put children's safety at risk. It also means that children have nowhere to turn for protection. In some cases, when a father or stepfather abuses a child and the mother is aware of the abuse, she may not provide assistance for fear of losing her husband and being left without a source of support. This can lead to continued abuse. The parent-child relationship is built on attachment and a sense of heroism, with children relying on their parents for guidance. Sexual abuse can shatter this perception, causing confusion and conflicting emotions in children, resulting in serious psychological harm such as feelings of fear, anger and guilt. This can lead to dependent individuals who struggle to develop personal maturity and independence. The second category of abusers consists of'secondary' family members, such as stepfathers, stepmothers, stepsiblings, uncles, grandfathers, grandmothers and likewise. Unlike primary family members, these individuals have less responsibility towards the child and their levels of interaction with the child may not be extensive. However, this group may also pose a risk of abuse to children due to their relationships with them. Additionally, because these individuals may not consider children as first-class family members and may not be held responsible for them, they may be more likely to harm them without concern for the consequences. The third group of abusers consists of non-immediate family members, such as the spouses of aunts and uncles or cousins. This group poses a high risk for child abuse due to their close relationships and easy access to children. Sometimes, parents may even entrust their children to these family members for care, which can further increase the risk of abuse. On the opposite end of the spectrum, there are strangers who the child has no prior relationship or connection with. In this type of situation, harassment often takes the form of physical attacks and is highly dependent on the child's environment. For instance, if the abuser notices that the child is alone and unattended in a certain environment, they may take advantage of the situation and attack the child. Family practices, specifically how children are raised, play a significant role in instances of sexual abuse. Research has identified several key components of ineffective parenting practices that contribute to such abuse. These include a lack of affection and love in the family environment, physical and emotional abuse of children, neglect of children's needs, absence of verbal restraint among family members, inadequate supervision or guardianship, parental addiction and mental illness, harsh family rules, uncontrolled living environments for children, entrusting children to inadequate caregivers, lack of effective protection, failure to report incidents of abuse, imposing economic restrictions on children, blaming and criticising the child, living with a domineering grandmother, incorrect beliefs on the mother's part, inadequate parenting skills and a lack of education from the family. Parental substance addiction can become a breeding ground for child abuse in various ways. If parents, or even one of them, are addicted to substances, they become less capable of giving their children the attention and love they need, as their focus and energy is consumed by the preparation and consumption of drugs. Addiction can turn a family into a hub of conflict, violence and aggression by altering or even eliminating roles in the family, disrupting the division of labour system and damaging the emotional equilibrium of the family. Children of single-parent or single-guardian families are also at a higher risk of sexual abuse by their guardian's intimate partners. Such families are present in modern societies across the globe, including in Iranian society, where a variety of conditions and circumstances can lead to this family structure. However, social institutions that support and assist these families may operate more effectively and with greater confidence in developed societies with stronger social welfare and policies, compared to in societies like Iran, which face economic challenges and a dominant political system that impacts the style of economy. --- E. Individual Causes The acceleration of sexual harassment can be attributed to certain characteristics of both victims and perpetrators, but determining which factors play more significant roles in the occurrence of child sexual abuse is not a straightforward matter and requires further discussion. --- 1) Individual characteristics of victims Certain personal characteristics can increase the likelihood of an individual becoming a victim of sexual harassment. This study has identified several traits that make individuals more vulnerable to abuse and its continuation, including physical and mental disabilities, low IQ, physical differences, beauty, passivity, non-conformity to local cultural norms, immigrant status, addiction, hyperactivity and bullying. However, the existence of these characteristics does not mean that other children are immune to abuse; rather, it highlights that this group may be at a higher risk of being abused. Children with dysfunctional personality traits are particularly susceptible to abuse, particularly from those who are close to them, making it difficult for them to respond effectively to prevent such abuse. Two notable characteristics among the abovementioned traits are the inability to defend oneself and the inability to report the abuse. Additionally, this group of children is different from other children, which makes them more vulnerable. For example, children who are unable to defend themselves due to physical or mental disabilities are more likely to be targeted by abusers. This distinction in a child's characteristics has been identified in various discourses as a contributing factor in sexual abuse by individuals close to them. In addition, the research narratives highlight the vulnerability of children who have limited speaking and communication abilities. This lack of communication skills can make them easy targets for sexual abusers. Furthermore, children with mental disabilities, hearing or speech impairments, physical disabilities and other similar conditions are often targeted by abusers. In some cases, parents and other family members may even abuse these children, considering them to be the cause of the family's problems and knowing that they cannot defend themselves. Due to these characteristics, these children may not be able to report the abuse, which makes them more vulnerable to ongoing exploitation by the abuser. How each country addresses this issue varies depends on its level of development and its social and economic status. However, it is important to note that even children without any special characteristics or disabilities can still be subjected to various forms of sexual abuse. In fact, such abuse can even cause certain characteristics to develop, such as isolation and withdrawal. Weakness in skills, such as the ability to assert boundaries and think critically, as well as personality traits like low self-esteem, anti-social behaviour and isolation, along with negative emotions such as anger, fear, guilt and shame, can create favourable conditions for sexual harassment. These characteristics, combined with abusive behaviours, can provoke and enable the harassment to continue. --- 2) Individual characteristics of harassers The personal characteristics of perpetrators of sexual harassment are also important to consider. These aggressive traits include low tolerance for failure, difficulty controlling anger, lack of empathy towards family members, verbal and physical aggression, drug and alcohol abuse, anxiety during sexual activity with adults, paedophilia, a history of childhood sexual abuse, suspicion towards family members, borderline antisocial tendencies, neuroticism, sexual impulsivity, loneliness, stereotyping of sexual roles, low selfesteem, emotional instability and self-regulation problems. Health problems may also contribute to these behaviours. In interviews, victims reported that feelings of shame, blame, guilt and fear and a sense of ownership were commonly expressed by their abusers. Irrespective of the moral perspective, sexual harassment can be viewed as a form of communication with the outside world. For individuals with antisocial personalities, their social lives may not have provided them with opportunities to satisfy their needs through healthy and balanced social relationships. It is important to examine the domineering and bullying tendencies of abusers in situational contexts, as an abuser is in a position of power over the victim at that moment and may have been in the opposite role in a different situation. --- V. RECOMMENDATIONS The following suggestions and solutions for addressing child abuse are derived from three primary sources: (a) the experiences of individuals who have been abused; (b) recommendations from experts and professionals in the field who were interviewed; and (c) existing literature on child abuse at the macro, medium and micro levels. At the macro (structural) level: • Implement education and welfare policies that address multi-dimensional deprivations in Iranian families through government and non-governmental organisations and support organisations. • Develop regional and neighbourhood policies to alleviate poverty and monitor defenceless areas. • Strengthen non-governmental organisations. • Ensure public safety in community spaces. • Improve coordination between educational, legal, medical and social institutions and develop educational programmes to help sexually abused children, while maintaining confidentiality and ensuring their safety. At the middle (institutional) level: • Develop content to teach children about sex. • Strengthen the educational function of schools. • Train coaches, teachers and school officials on how to deal with children who are victims of sexual abuse. --- Strangers Familiar people such as the local shopkeeper, neighbor, school bus driver, local baker, teacher, coach, local cleric, business owner --- Friends Other non-mahram family members such as the husband of an aunt, uncle, cousin, etc. Second-degree relatives such as father, mother, stepsiblings, uncles, grandfathers, grandmothers, etc. First-degree relatives such as parents and other close family members • Pressure governments and legislators to amend laws and reduce the gaps between jurisprudential laws, the Convention on the Rights of the Child, and the law's effective implementation. • Eliminate and reduce gender perspectives in curriculum and media. • Create intervention-and-treatment centres with an emphasis on high-risk areas. • Develop plans to prevent further harassment by aggressors. • Teach children social and individual awareness to actively stand up to abuse in the home and community environment. At the micro (family) level: • Increase knowledge and skills of families and children through age-appropriate education and information. • Critically review socialisation and parenting styles. • Raise awareness about the harms of hiding sexual harassment and delegitimise the construction of shame, modesty and honour. • Teach children to resist sexual requests and strengthen their abilities to say no. --- VI. CONCLUSION Sexuality, as a construct, is a socially influenced phenomenon, shaped by cultural norms and social relations. Effective education can manage it. However, in Iranian society, the dominant moral discourse makes taboo unconventional sexual relationships, making it challenging to investigate sexual harassment in all its dimensions. Moral standards are subjectively prescribed, and the dominant discourse treats sexual harassment as dishonourable. Victims are blamed, and the domination of the abuser is legitimised through the rejection, blame and punishment of the victim. This study shows that structural and functional problems and crises in socialisation and support institutions in Iranian society have led to the sexual abuse of children in the family, which, instead of being addressed, prevented and moderated, provides a platform for other social harms, such as children running away from home and being forced into marriages. In Iran's religious and ideological society, the guardian's view dominates all areas of the social system and the individual sphere, and the norms that legitimise them provide a cover based on protection and not being contaminated by sin. These norms are institutionalised in such a way that they prevent or 'justify' abuse, in some cases. The sexually abused person is often left unsupported, and the lack of support can fuel the problems and social harms of the same society, continuing a vicious cycle. The most important causes of child sexual abuse are poverty and deprivation, disordered families, the ineffectiveness of institutions in providing sexual education and support, the lack of clear law, and conflicts and contradictions between existing laws. If appropriate measures are not taken to prevent and moderate child sexual abuse, it will create and intensify other issues and social harms and hinder society's development. The logical conclusion from the main findings of the study is that the causes of child sexual abuse in Iran are multifaceted and complex. One of the primary factors is poverty and deprivation, which can lead to a range of issues including lack of education, poor living conditions and reduced access to healthcare. Disordered families and weak family structures also contribute significantly to this problem. Children from such families are often exposed to physical, emotional and sexual abuse, which can have long-term impacts on their physical and mental health. In addition, the ineffectiveness of institutions in providing sexual education and support is a significant factor that contributes to child sexual abuse. The lack

According to structuralist theory in anthropology, the family unit has an internal order based on the rule 'no adultery', but through evolution and transformation, this cultural order can become its opposite. In some cases, this can lead to the violent suppression of individuality, rejection, isolation, harassment, sexual assault and even honour killings. In Iran, sexual abuse by incest is a taboo topic with significant social stigma attached to it. Victims' fears of punishment and rejection, combined with the lack of registration and reporting, means that there are no reliable statistics or evidence, but some studies show that it is prevalent in Iranian society. This study aims to investigate the causes and factors associated with the sexual abuse of children by family members. It uses semi-structured interviews with 452 people who experienced incest in childhood. The study confirms that child sexual abuse by family members is facilitated by favourable circumstances and makes abused people more vulnerable to their abusers. The study identified several factors that contribute to sexual abuse, including inequality, poverty, patriarchy, ineffective sex education, lack of community support and family dysfunction. These factors lead to subsets of social and individual consequences, such as weakened social relations, early or delayed marriage, interpersonal problems, divorce, dysfunction, negative feelings and a sense of being 'other'. Efforts to address these underlying factors are necessary to prevent sexual abuse and improve the well-being of victims.

. The sexually abused person is often left unsupported, and the lack of support can fuel the problems and social harms of the same society, continuing a vicious cycle. The most important causes of child sexual abuse are poverty and deprivation, disordered families, the ineffectiveness of institutions in providing sexual education and support, the lack of clear law, and conflicts and contradictions between existing laws. If appropriate measures are not taken to prevent and moderate child sexual abuse, it will create and intensify other issues and social harms and hinder society's development. The logical conclusion from the main findings of the study is that the causes of child sexual abuse in Iran are multifaceted and complex. One of the primary factors is poverty and deprivation, which can lead to a range of issues including lack of education, poor living conditions and reduced access to healthcare. Disordered families and weak family structures also contribute significantly to this problem. Children from such families are often exposed to physical, emotional and sexual abuse, which can have long-term impacts on their physical and mental health. In addition, the ineffectiveness of institutions in providing sexual education and support is a significant factor that contributes to child sexual abuse. The lack of effective educational programmes and support mechanisms means that children are not equipped to identify and report sexual abuse, nor do they have the support structures in place to help them cope with such experiences. Moreover, the absence of clear and concise laws on the prevention and treatment of child sexual abuse, as well as the conflicts and contradictions between existing laws, further exacerbate the problem. Therefore, addressing the issue of child sexual abuse requires a comprehensive and multi-faceted approach that targets all these underlying causes. This would involve implementing effective educational programmes that equip children with the knowledge and skills necessary to protect themselves against sexual abuse, strengthening family structures and support mechanisms, improving living conditions for families living in poverty, and enacting clear and effective laws that protect children and hold perpetrators accountable. By addressing these factors, it is possible to prevent and mitigate the negative impacts of child sexual abuse in Iranian society. --- CONFLICT OF INTEREST Authors declare that they do not have any conflict of interest.

According to structuralist theory in anthropology, the family unit has an internal order based on the rule 'no adultery', but through evolution and transformation, this cultural order can become its opposite. In some cases, this can lead to the violent suppression of individuality, rejection, isolation, harassment, sexual assault and even honour killings. In Iran, sexual abuse by incest is a taboo topic with significant social stigma attached to it. Victims' fears of punishment and rejection, combined with the lack of registration and reporting, means that there are no reliable statistics or evidence, but some studies show that it is prevalent in Iranian society. This study aims to investigate the causes and factors associated with the sexual abuse of children by family members. It uses semi-structured interviews with 452 people who experienced incest in childhood. The study confirms that child sexual abuse by family members is facilitated by favourable circumstances and makes abused people more vulnerable to their abusers. The study identified several factors that contribute to sexual abuse, including inequality, poverty, patriarchy, ineffective sex education, lack of community support and family dysfunction. These factors lead to subsets of social and individual consequences, such as weakened social relations, early or delayed marriage, interpersonal problems, divorce, dysfunction, negative feelings and a sense of being 'other'. Efforts to address these underlying factors are necessary to prevent sexual abuse and improve the well-being of victims.

INTRODUCTION At its most visceral, the gun debate in American politics, litigation, and scholarship is about the relationship between firearms and physical safety. But a growing body of research has begun to illuminate other important factors. Personal protection has become the primary reason for gun ownership. Further, firearm ownership and public carry are deeply intertwined with issues of status and identity, especially, but not exclusively, for White male gun owners. More recently, researchers have begun to investigate why people choose not to keep or bear arms and why people support regulating them. Altogether, scholarship is unearthing important aspects of the gun debate that go beyond the conventional focus on crime and physical safety. We first situate the importance of scholarship in firearms law and then provide a brief overview of some of the representative research. --- SCHOLARSHIP AND THE TRANSFORMATION OF GUN LITIGATION For decades, the central question for firearms law and litigation was whether the Second Amendment right is limited to people, arms, and activities having some connection to the organized militia, or whether it also encompasses a right to keep and bear arms for certain private purposes like self-defense (Blocher & Miller 2018). The militia-centric view prevailed overwhelmingly in courts, and many scholars took it as a given. But, beginning in the 1950s and 1960s, and accelerating in the 1970s and 1980s, scholarship began to appear that supported the private purposes view-sometimes called the "individual right" view (Winkler 2009, pp. 95-96). Much of this scholarship was historical, purporting to present "originalist" claims about how the Founding generation understood the Second Amendment and connecting gun rights to other American values and traditions-sometimes by projecting the present into the past (Siegel 2008). But among elites within the legal academy, there was little activity; few prominent scholars wrote on the Second Amendment until the 1990s (Levinson 1989). Then, in 2008, the Supreme Court handed down District of Columbia v. Heller (2008), which found that the Second Amendment encompasses a right to keep and bear arms for purposes unconnected to militia service, the "core" purpose of the right being self-defense within the home. In reaching that decision, the justices cited more secondary sources-including scholarship-and cited them more often than all traditional legal sources (cases, statutes, and constitutional provisions) combined. Although it would be too much to claim causation, it is safe to say that the historical and legal scholarship that preceded Heller played a prominent role in the decision itself. But Heller also made clear that the right to keep and bear arms, like all constitutional rights, is subject to regulation. The court specifically approved as "presumptively lawful" such "longstanding prohibitions" as those regarding possession of firearms by felons and the mentally ill, carrying firearms into sensitive places such as schools and government buildings, concealed carrying, possession of "dangerous and unusual" weapons, and potentially other categories of regulation as well [District of Columbia v. Heller (2008), pp. 626-27, n. 26]. The court did not fully explain why these gun laws are constitutional, and it explicitly disclaimed any effort to articulate a generalized test or standard. To the degree that these exceptions (and potentially others) are justified because they are rooted in history, Heller helped generate demand for further historical research on gun regulation. In dissent, Justice Breyer took a different approach, arguing that the constitutionality of contemporary gun laws should be evaluated based on a kind of interest-balancing test, "with the interests protected by the Second Amendment on one side and the governmental public-safety concerns on the other" [District of Columbia v. Heller (2008), p. 689]. Such a test naturally relies on empirical evidence and thus has generated demand for a different kind of scholarship about the effectiveness of modern gun laws. As the dissenting justices predicted it would, Heller generated a wave of Second Amendment litigation-more than 1,000 constitutional challenges were filed in the 10 years after the case was decided (Ruben & Blocher 2018). Prior to June 2022, judges generally applied tests that combined elements of the majority's historicism and the dissent's means and ends empiricism. And-albeit with an increasing partisan difference (Germano & Samaha 2018)-they overwhelmingly rejected Second Amendment challenges, meaning that the boundaries of gun rights and regulation were still primarily the responsibility of the political branches. The political arena proved broadly hospitable to gun rights advocates, who generally prevailed both in blocking federal regulation and in expanding gun rights in many states through such measures as preempting local firearm regulation (Simon 2022), loosening or eliminating permit requirements for public carry, and guaranteeing extra-constitutional legal protections for firearms (Charles 2022a). For more than a decade after Heller, the political branches remained the primary site of contestation, as the court declined dozens of petitions seeking review of Second Amendment cases. Then, in 2022, the court issued its decision in New York State Rifle & Pistol Assoc. v. Bruen (2022). The court held unconstitutional New York's strict concealed-carry licensing law, which required applicants to show a heightened need for self-defense distinguishable from that of the general community. That holding had an immediate impact on the approximately 80 million Americansroughly a quarter of the population-living in jurisdictions with similar laws. But the court's more consequential holding was its rejection of the prevailing Second Amendment methodology, which permitted some evaluation of government interest and the fit between the regulation and that interest, and its adoption of a Second Amendment test that looks solely to history and analogy. If a modern law does not have an equal or analog in the Anglo-American historical tradition of firearm regulation, it cannot stand, seemingly regardless of its modern public safety benefits. The court's decision in Bruen presents a new set of challenges. For example, the decision makes it much harder for courts to consider the government's contemporary reasons for regulating weapons or how effective those regulations are in preventing death, injury, intimidation, and other harms. But Bruen does not necessarily render social science irrelevant to legal decisions. It directs courts to consider whether a current law is analogous to a historical one by comparing both the justification for each law and the burden each law imposed. Social science can shed light on the burdens and justifications of contemporary laws, and perhaps also historical ones. Traditional legal scholarship is still very much needed to give shape to the emerging law and doctrine of the Second Amendment, which is at roughly the same stage of development as the First Amendment was a century ago. Heller itself was profoundly shaped by sources outside of the legal academy (primarily history), and Bruen further emphasizes the need for research in the humanities and social sciences. Section 3 provides a brief overview of some important recent developments and possible future trajectories in that regard. --- THE STATUS AND TRAJECTORY OF FIREARMS SCHOLARSHIP Like the Second Amendment-and partly in a response to its legal transformation-firearms scholarship has changed in the past 15 years. One major change, chronicled by Carlson (2020) in this journal three years ago, has been from "Gun Studies 1.0"-which focused on generating scientific and quantitative empirical evidence-to an increasing focus on "Gun Studies 2.0," which includes a broader and more sociological focus on the political and cultural considerations that make such evidence "meaningful." Even as both quantitative and qualitative branches of gun studies have continued to develop, the themes of gun studies have begun to shift-largely in response to changes in law, gun ownership, and use. Empirical studies of crime and physical harm, of course, remain important and hotly contested (Donohue et al. 2021). But a growing literature, much of it based in sociology and social psychology, has also begun to explore the transformation in modes of gun ownership and use in the years since Heller was decided-especially the increased primacy of self-defense as a stated reason for gun ownership and the spread and politicization of public carry as a social practice. Even more recently, some scholars have begun to engage with the nonphysical harms of gun use: threats and fear; social trauma; deterrence from the exercise of constitutional rights, such as speech, assembly, and voting; and the inequality that can be reinforced both by gun use and by the enforcement of gun laws. This is in some ways a natural parallel to the growing body of literature illuminating the psychic and social benefits that gun owners experience. It shows, as gun law and scholarship must, the considerations on all sides. Below, and with no claim to complete coverage, we highlight a few major developments. In the decades before Heller, academic work occasionally engaged with America's gun "culture," generally to bemoan or criticize it. Hofstadter's (1970) lamentation of the United States "as the only modern industrial urban nation that persists in maintaining a gun culture" is largely representative. Some have noted that the study of lawful gun use has been left largely to criminologists and public health scholars rather than sociologists (Yamane 2017) or social psychologists (Buttrick 2020). But the past decade or so has seen an impressive growth in the quantity and quality of sociological work on the place of guns in American life. And that scholarship has emerged at a time when gun ownership and use are undergoing a transformation. Self-defense and protection have recently become the primary reasons for gun ownership and are deeply intertwined with issues of status and identity (especially, but not exclusively, for White male gun owners). And some gun owners are increasingly carrying their guns in public-both individually and in groups-which in turn implicates the interests of others and raises the importance of work identifying and articulating the ways guns generate effects beyond physical safety. Until relatively recently, US gun owners identified hunting and recreation as the primary reasons for gun ownership, even though most also identified "protection" as a somewhat-distant secondary reason for owning a gun. A 1999 Pew study found 49% of gun owners identified hunting and recreation as their primary reasons for gun ownership (even if they also selected "personal protection"), and only 26% chose personal protection as the primary reason (Pew 2013). [Even the Supreme Court, in finding self-defense to be the "core" of the Second Amendment, recognized that most Americans in the eighteenth century "undoubtedly thought it...even more important for...hunting" (District of Columbia v. Heller (2008), p. 599).] But by 2017, 68% of gun owners gave protection as their primary reason (Gallup 2019, Parker et al. 2017). This changing proportion can be attributed in part to an overall decline in hunting (Smith & Son 2015) and a general loosening of laws restricting concealed carry (Shapira et al. 2018). It is also both a cause and a result of gun owners' changing self-conceptions (Lacombe 2021). Self-defense has become not only the primary reason for gun ownership but also the animating principle of what Yamane (2017, p. 5) calls "Gun Culture 2.0." In the words of National Rifle Association Executive Vice President Wayne LaPierre, "What is the 'gun culture'?...To millions of Americans, especially those who own firearms, the term refers to America's traditional bedrock values of self-reliance, self-defense, and self-determination" (cited in Melzer 2012, p. 29). Since 2014, and for the first time, "personal protection" and "concealed carry" have overtaken hunting and sport as the dominant themes in gun advertisements ( Jacobs & Villaronga 2004, Yamane et al. 2018). But protection can encompass a variety of different things. Perhaps the most obvious and visceral form-and the one most closely connected to the law of self-defense-is the use of guns to defend against criminal threats. The data about how often this actually happens are strenuously disputed, but there can be little doubt that Americans have strong views about the likelihood of being attacked. Even as crime rates started to fall in the mid-1990s, fear of crime did not decline proportionately (Gramlich 2022), and fear continues to shape gun use and the gun debate. Scholars have studied the relationship between perceptions of risk, self-protection, and firearm purchase (Kleck et al. 2011). Notably, women are more likely than men to be afraid of crime (Logan 2020), although nearly twice as many men as women actually own guns for self-protection (Parker et al. 2017). Given most metrics indicate that incidents of armed self-defense are quite rare (although how best to quantify these incidents is highly contested), it is all the more important to understand how hypothetical incidents appear to gun owners (Livingston 2022). Indeed, much of the focus of concealed carry courses is on developing the mental readiness to be able to use a gun against a threat, should the need arise (Carlson 2015a). Research has found that the hypotheticals used to prepare tend to be less complex than the average incident of self-defense (Barnhart et al. 2018). A related but distinct line of scholarship has focused on another dimension of protectionprotection not just from specific physical threats like crime but from instability or danger in a more generalized sense (Leander et al. 2017). In 2008, then-presidential candidate Barack Obama remarked, "You go into these small towns in Pennsylvania, and like a lot of small towns in the Midwest, the jobs have been gone now for 25 years, and nothing's replaced them.... And it's not surprising then they get bitter; they cling to guns or religion" (Seelye & Zeleny 2008). Obama faced immense and intense criticism (many defiantly embraced the "bitters" label), but his basic message was consistent with that of many social science scholars. As Kohn (2004, p. 111) puts it, "One of the ways that shooters cope with the instability and anxiety of contemporary society is to grasp onto objects of safety, control, and profound symbolic meaning: guns." Changes in economics, family structures, and gender/racial dynamics have left many White men feeling left behind; for some, guns can help restore "the strength and prestige of their idealized past" (Metzl 2019, p. 3). Rural Americans "facing unsettling economic times utilize guns as a foundational source of power and identity"; guns provide "moral purpose to white males who have lost, or fear losing, their economic footing" (Froese & Mencken 2019, pp. 23-24). Their loss of "breadwinner" confidence and power leads them to seek alternatives: a means to protect themselves (Froese & Mencken 2019) or to shift from a "provider" to a "protector" role (Carlson 2015b, Carlson et al. 2018, Squires 2018). Qualitative sociological studies have helped illustrate the importance of firearms not only as a means of self-defense-in the narrow sense of preserving physical safety-but also as a means of retaining gendered status and authority in the face of socioeconomic stagnation that threatens traditional markers of masculinity (Carlson 2015b, Stroud 2016). "Gun advocates describe ways that firearms represent forms of selfhood forged through the protection of home and family" (Metzl 2019, p. 2). Elements of this emotional protection argument are supported in other sources as well. Warner's research has shown that stereotypically masculine attitudes were positively associated with protective ownership of guns-and that such attitudes are a far more important driver than economic precarity alone. Those who advocated stereotypically masculine ideals were also much more likely to own guns for protection if they faced economic precarity (Warner et al. 2021). For some, guns provide a way to assert masculinity (Cassino & Besen-Cassino 2019). Whether these responses are normatively desirable is a separate question. Froese & Mencken (2019) use a "gun empowerment" scale to capture the degree to which gun owners feel morally and emotionally empowered by guns-finding in particular that White men in economic distress experience these benefits. Surely there is nothing wrong, in the abstract, with feelings of security; some gun owners feel that they are stigmatized for the legitimate benefits they experience from gun ownership (French 2018). But Buttrick (2020, p. 836), writing from a social psychology perspective, argues that "guns act as a maladaptive coping mechanism that allows their owners to manage the psychological threats that they face in their everyday lives." At a broad level, the point is that "protection" as a reason for gun ownership is itself a complex topic worthy of further study-it encompasses not only self-defense from physical harm but psychological self-defense from a broader set of threats: "Gun ownership has been linked to fear, victimization, and collective security concerns; political attitudes and identities; socializations/social learning; and racial prejudice. Although often examined independently, these correlates of gun ownership share a common thread: to some degree, they are manifestations of a particular sensitivity to threat" (Warner et al. 2021, p. 112). Gun manufacturers have marketed this aspect of guns, as in Glock advertisements suggesting that their weapons convey "the confidence to live your life" ( Johnson 2012) or Bushmaster's "consider your Man Card reissued" campaign (Boston Globe 2012). [Such ad campaigns are central to ongoing lawsuits against the industry, which, despite the high-profile success of the Sandy Hook plaintiffs, face significant legal hurdles [Soto v. Bushmaster Firearms Int. (2019)].] --- CHANGING MODES OF GUN USE: CONCEALED AND OTHER FORMS OF PUBLIC CARRY The protection-driven increase in gun ownership has direct implications for how people use their weapons. Those with low trust in law enforcement, for example, are far more likely to keep their gun nearby, act as public vigilantes, and be open to using the weapon in public if needed (Kreienkamp et al. 2021). "Central to Gun Culture 2.0 is the legal carrying of concealed weapons, mostly handguns, in public by ordinary Americans" (Yamane et al. 2018, p. 9). Although data on public carry are relatively sparse, especially before Heller, various sources suggest that the rate at which gun owners bring their firearms into public spaces has increased. A 1993 National Self-Defense Survey found that 3.8% of respondents (both gun owners and nonowners) and 12.5% of gun owners had carried a gun on their person for protection at least once in the past 12 months (Kleck & Gertz 1998). The 1994 National Survey of the Private Ownership of Firearms found that 8.7% of gun owners "usually" carried on their person (Cook & Ludwig 1996). Researchers in a 2015 study estimated that 23.5% of the 38 million adult handgun owners in the United States had carried a gun publicly in the last 30 days. A third of those people carried their gun every day, and approximately half of those who reported carrying had carried their gun at least 18 of the past 30 days (Rowhani-Rahbar et al. 2017). Data on the growth of both concealed permit holders and applications align with the 2015 findings. The number of concealed permit holders increased from 2.7 million in 1999, to 4.6 million in 2007, to 14.5 million in 2016 (Rowhani-Rahbar et al. 2017). One study of Florida, Indiana, Massachusetts, Texas, and Utah found that concealed handgun license applications had risen significantly. In Utah in 2010, there were approximately 11 applications per 1,000 observations in the group. By 2014, that number had risen to approximately 60 applications. In Florida in 2004, there were approximately 8 applications per 1,000 observations, whereas in 2014 there were approximately 16 applications (Shapira et al. 2018). Rowhani-Rahbar et al.'s (2017) study of loaded handgun carrying included a questionnaire as to motivators for public carrying. The study found that 82.2% of respondents who had carried a loaded handgun in the past month did so for protection. This motivator was strongly correlated with the frequency with which the respondents tended to carry firearms in public. Whereas approximately 70% of respondents who had carried a handgun 1-6 days in the past month did so for protection, approximately 90% of respondents who had carried one either 7-29 days or all 30 days had done so for protection. A large percentage of respondents who had carried a handgun 1-6 days, approximately 20%, did so for transportation. This might capture gun owners who, for example, simply transported their handgun from their home to their car. Especially after Bruen, quantitative and qualitative studies of the practice of public carry would be exceptionally valuable. What percentage of gun owners carry their guns publicly, and why? Do they do so openly or concealed? How often are they used for defensive purposes? Against whom, and in what circumstances? How do other people-especially non-gun owners-experience such displays? --- Social and Nonphysical Harms The preceding section identified research exploring gun owners' perspectives-their reasons and ways of keeping and bearing arms. Scholars are also beginning to bring fresh perspectives on the reasons why others choose not to keep or bear arms, and why concerned citizens may wish to regulate them. As noted in Section 3, the traditional focus here has been on the preservation of physical safety and prevention of physical harm. That frame remains crucially important, especially as gun deaths have skyrocketed in recent years. But recent scholarship in the social sciences has started to supplement that focus with accounts of nonphysical harms such as threats and fear, social trauma, and the compounding inequalities generated from gun violence. Making those harms legally legible remains a major task for legal scholarship and doctrine (Blocher & Siegel 2021). Robust empirical evidence demonstrates that gun-related harms go far beyond physical loss (Cook & Ludwig 2000), and that these harms disproportionately impact vulnerable communities (Miller et al. 2000, pp. 710-11). A recent Pew survey reports that "overall, roughly one-in-four Americans (23%) say someone has used a gun to threaten or intimidate them or their family"; this includes a third of Black Americans (32%) (Parker et al. 2017, Vargas & Bhatia 2020). The secondary trauma from school shootings reverberates for millions of American students and parents, with a majority of teenagers and their parents reporting that they are very or somewhat worried about a shooting happening at their school; like gun threats, these numbers are also elevated for people of color (Graf 2018, Koo 2023). One recent study explored the effects of Experiences of Violence (EVs) that include and go beyond individualized acts of victimization, including occurrence of gunshots in one's neighborhood, encounters with sidewalk memorials for individuals killed violently, or knowing someone at risk of violence to themselves or others. Communities that have experienced school shootings exhibited widespread symptoms of post-traumatic stress disorder (Palinkas et al. 2004). In California, Black and Latinx individuals were four times more likely than White Californians to report that gunshots were a "big problem" in their neighborhood. More than 6 in 10 White Californians saw no sidewalk memorials for those who had been killed by violence in an average week; for Black and Latinx Californians, the numbers were reversed. Mapped onto firearm ownership, "non-owners of firearms who lived with owners reported more prevalent and extensive social network EVs than others did. They were much more likely than firearm owners and non-owners in households without firearms to know persons they perceived to be at risk of violence" (Wintemute et al. 2022, p. 6). Accounting for these nonphysical harms has concrete and important implications for how gun laws are written, enforced, and litigated. For example, federal law currently prohibits gun ownership by those convicted of domestic violence crimes [Unlawful Acts, 18 U.S.C. <unk> <unk>922(g)( 9)], and that law has been evaluated by judges based on whether it prevents physical violence [United States v. Skoien (2010), pp. 642-45]. But social science research has shown that most abusers use guns to intimidate their victims rather than to physically harm them (Sorenson 2017). Victims of hostile weapon displays suffer psychological, and not just physical, trauma and an ongoing sense of intimidation and threat, and such displays are a significant predictor of the severity of post-traumatic stress disorder symptoms (Sullivan & Weiss 2017). Reviewing domestic violence protection order cases in North Carolina, researchers discovered a significant portion (24.2%) involved firearm abuse short of shooting (Sullivan & Weiss 2017, p. 31). There is a symmetry here with the rise of self-defense as a reason for gun ownership and useeven as some gun owners may find security or identity in their guns, they can inflict corresponding fear and threats on others. The expansion of public carry, both legally and as a social practice, makes this dynamic all the more important. But there is not yet a rich literature describing the ways in which choosing not to own a gun (or, for that matter, to support gun regulation) intersects with, and has its own parallels in, the kind of threat, status, and identity issues identified with gun ownership. That symmetry-and the ways in which law might enable its expression-is well worth further exploration (Ayres & Vars 2020, Stevenson 2021). --- Race and Policing Another crucial dimension of gun law and scholarship that has drawn increasing public and scholarly attention in recent years is the complicated and fraught relationship between guns, race, and law. In public discourse, as in scholarship, there are competing narratives, all of which contain an element of truth (Blocher & Siegel 2022, Duke Cent. Firearms Law 2019, Winkler 2022). Like any tool, guns can be used to combat repression or to exacerbate it. Enforcement of gun laws can help staunch the disproportionate loss of Black life to gun violence, but it can also worsen the already horrific toll of police violence and incarceration. There is no single "solution" to this complex set of problems. Broad decriminalization of guns through the Second Amendment-as some advocates on the right and the left have urged1 -might well deliver some relief for communities of color torn apart by over-carceralization. Some scholars in the gun rights tradition-more recently joined by new allies-have emphasized the potential utility of guns as tools to resist tyranny and oppression (Cobb 2014, Jackson 2019, Johnson 2014), a theme that may resonate more strongly as the country grapples with the reality and extent of racialized police violence. On the other hand, expansion of gun rights threatens to introduce new forms of inequality and exacerbate other existing racial harms. Gun deaths are heavily concentrated among Black Americans (Davis et al. 2022), and polls and studies have shown consistently that Black Americans favor gun regulation more than White Americans do (Crifasi et al. 2021). Further research into the views and preferences of communities of color-and, in particular, how they weigh the costs and benefits of gun deregulation-would be quite valuable. It is also important to know as much as possible about the likely outcomes of such deregulation. For example, existing research suggests ways in which a more heavily armed society is one in which Black Americans are at even further risk of being killed-not only by police but by private citizens. Studies on threat perception have found consistently that people are especially likely to perceive Black people as threatening, for example, by mistaking a harmless item for a weapon when the person holding it is Black (Cothran 2011, p. 348;Eberhardt et al. 2004, p. 878;Judd et al. 2004, p. 75;Lee 2016, pp. 157-58;Payne 2001, p. 190), which could in turn worsen the problem of "false positive" defensive gun uses. Other studies cast some doubt on whether, in practice, people of color will be able to benefit fully from a seemingly expanded right to armed self-defense-evidence regarding Stand Your Ground laws is not particularly encouraging (Murphy 2018, Roman 2013). In the other direction, advocates of gun regulation must continue to grapple with the harms that law enforcement inflicts on communities of color, and whether alternative approaches might mitigate those harms while furthering public safety goals. Recent years have seen enormous growth in support for community violence intervention programs, and the Biden administration has directed unprecedented amounts of funding to the effort (White House 2021). To the degree that such programs can offer a reduction in gun violence without exclusive reliance on police and prosecutors, they could offer a way forward-one that responds to a complex social issue by targeting the underlying causes and conditions of violence (Charles 2022b). Evolving approaches to guns and domestic violence show how law can simultaneously recognize nonphysical gun harms and also rely less heavily on state-enforced forms of control like prosecution and imprisonment. As noted above, there is growing awareness of the ways that guns are used not only to physically injure and kill intimate partners but also to intimidate and coerce them. At the same time, legal responses have expanded beyond state-backed coercion such as policing and incarceration. Domestic violence scholars and advocates have drawn attention to the physical and nonphysical costs of these purely punitive approaches-including to women, and especially in communities of color (Gruber 2020, p. 87). One result has been an increasing emphasis on restorative justice and community-based approaches rather than imprisonment alone (Coker 2020, Goodmark 2021). --- CONCLUSION Research and scholarship have never been more important to understanding the gun debate and its legal implications. In the same week the US Supreme Court curtailed the options for elected representatives to stem gun violence, Congress passed the first major federal firearms legislation in nearly three decades, the Bipartisan Safer Communities Act. Both of these developments came after two years of a global pandemic, during which significant changes in gun buying and gun violence trends materialized. A surge of gun purchases punctuated the pandemic. Although most gun purchases during the height of the surge were made by existing owners (Simonson et al. 2021), many Americans became first-time gun owners, and data suggest that these new owners are more diverse than existing owners along at least race and gender lines (Azrael et al. 2021). At the same time, gun violence also surged. One study found a more than 30% increase in firearms-related nonfatal injuries during the first year of the pandemic (Sun et al. 2021). And national statistics show rising rates of firearm deaths after two decades of falling fatalities (Gramlich 2022). And even as we write in the fall of 2022, gun displays at election-related sites are reinforcing the ways in which firearms impact not only physical lives but the public sphere on which a constitutional democracy depends. Grappling with these changes through legislation and court decisions will continue to require scholarship that explores the meaning and impact of guns beyond bodies and bullets. --- DISCLOSURE STATEMENT J.B. and D.A.H.M. are co-directors of the Center for Firearms Law, a non-partisan, independent scholarly center dedicated to the development of firearms law as a scholarly field. The Center is partially funded by outside grants from individuals and organizations including Everytown for Gun Safety, the Joyce Foundation, and Arnold Ventures.

Academic work is increasingly important to court rulings on the Second Amendment and firearms law more generally. This article highlights two recent trends in social science research that supplement the traditional focus on guns and physical harm. The first strand of research focuses on the changing ways that gun owners connect with firearms, with personal security, status, identity, and cultural markers being key reasons people offer for possessing firearms. The second strand focuses on broadening our understanding of the impact of guns on the public sphere beyond just physical safety. This research surfaces the ways that guns can create fear, intimidation, and social trauma; deter civic participation and the exercise of constitutional rights; and further entrench racial inequality.

Background Socioeconomic status (SES), conceptualized as the social standing or class of an individual or group, has been identified as an important factor in health inequalities [1,2]. People with higher SES tend to live longer, healthier lives, and suffer less from disease and disability [3,4]. Furthermore, SES and disability appear to have a gradient relationship, with better health accompanying increases in SES [5]. Adler and Newman have proposed several pathways through which SES may influence health [6]. These include SES and environmental exposures (i.e. exposure to damaging agents in the work or home environment), SES and social environment (i.e. isolation and engagement in social networks), SES and health care (i.e. access, use, and quality of health care), and SES and behaviour and lifestyle [6]. With many pathways through which SES can influence health, many approaches to measure SES have been taken in health research. For example, level of education, occupation and occupational status, income and wealth, and geographical features have often been used as measures of SES [7][8][9]. SES is often investigated in health disparities research, but as of yet, not much is known about the relationship between socioeconomic factors and low back pain (LBP). Results of the few studies that have reported on this relationship are conflicting [10,11]. Considering that LBP is one of the most prevalent disorders worldwide, and has an enormous economic and societal burden, it is important to identify factors that might help reduce the prevalence of LBP and its associated disability [12,13]. Evidence indicates that staying active during a LBP episode leads to quicker recovery and clinical practice guidelines consistently recommend remaining active despite LBP [14]. Disability among adults with LBP has been found to be associated with maladaptive LBP beliefs, such as the belief that movement will cause physical damage to the spine and that bed rest is needed for managing LBP [15][16][17][18]. Indeed, beliefs about LBP in the general public tend to be maladaptive [19][20][21][22][23][24]. This has led developers of mass media interventions to focus on changing beliefs about activity in the hope that it will lead to more adaptive beliefs that change associated health behaviour (i.e. more activity during LBP episodes and thus less disability). Unfortunately, most mass media campaigns have resulted in improvements in beliefs, but have failed to result in sustainable changes in associated disability behaviours [25][26][27]. Various explanations have been suggested, many of which were campaign-related. One factor that may have influenced the success of LBP campaigns is SES. Personal and environmental factors play a role in health behaviour, as many health models have suggested. For example, education has been found to be related to LBP beliefs [28]. Individuals with a higher level of education may be more adept at sifting through the vast amount of information about LBP and adopting more adaptive beliefs about their LBP (i.e. believing that one should stay active during an episode of LBP) [29,30]. Since none of the previous mass media campaigns have examined the relationsship between SES and campaign effects, it is possible that more targeted messaging could result in better outcomes. This study examined the relationship between measures of SES and the belief that one should stay active through LBP among the general population of Alberta, Canada. We also examined the association between measures of SES and exposure to a mass media campaign aimed at improving back beliefs. --- Methods --- Design Over the past decade, the Workers' Compensation Board and partners in the province of Alberta, Canada have undertaken a mass media campaign designed to improve back beliefs among the general public. This campaign was evaluated in a previous study [25]. From 2010 through 2014, annual data on public beliefs continued to be gathered using cross-sectional surveys. These surveys contained the key question related to beliefs about staying active during LBP that was also used during the initial study [25]. The Workers' Compensation Board-Alberta provided access to the survey data that contained measures of LBP beliefs along with several demographic characteristics. Informed consent was not written, but obtained by the polling firms verbally for telephone surveys and online for web-based surveys. Consent was also implied through completion of the survey. The University of Alberta's Health Research Ethics Board approved this study. --- Study population Between 2010 and 2014, 9572 randomly selected Alberta residents aged 18-65 years were surveyed. The sample appeared representative of the overall population of adult Albertans based on a comparison with region, sex, and age information available in the most recent Statistics Canada census information [31]. Experienced polling firms collected data using Computer-Assisted Telephone Interviews (n = 4500) and web-based surveys (n = 5072). The telephone surveys were conducted in January 2010 (n = 900), January 2011 (n = 900), July 2013 for the year 2012 (n = 900), November 2013 for the year 2013 (n = 900) and May 2014 (n = 900). Web-based surveys were conducted in January 2010 (n = 1002), January 2011 (n = 1066), July 2013 for the year 2012 (n = 1002), November/December 2013 for the year 2013 (n = 1001) and May 2014 (n = 1001). Respondents to the telephone interviews were randomly selected while the web-based surveys were not random (i.e. self-selected respondents to the online survey). Since the majority of respondents were self-selected, we were unable to calculate response rates. --- Outcome measures The surveys contained the key belief question from the original campaign surveys regarding staying active with back pain. Respondents were asked their level of agreement (from 1-Completely Disagree to 5-Completely Agree) with the statement "If you have back pain you should try to stay active". Level of agreement with this statement was considered the primary outcome measure for the current study, and responses were dichotomized by combining the agree options (4 and 5) into one category and disagree options (1 and 2) into a second category with the neutral option (3). Agreement with this statement was considered an adaptive back belief, while not agreeing with the statement was considered a maladaptive back belief. Although there has been little formal reliability or validity testing of this outcome measure of beliefs about LBP, the previous study by Gross et al. highlights the validity of the belief question [25]. It has been used in research performed in Scotland and Canada, and in both locations it was capable of detecting changes in general public back pain beliefs [25,26]. The surveys also inquired about respondents' exposure to campaign messaging, asking whether they recalled seeing or hearing any advertising that says "Back pain: Don't take it lying down" or advising that it is important to stay active through back pain. This selfreported exposure to campaign messaging was considered a secondary outcome measure for this study. Available measures of SES that were used as independent variables were region of residence (Edmonton/Calgary or other region in Alberta, where Edmonton/Calgary were considered urban and other regions were considered rural), the language respondents first learned at home in their childhood (French/English or other, where French and English were considered native and other languages were considered immigrant), level of education, employment situation, occupation, marital status, income category, and the number of people in the respondents' household. Education, employment, occupation, and marital status had multiple categories and were collapsed into variables with more meaningful categories for analysis. The specific categories used can be seen in Table 1. Furthermore, the surveys contained basic descriptive information regarding characteristics of the study population. This included type of survey (phone-or web-based), age category, and sex of respondents. The original survey items used in this study are shown in Additional file 1. --- Data analysis Descriptive demographic and SES characteristics of the sample population were summarized. Logistic regression analysis was performed to identify SES measures associated with back beliefs as well as campaign exposure. For the continuous variable (i.e. number of people in respondents' household), a test for linearity with the outcome measures was performed first. As the assumption of linearity was not violated, this variable was kept as continuous in all models. All SES variables were entered into univariable models first. Variables that were significant in univariable models were then entered into a final multivariable model. However, in cases where eligible variables were highly correlated, as measured by Cramer's V (>0.90), only the most significant variable was entered to avoid problems with collinearity. Hosmer-Lemeshow tests were performed to examine goodness-of-fit. For all analyses, significance levels were set to a p-value of 0.05. All analyses were conducted using IBM SPSS Statistics 23.0 (Armonk, New York). --- Results --- Sample characteristics Table 1 provides an overview of the characteristics of the sample population. The majority of respondents were older than 44 years of age, female, had completed the web-based survey, lived in an urban region, and their native language was English and/or French. The average household consisted of 2.7 people, and one third of respondents reported an annual household income of $100,000CDN or more. Furthermore, 67.6% of respondents reported agreeing with the statement "If you have back pain you should try to stay active", and 42% of respondents reported being exposed to campaign advertising. Most respondents were married, had completed College or Technical training, and were employed fulltime. The types of occupations reported by the respondents varied widely, but most respondents (44.2%) were homemakers, students, retirees, or unemployed. --- Logistic regression modeling'stay active' item Univariable logistic regression analysis showed statistically significant associations between agreement with the 'Stay Active' item, age, and several SES measures. People that learned a language other than English and/or French as their first language were less likely to agree with the item (Odds Ratio (OR) 0.78, 95%-Confidence Interval (CI) 0.63-0.98, p = 0.03). A higher educational level was positively related to agreement with the item, and there appeared to be a significant and gradient increase (OR 1.23 and 1.25 for college/technical training and university education respectively, both p = <unk>0.001). Homemakers, retirees, students, and unemployed people were less likely to agree with the item than people that were employed either full-time or part-time (OR 0.88, 95%-CI 0.78-1.00), and this was statistically significant (p = 0.05). Marital status was also significantly related to agreement with the item. People who were married or in common law union were more likely to agree than single people (OR 1.34, 95%-CI 1.20-1.51, p = <unk>0.001), as were people that were divorced, separated, or widowed (OR 1.31, 95%-CI 1.13-1.53, p = <unk>0.001). Having an income between $40,000 and $59,999, between $80,000 and $99,999, or >$100,000 led to a significant increase in agreement with the statement, compared to having an income of $19,999 or less. Respective ORs for these income categories were 1.24 (95%-CI 1.00-1.55, p = 0.05), 1.41 (95%-CI 1.12-1.78, p = 0.004), and 1.66 (95%-CI 1.34-2.05, p = <unk>0.001). Variables entered into the multivariable logistic regression analysis for agreement with the'stay active' statement included age, educational level, employment situation, marital status, and income category. While language was significant in the univariable model, there were insufficient cases in the dataset to run this variable in the multivariable model. The only association that remained significant in multivariable regression was that between agreement with the statement and income (p = 0.005). A Hosmer-Lemeshow test for the multivariable model showed a p-value of 0.16 (X 2 11.9 with 8 degrees of freedom), suggesting that the data fit the model. Table 2 shows the crude and adjusted associations between the 'Stay Active' item and SES-measures. --- Logistic regression modeling for campaign exposure Table 3 shows the associations between campaign exposure and SES measures. Univariable regression showed a significant association between campaign exposure and a first language other than English/ French, where this group was less likely to remember being exposed to campaign advertising than people that learned English and/or French as their first language (OR 1.41, 95%-CI 1.06-1.87, p = 0.02). The association between campaign exposure and overall educational level was not significant (p = 0.06), while respondents with university education were significantly less likely to remember being exposed to the campaign than respondents with a high school diploma or a lower educational level (OR 1.17, 95%-CI 1.02-1.34, p = 0.03). A significant association was also found between occupation and campaign exposure (p = 0.003), where respondents who were homemakers, students, retirees, or unemployed were less likely to remember being exposed to the campaign than manual workers (OR 1.24, 95%-CI 1.01-1.52, p = 0.04). Lastly, a significant association was observed between age categories and campaign exposure (p = <unk>0.001). Age, educational level, and occupation were entered into the multivariable logistic regression for campaign exposure. While language was a significant determinant in the univariable model, there were insufficient cases in the dataset to run this variable in the multivariable model. Employment status was not entered into the multivariable model, because it showed a high correlation with occupation (Cramer's V = 0.92). The associations between campaign exposure and educational level and age remained significant in the multivariable model (p <unk> 0.05), while occupation became non-significant. Respondents with university education were significantly less likely to remember being exposed to the campaign than respondents with a high school diploma or lower education (OR 1.22, 95%-CI 1.04-1.43, p = 0.02). A Hosmer-Lemeshow test for the multivariable model showed a p-value of 0.40 (X 2 8.30 with 8 degrees of freedom), again suggesting a good fit of data. --- Discussion The current study examined associations between various measures of SES and having adaptive beliefs about back pain (i.e. agreeing with the statement 'If you have back pain you should try to stay active'). We also examined associations between SES measures and selfreported exposure to a mass media campaign highlighting the importance of staying active through an episode of back pain. Results suggest that annual household income, as s measure of SES, was significantly associated with beliefs about LBP. We also observed a significant association between educational level and self-reported exposure to campaign advertising, where respondents with a high level of education were less likely to remember being exposed to campaign advertising (OR 1.22, p = 0.02). This may be due to the nature of the advertising, which targeted industries and workplaces with high risk of back pain (e.g. posters were sent out to construction and manufacturing type workplaces, but they were not sent out to offices or workplaces with a high ratio of university educated workers). The targeted nature of the campaign is an important factor to keep in mind when interpreting our results. It may be that the LBP campaign did not yield any new information for higher educated respondents, which did not trigger them to remember this campaign. Recent studies have shown that tailored messages and targeted campaigns appear to stimulate greater cognitive activity among recipients than messages that are not tailored [32]. Making information relevant to the target audience has a better chance of effectiveness and is more likely to produce positive changes in health-related behavior [32,33]. However, adequate exposure to the messages remains important, and supportive activities and policies can contribute to better behavioural or cognitive outcomes [33]. Additionally, targeted information campaigns may assist in reducing health disparities because in this study the targeted campaign was recalled more by low SES groups. This suggests the campaign reached and was understood by its intended audience. If low SES patients' beliefs become more aligned with those of high SES patients, then recovery from LBP may improve to be similar to recovery rates of high SES groups. However, given that other studies have found that changed beliefs do not necessarily lead to changed actions [25][26][27], more research to help people translate realigned beliefs into new behaviours is needed. In our univariable models, several SES measures were associated with adaptive back beliefs regarding staying active through LBP. For example, significant associations were observed between the LBP belief item and language, education, employment, and income. Learning a first language other than English or French, which could be interpreted as being immigrant to Canada, was a significant determinant for not agreeing with the'stay active' item. When looking at language as a determinant for racial or immigrant status, our finding is in line with other research that suggests racial and ethnic disparities exist in health care [34,35]. Specific to pain-related issues, a previous review showed that such disparities are prominent in pain perception, assessment, and treatment of pain, which underlines our finding that immigrant respondents usually are less likely to have adaptive beliefs about staying active through back pain [36]. Education, employment, and income category were also significantly associated with adaptive LBP beliefs in univariable models, which is in line with other research showing that more education is linked to higher income, and that both are associated with better health [37,38]. Employment status (employed versus unemployed) might be a mediator between education and income, with more education being linked to higher employment rates, and being employed leading to higher income than being unemployed. Although little is known about the relationship between SES and beliefs about LBP, our results are consistent with a review of survey data from two U.S. national surveys [39]. This study suggests that prevalence of LBP declines with an increase in education and income. Another review on formal education and LBP suggested that low education is associated with longer duration and higher recurrence of LBP [40]. In general, both higher incomes and higher levels of education have been reported as positively associated with healthy behaviour and thus positive health outcomes [6][7][8][9]41]. However, the potential mechanisms through which SES influences LBP are unclear. One explanation might be that higher educational levels are related to healthy behaviour (e.g. exercise habits), less exposure to occupational risk factors (e.g. heavy manual work), and to higher incomes. Higher incomes can further reduce occupational and environmental risk factors (e.g. better living conditions), increase access to preventive health services, and aid in implementing healthy behaviours. However, other known and unknown factors may influence the relationship between SES and LBP, making the understanding of underlying mechanisms difficult. Furthermore, evidence has suggested that correlations between education, income, and other SES measures are modest, and that SES measures are not interchangeable [7]. Different SES factors can affect health at different times in life, on different levels, and through various causal pathways [7]. SES measures can further interact with other respondent characteristics, such as age. For example, older people have had more time to generate wealth than younger people, despite generally reporting lower incomes than younger people due to being retired, unemployed, or unable to enter the labour market. This interplay between various SES and non-SES measures further complicates interpretation of the relationship between SES and health. Our results were based on a large, population-based sample that appeared representative of the overall target population based on recent census information available from Statistics Canada [31]. This improves generalizability of these results. However, the current study encountered some limitations. Unfortunately, no information on campaign exposure was available for the years 2010 and 2011, and no control group was available from areas without campaign exposure. We also did not have data on selfreported LBP to relate to measures of SES, and future studies should ideally include data on self-reported LBP. Furthermore, while most of the SES measures had many categories, not all categories were meaningfully interpretable and were collapsed. For example, 11 random categories were available for the 'occupation' variable, which was subsequently collapsed into 5 meaningful categories. While it has been recommended that researchers use many categories in order to establish knowledge on which SES factors specifically influence health, the categories chosen must be meaningful and preferably based on evidence [7]. Furthermore, the partially nonrandomized sample (web-based survey) might have influenced our results and the cross-sectional nature of the surveys prevented examination of individuallevel changes in LBP beliefs due to the campaign. --- Conclusion Individuals with higher annual household income appear more likely to believe that one should stay active during an episode of LBP. Additionally, targeted information campaigns are recalled more by low SES groups and may thus assist in reducing health disparities. More research is needed to fully understand the association between socioeconomic factors and LBP and to target campaigns accordingly. --- Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. --- Additional file Additional file 1: Survey questionnaire items. Shows the original survey questions that were used in this study. (DOCX 19 kb) Abbreviations CI: Confidence interval; LBP: Low back pain; OR: Odds Ratio; SES: Socioeconomic status Authors' contributions AS and DPG designed the study and discussed analysis. AS, GPB, and DPG discussed results, and all authors were involved in interpretation of results. AS wrote the initial manuscript, GPB, FGS, JRA, and DPG edited subsequent versions of the manuscript, and approved of the final manuscript. --- Competing interests The authors declare that they have no competing interests. --- Consent for publication Not applicable. --- Ethics approval and consent to participate The University of Alberta's Health Research Ethics Board approved this study. Consent to participate was obtained by the survey polling firms who collected data. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Low back pain (LBP) is one of the most common and costly healthcare problems worldwide. Disability from LBP is associated with maladaptive beliefs about the condition, and such beliefs can be influenced by public health interventions. While socioeconomic status (SES) has been identified as an important factor in health literacy and inequalities, not much is known about the association between SES and beliefs about LBP. Therefore, this study examined the relationship between measures of SES and the belief that one should stay active through LBP in a representative sample of the general population in Alberta, Canada. We also examined the association between measures of SES and self-reported exposure to a LBP mass media health education campaign. Methods: Population-based surveys from 2010 through 2014 were conducted among 9572 randomly selected Alberta residents aged 18-65 years. Several methods for measuring SES, including first language, education, employment status, occupation, and annual household income, were included in multivariable logistic regression modeling to test associations between measures of SES and outcomes. Results: Univariable analysis showed that age, language, education, employment, marital status, and annual household income were significantly associated with the belief that one should stay active through LBP. In multivariable analysis, income was the variable most strongly correlated with this belief (odds ratios ranged from 1.04 to 1.62 for the highest income category, p = 0.005). Univariable analysis for exposure to the campaign showed age, language, education, employment, and occupation to be significantly associated with self-reported exposure, while only education (p = 0.01) and age (p = 0.001) remained significant in multivariable analysis. Conclusions: Individuals with higher annual income appear more likely to believe that one should stay active during an episode of LBP. Additionally, targeted information campaigns are recalled more by low SES groups and may thus assist in reducing health disparities. More research is needed to fully understand the association between socioeconomic factors and LBP and to target campaigns accordingly.

Background There is growing awareness about widespread disrespect and mistreatment that women experience during childbirth in facilities around the globe. Recent systematic reviews of both qualitative and quantitative studies have identified domains of mistreatment, including physical, sexual, and verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health care-related conditions and constraints [1,2]. An increasing number of studies address mistreatment and disrespectful care globally, though few studies have measured the magnitude and factors associated with women experiencing mistreatment. A study of 13 public, private, and faith-based facilities in Kenya found that one-fifth of women reported experiencing some form of disrespect, most commonly undignified care and neglect or abandonment [3]. In Tanzania, 14.8% of women delivering at an urban referral hospital reported disrespectful care [4]. In a separate study in Tanzania, 19-28% of women surveyed reported experiences of disrespect, with reports of disrespect increasing when women were interviewed several weeks after delivery [5]. This study found that more educated women and poorer women were more likely to report disrespect [5]. Providers are more likely to discriminate against poorer, lower-status, and less-educated patients [6], in part because these patients are less empowered to seek recourse for poor treatment [1,5]. However, more educated women may have higher expectations around birth, leading to a higher likelihood of reporting mistreatment [5]. These rates of disrespectful care suggest mistreatment during delivery is not uncommon, which merits further examination, especially to understand the mechanisms through which it occurs and factors that may predispose or protect women. Empowerment is one such characteristic that may influence a woman's experience at delivery. The concept of empowerment comprises multiple constructs, such as agency, power, the ability to access and utilize resources, mobility and autonomy, and self-efficacy, among others [7,8]. Kabeer conceives of empowerment as having three components: (1) an ability to exercise choice among a series of alternatives, (2) agency to define and achieve goals, and (3) autonomy to utilize resources and agency without structural or social constraints [7]. Upadhyay et al. emphasize that empowerment goes beyond the domain of interpersonal relationships, building on Kabeer's work to define empowerment as "the expansion of people's ability to make strategic life choices in a context where this ability was previously denied to them" [8]. Indeed, macro-level factors must be considered in a definition of empowerment, as many women face social and structural barriers to exercising agency, beyond the constraints they face within their marriages or families. The degree to which an individual woman is empowered is determined by cognitive, psychological, economic, social, and political factors at the intrapersonal, interpersonal, and ecological levels [9]. These same factors drive her ability to access health care [10,11], including facility delivery, and likely also influence her experiences within the facility. A number of prior studies have found that various measures of women's empowerment, such as financial autonomy, household decision-making power, and freedom over movement, are associated with reproductive and maternal health outcomes. In India, Bangladesh, and other settings, these include use of antenatal care and delivery with a skilled provider [12][13][14][15][16]. An analysis of Demographic and Health Surveys from 33 low-and middle-income countries found that women who reported greater decision-making power within their household were significantly more likely to use a modern method of family planning, attend at least four antenatal care visits, and deliver with a skilled birth attendant [17]. However, measures of empowerment are not universally associated with reproductive and maternal health outcomes in these settings [16,18]. The mechanisms and domains by which empowerment influences reproductive and maternal health are not well understood and require further examination. Empowerment is a complex and multifaceted concept. Thus, past scholars have adopted various measures and combinations of measures to try to capture women's empowerment. A review of different measures of empowerment and their association with fertility found a breadth of measures have been used, including demographic factors such as age and education, as well as more complex measures including measures of women's household and sexual or reproductive decision-making, financial autonomy, mobility, gender attitudes and beliefs, exposure to media, and various community-level measures [19]. The Gender Equitable Men (GEM) scale is one such measure, and it captures information about cultural norms and beliefs, rather than individual experiences [20]. It includes four subscales, which examine violence, including intimate partner violence; gender norms and roles in sexual relationships; sexual and reproductive health behaviors, outcomes, and stigma; and domestic roles and decision-making. The GEM scale was originally developed to measure men's gender norms, and it has been used in many contexts to measure norms around gender equality, including India [21,22]. Since its development, it has also been used to measure gender norms among women [23][24][25]. There is less known on the association between women's empowerment and mistreatment during the time of childbirth. A past landscape review of the evidence on disrespect in childbirth noted the lack of quantitative data linking empowerment and experiences of disrespect in childbirth (7). Of the six studies cited in the landscape review, there were no standardized measurements of empowerment and autonomy, and no studies directly assessed associations between empowerment or autonomy and respectful care. In this paper, we aim to identify associations between women's empowerment and experiences of mistreatment during childbirth by examining associations between reports of multiple types of disrespect and empowerment, utilizing the GEM scale. We study this issue in a sample of women residing in slum areas of urban Lucknow, Uttar Pradesh, India, who have delivered in a health facility. Where women have greater decision-making power and autonomy, and are less accepting of genderbased violence, they may have greater agency in health care decision-making and negotiations, and be less likely to experience mistreatment in a facility delivery. We hypothesize that women who report a greater degree of empowerment are less likely to report experiences of mistreatment. --- Methods Data were collected from a cross-sectional study in Lucknow, Uttar Pradesh, India in May 2015 from a total of 759 young women aged 16-30 living in economically disadvantaged (slum) areas. All women had given birth in the last 5 years. At the city level, 38 slums were randomly selected out of about 713 slums in Lucknow, to carry out the study. This sampling was done by taking the list of slums compiled in the Urban Health Initiative program and systematically selecting every 18th slum (713/38) starting at number 5 and adding 18 every time (5, 23, 41, etc.) The number 38 was derived based on the assumption that 20 respondents would have to be interviewed from each slum. This was a quota sampling at the slum level. A sampling frame was prepared by listing all houses in the slums and then moving from house to house, starting at a randomly selected house in the selected slum. The first house where a woman had at least one child and was aged 30 years or younger was chosen for interviewing. Interviewers then moved to the next house in some order until they completed the predefined number of interviews, about 20 per slum; half of the women (380) had to be recent migrants and the other half (380) were not migrants. We selected women 16-30 years old, as these women were mostly likely to have had a child in the last 5 years and young women might be more likely to experience mistreatment. For the purposes of this analysis, we include the 392 women who delivered in a facility at their last birth, since they were the only ones asked about their personal experiences of mistreatment at the time of delivery. Of the women who delivered in a facility, 21% delivered in a public primary health center, 50% in a government hospital, 21% in a private hospital, and 8% in a private clinic. Household surveys were administered by four trained research assistants and covered a broad scope of topics, including demographic characteristics, migration experiences, fertility, pregnancy, and delivery experiences. Verbal informed consent was obtained from all study participants due to the low literacy levels in these communities. All study documents were reviewed and approved by the Institutional Review Boards at the University of California, San Francisco, and the Foundation for Research in Health Systems, India. The outcome of interest is a score of women's experiences of mistreatment at the time of delivery for their most recent delivery. This scale comprises a series of questions women answered about whether they experienced mistreatment during childbirth (Additional file 1). The questions asked to women included whether or not they experienced discrimination, physical or verbal abuse, threats to withhold treatment, lack of information, abandonment, their choice of position denied, requests for bribes, or unnecessary separation from the baby. These are subjective measures of a women's perception of her treatment. The results were combined into a score from 1 to 10, with 10 indicating experiencing mistreatment in all of these categories. The total score a woman received was divided by the number of questions that she answered. Therefore, the mistreatment score of a woman who answered all the questions was comparable to that of a woman who answered only some of the questions. The overall mean mistreatment score was 1.87 (standard deviation, SD 2.86). Since just about half of women reported not experiencing any mistreatment, for this analysis, we also created a binary variable for experiencing no forms of mistreatment compared to at least one instance of mistreatment. We recognize that some of the items in this combined scale ask about potentially overlapping experiences (for example, being neglected and delivering alone). Thus, we focused on the binary indicator of no mistreatment vs. at least one reported type of mistreatment as our main outcome variable in our analyses. The GEM scale is the main independent variable. The scale is considered to be sensitive and to have good predictive value [20]. It comprises four domains, each of which includes a number of items, ranging from five to eight. The four domains are Violence, Sexual relationships, Reproductive health and disease prevention, and Domestic chores and daily life. We analyzed each of these domains individually and created a total combined score of all four domains. We then created a binary variable for women who scored above the mean total GEM score and those who scored below the mean. The scoring for each indicator was 1 for "agree," 2 for "partially agree," and 3 for "do not agree"; therefore, higher scores correspond to women having a more gender equitable view. We also included a number of demographic variables in logistic regression models. We included a categorical variable for the woman's age (16-19, 20-24, and 25-30) and the total number of living children that she had. We included categorical variables for the woman's education attainment (none, primary school (<unk> = 6 years), and higher than primary school). We also included a variable for the difference in the educational attainment between the woman and her husband (coded as a binary of the husband being more educated compared to equal/the wife being more educated). We included three other binary variables: one for if the woman currently had paid work outside the home, the second for if she had migrated to Lucknow in the last 10 years (compared to before 10 years ago or never migrated), and the third for being Muslim (1) compared to Hindu (0). We included a caste variable for four categories: being of scheduled caste, tribe, or other backward castes (all socially disadvantaged castes), compared to other groups ("Other"). While these terms may sound derogatory, these are the standard terms used in the Indian context to describe different socially disadvantaged groups. Finally, using principal component analysis [20], we included a wealth quintile variable constructed from a series of questions about access to water, toilet, and household materials, etc. Demographic differences between mistreatment subgroups were identified using t tests. Significance was defined as p <unk> 0.05. The first multivariate logistic regression model looked at the relationship between various socio-demographic and household variables and the odds of a woman having a GEM score above the mean (more equitable views). The second model was a bivariate logistic regression model exploring the association between having an above-the-mean GEM score and reporting mistreatment. The final multivariate logistic regression model explored the association between having an above-the-mean GEM score and reporting mistreatment, controlling for the demographic factors listed above. All analyses were run using STATA 12.1. --- Results --- Demographic characteristics, by mistreatment level The majority of respondents (60.97%, N = 239) were aged 25-30 years, with 34.18% (N = 134) being 20-24 years and 4.85% (N = 19) 16-19 years old (Table 1). The mean number of living children that women had was 1.87, ranging from none to six. A little over a third (36.48%, N = 143) of women had no education, 37.76% (N = 148) had primary education, and 25.77% (N = 101) had secondary or higher education. In about two thirds of couples (60.71%, N = 238), the husband and wife had the same amount of education or the wife had more; in the remaining 39.29% (N = 154) the husband had more education. The majority (66.84%, N = 262) of women had paid work. The majority of women were Hindu (68.62%, N = 269) and the rest Muslim. The largest caste subgroup was other backward castes (OBC), who made up 40.56% (N = 159) of the women, followed by 33.42% (N = 131) being scheduled caste, 14.29% being other, and 11.73 (N = 46) being scheduled tribe. There were no differences in mistreatment reports by age, number of living children, education, education gap, religion, or work status. Smaller percentages of other and scheduled caste women reported mistreatment (between 30-40%), whereas 71.74% of scheduled tribe and 63.52% of scheduled caste women reported mistreatment. These levels of mistreatment were statistically significantly different by caste. A little over half (52.30%, N = 205) of women were migrants. There was a statistically significant difference in mistreatment scores by migration status, with non-migrants reporting more mistreatment. There were also statistically significant differences in mistreatment scores by wealth quintiles, with higher wealth quintiles reporting more mistreatment. The mean GEM score was 8.11 in the full sample (ranging from 4.49-11.88), and women who reported mistreatment had statistically significantly lower mean GEM scores than women who did not report mistreatment. Mistreatment in this study sample has been described in more detail elsewhere. In summary, 16.8% of women reported discrimination, 15.5% physical abuse, 28.6% verbal abuse, 12.2% threats to withhold treatment, 4.6% lack of information, 10.2% being abandoned or ignored, 10.5% delivering alone, 10.5% choice of delivery position ignored, 19.6% companion not allowed, 24.2% request for payment or bribe, and 4.3% unnecessary separation from the baby. Mean scores of the GEM subscale measures that are higher reflect more disagreement with the various statements, suggesting more gender equality (Table 2). The overall mean score for the Violence domain was 11.75 (interquartile range, IQR = 10-14), for the Sexual relationships domain the mean was 15.21 (IQR = 11-18), for the Reproductive health and disease prevention domain the mean was 12.01 (IQR = 10.5-14), and for the Domestic chores and daily life domain the mean was 9.24 (IQR = 8-10). Since each domain had a different number of questions, we also calculated a standardized mean (taking the overall score for each person and dividing it by the number of questions, so that it was on a scale of 1-3). This allows us to compare the domain means directly. When we look at the standardized means, the Violence domain had a mean of 1.96, the Sexual relationships domain a mean of 1.90, the Reproductive health and disease prevention domain a mean of 2.40, and the Domestic chores and daily life domain a mean of 1.85. The overall mean GEM score was 8.112. --- Factors associated with above-the-mean GEM score, mistreatment, and combined model Being of scheduled tribe or other backward castes, compared to scheduled or other caste, was significantly associated with lower odds of having a GEM score above the mean (odds ratio, OR = 0.0516, p <unk> 0.01 and OR = 0.133, p <unk> 0.01 respectively) (Table 3). Being a woman in the richest wealth quintile, compared to the poorest, was significantly associated with lower odds of having a GEM score above the mean (OR = 0.211, p <unk> 0.01). Being a woman who had a husband who was older than her was associated with lower odds of having a GEM score above the mean (OR = 0.600, p <unk> 0.05). In the bivariate model of the association between having an above-themean GEM score and reporting mistreatment, having a GEM score above the mean was associated with lower odds of reporting mistreatment during childbirth (OR = 0.182, p <unk> 0.01). In the model controlling for other sociodemographic factors, having a GEM score above the mean remained significantly associated with lower odds of reporting mistreatment during childbirth (OR = 0.266, p <unk> 0.01). Being in the richest (compared to the poorest) wealth quintile was significantly associated with reporting mistreatment during childbirth (OR = 3.268, p <unk> 0.01). Being a recent migrant was also significantly associated with increased odds of reporting mistreatment (OR = 1.773, p <unk> 0.05). --- Domains of the GEM scale and mistreatment Each domain of the GEM scale was significantly associated with lower odds of reporting mistreatment in an unadjusted model (analyses not shown). When socio-demographic variables were included in each model, a higher score on the Domestic chores domain was associated with 0.846 times the odds of reporting mistreatment (p <unk> 0.01); a higher score on the Violence domain was associated with 0.820 times the odds of reporting mistreatment (p <unk> 0.01); a higher score on the Sexual relationship domain was associated with 0.856 times the odds of reporting mistreatment (p <unk> 0.01); a higher score on the Reproductive health domain was associated with 0.731 times the odds of reporting mistreatment (p <unk> 0.01) (Table 4). Each additional point on the total GEM scale was associated with 0.914 times the odds (p <unk> 0.01) of reporting mistreatment. Being from a scheduled tribe, compared to "Other", was consistently associated with increased odds of reporting mistreatment in all models (OR = 2.764, p <unk> 0.05 in the final model). Being from the OBC, compared to "Other", was associated with increased odds of reporting mistreatment in some models, but not all, including the final model with the full GEM scale. Being from the richest, compared to poorest, wealth quintile was associated with increased odds of reporting mistreatment in all models (OR = 2.856, p <unk> 0.05 in the final model). Finally, having migrated to Lucknow in the last 10 years was associated with increased odds of reporting mistreatment in all models (OR = 1.767, p <unk> 0.05 in the final model). --- Discussion Our findings suggest that women's norms about women's empowerment, as measured by the GEM scale, are associated with their likelihood of reporting experiences of mistreatment during childbirth. To our The indicators are as follows: 1 = Agree, 2 = Partially agree, 3 = Do not agree; higher score means a more gender equitable view knowledge, this is the first study to assess women's empowerment and reports of mistreatment during childbirth. Results suggest that women who report more equitable norms on all of the separate subscales and the combined total score for the GEM scale had a lower likelihood of reporting experiences of mistreatment. The GEM scale is a measure of norms of different aspects of women's empowerment, such as whether she thinks it is acceptable for a man to beat his wife, for women to initiate sex, or expects men to take on a role in housework. Women who had more progressive views about these factors were less likely to report mistreatment in childbirth. These results are corroborated by other studies on gender equality and health services. For example, a study in Nepal found that women who discussed family planning with their spouse and had higher levels of secondary education have a higher likelihood of receiving skilled antenatal and delivery care [26]. If women are more empowered, they may be more likely to recognize that formal health services are valuable, have the skills and resources to act on their demand, and be less likely to see the treatment by providers as mistreatment. Additionally, it is possible that women with more equitable gender norms are better able to advocate for themselves during childbirth and thus actually experience lower levels of mistreatment. It is also possible that these women interact with providers differently (present themselves as being worthy of more respect), and thus providers treat them with more respect. It is also possible that women who have more equitable views are more likely to have husbands and families with more equitable views, who are more likely to be with the woman in the facility, advocate for her, and help her receive better care. Another paper from this same dataset found that women who had the support of their husbands during delivery reported lower mistreatment scores [27]. When we turn to the specific domains of the GEM scale, each domain is associated with reports of mistreatment during childbirth. First, not surprisingly, women who hold more progressive views are less likely to report mistreatment during childbirth. Several researchers suggest that social norms around violence against women are directly related to how women are treated in health facilities, even during childbirth [28,29]. In Albania, women's attitudes towards domestic violence were associated with antenatal care and postnatal care utilization [30]. In this study, women's reports of acceptance of violence may be reflective of either community norms of violence or their relationships with their husbands. Acceptance of violence against women at the community level may trickle down to how women are treated in facilities by providers, their acceptance of that treatment, and how health systems support women in general [3,28]. Therefore, women who report less acceptance of violence against women may be living in households and communities that also support these views and improve women's quality of care in general. Furthermore, these women may be more likely to recognize specific provider behaviors as mistreatment. Women who held more progressive views in the Sexual relationship domain may reflect more egalitarian relationships with their husbands. In our study, 77% of women reported that their husband provided some form of support to them during delivery [27]. Past studies suggest that, compared to women who delivered with an untrained provider, women who delivered with a skilled attendant were more likely to have social support from their husbands during delivery, have higher spousal involvement in regard to health care, and receive instrumental, emotional, and informational support from their husbands [31]. Additionally, there is a clear link between spousal communication and family planning use [32]. It can be hypothesized that women who are more empowered in regard to sexual relationships with their husbands may also have increased support from husbands in the facility, ultimately leading to improved experiences with providers. This may also reflect a greater degree in these women's autonomy and agency around facility and provider choice. In regard to the Domestic chores and daily life domain, other studies find that women in higher social standing in their households may also have more progressive attitudes toward modern methods of health care [26]; therefore, they may also have more experience with modern types of health care settings and be able to demand better care. Women with previous experiences with antenatal care, for example, may be sensitized to patient-provider norms and relationships and be more equipped to negotiate the health care system. Women with family members who support them with household chores are also more likely to use antenatal care and a skilled attendant at delivery. Potential explanations for this include family members encouraging women to attend antenatal care, not only by physically taking over their household chores, but also by improved communication among family members about appropriate health care [33,34]. These mechanisms may lead to increased family support and communication within the health care setting and explain lower reports of mistreatment among more empowered women. In addition to our findings on the relationship between women's normative views about the status of women, as measured by the GEM scale, and women's perceptions of mistreatment during childbirth, this study also provides insight into the norms about gender equality among young women living in slums in Lucknow, Uttar Pradesh. Overall, mean responses were just about in the middle of the spectrum (around 2), suggesting that this measure can capture a diversity of viewpoints. For all domains, there were some women who gave the highest, and some who gave the lowest, scores for all items in that domain. The Reproductive health and disease prevention domain had the highest scores, which encompassed questions about family planning use and a woman's value resting in her ability to bear children, especially boy children. This suggests that women in this setting are accepting of family planning use, and do not see condom use specifically as meaning that women are promiscuous. It is interesting that women disagreed with statements about women's value resting in having a child, especially a son, since son preference is common in northern India, where this study took place. In northern India, child sex ratios are very imbalanced favoring males, and the transition from marriage to first birth is quite short, suggesting an emphasis on childbearing [35]. It is possible that government programs and policies aimed to reduce discrimination against girl children are impacting norms, or that women feel pressured (or know the "right" answer) to these questions. This bias is also possible for items in the other domains. To date, there are no known studies in India measuring gender norms using the GEM scale with women. A study in Tanzania found that mean GEM scores were higher in men than women, and that women's mean GEM scores were about 47.0, compared to 54.9 for men [36]. The mean GEM score for the women in our sample was comparable to that for the women in the Tanzanian sample, at 48.22. A study in India (Mumbai) that only included men and used the GEM scale to measure the impact of an intervention that promoted gender equality found, at baseline, overall higher levels of agreement with the items in the scale than we found [21]. This intervention was in 2005-2006, so it is possible that gender norms have changed in India in the past 10 years. The intervention was also from a different part of the country. However, taken together, these findings suggest that women in India may have higher GEM scores than men (more equitable views), which would contrast the Tanzania data. Other studies only with men in other countries (Brazil and China) also found less equitable gender norms than we found among the women in our sample [37,38]. More studies are needed that utilize this measure in the Indian context and compare women and men's views about gender equality, to truly understand its value as a measure of women's empowerment. Across all models, higher wealth quintile women (compared to lower) reported more mistreatment. Higher wealth quintile women also had lower odds of reporting above-the-mean GEM scores (more equitable GEM scores). This means that wealthier women are more likely to report mistreatment and also more likely to have less equitable norms about the role of women. Even controlling for gender equity norms, wealthier women still report more mistreatment. It is important to remember that our sample comprised women living in slum areas, so these women are not "rich" compared to the national, state, or even city, average-rather, they are richer than their immediate peers in a low-income neighborhood. There are many possible explanations for this finding, which are discussed in more detail elsewhere [39]. One possible explanation is that wealthier women have higher expectations of the care they should receive, perhaps because they are used to being treated better, have more experience with the health care system, or because they are more aware of their rights. It is also possible that wealthier women are actually treated worse by providers, perhaps because providers resent women who might have higher status than they do. This is unlikely to be the case in this population, because all women lived in slums, and therefore, even though there is a distribution among the sample, compared to the population as a whole, these women would all be poorer and of lower status. In the reverse situation, women who belonged to scheduled tribes (compared to "Other") were more likely to report mistreatment and also less likely to have GEM scores above the mean. These women are of very low status, as scheduled tribe populations are often more marginalized than other social groups in India, although it differs by region, tribe, and caste. Another paper published from this same dataset discusses the contradictory findings about wealth, caste, and reproductive health outcomes in more detail [40]. It is interesting that women of low social status have the same associations (directionally), with both the GEM score and mistreatment score, as the wealthiest women. Past research in India has found that certain gender norms, such as son preference, are stronger among wealthier or more educated women, although results are mixed [41,42]. Similarly, past literature has found that lower castes have less restrictive gender norms, including those related to son preference, but again, evidence is mixed [43,44]. In examining the role of empowerment in respectful treatment at delivery and in other reproductive and maternal health outcomes, the multiple domains of empowerment should be considered together. As we find that each of the four domains in the GEM scale is associated with mistreatment, these should be considered holistically in the design of interventions to reduce mistreatment at delivery. Demand for respectful maternity care must be increased, but women will not enjoy a higher quality of care without concomitant improvements in their agency and autonomy to seek this type of delivery care. Our findings highlight the need to consider how empowerment affects and is affected by multiple domains of a woman's life: her socio-demographic characteristics, her social role and opportunities, and the structural and institutional context, for example, her political and legal rights. In India and elsewhere, women's ability to advocate for and seek reproductive and maternal health care has its foundations in adolescence [45]. Thus, interventions that seek to empower women for improved reproductive and maternal health must begin early in women's lives. There are several limitations of this study. Its crosssectional nature does not allow us to establish causality between women's views and their childbirth experiences. However, given the young age of respondents and relative recent timing of their latest delivery, it is unlikely that their views about empowerment or experiences have changed greatly in the intervening time since their latest birth. Past research has found that women's perceptions of quality change over time, thus, it is possible that women who had a birth in the past few months compared to those who had a birth 5 years ago had different memories of their experience. Again, since the women were young, most births were relatively recently. A prior study in India found that women's levels of empowerment were not affected greatly by reproductive events and did not change greatly from the time around marriage [45]. That being said, there is evidence that having a child increases a woman's autonomy, so it is possible that some women have become more empowered since giving birth [26]. Additionally, while we have a fairly large sample size, these data are not representative of women in Lucknow as a whole; rather, they are focused on young, mostly migrant, poor urban women in the setting. However, the findings may be comparable to research on other young, migrant, urban women in large cities in north India. --- Conclusions Despite these limitations, this is one of the few studies to not only provide quantitative insight into women's experiences of mistreatment in childbirth, but to look beyond the usual demographic predictors and explore how women's empowerment is associated with these negative experiences. Our findings suggest that normative acceptance of gender equality and women's empowerment is important to take into account when understanding women's perceptions of mistreatment in childbirth and likely other subjective measures of experiences influenced by expectations and power dynamics. If this is indeed the case, then efforts to improve the quality of interpersonal care for women at the time of delivery, and possibly for other reproductive, maternal, and child health care interactions, need to focus on changing both the broader social context of women's position and norms around equality as well as individual level factors. --- Open peer review Peer review reports for this article are available in Additional file 2. --- Additional files Additional file 1: Mistreatment questions. (DOCX 13 kb) Additional file 2: Open peer review. (PDF 189 kb) --- Availability of data and materials All data generated or analyzed during this study are included in this published article. --- Authors' contributions The study was conceptualized by NDS and MS. NDS, MS, and NM created the study tools and design and, with the help of ET, conducted the data collection. NDS led the data analysis and the writing of the paper. ET contributed to the data analysis and background literature review. MS and NM contributed to the writing of the paper. All authors read and approved the final manuscript. --- Ethics approval and consent to participant Verbal informed consent was obtained from all study participants due to the low literacy levels in these communities. All study documents were reviewed and approved by the Institutional Review Boards at the University of California, San Francisco, and the Foundation for Research in Health Systems, India. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Recent evidence has found widespread reports of women experiencing abuse, neglect, discrimination, and poor interpersonal care during childbirth around the globe. Empowerment may be a protective mechanism for women against facility mistreatment during childbirth. The majority of previous research on mistreatment during childbirth has been qualitative in nature. Methods: In this analysis, we use quantitative data from 392 women who recently gave birth in a facility in the slums of Lucknow, India, to explore whether measures of women's empowerment are associated with their experiences of mistreatment at their last childbirth. We use the Gender Equitable Men (GEM) scale to measure women's views of gender equality. Results: We find that women who had more equitable views about the role of women were less likely to report experiencing mistreatment during childbirth. These findings suggest that dimensions of women's empowerment related to social norms about women's value and role are associated with experiences of mistreatment during childbirth. Conclusions: This expands our understanding of empowerment and women's health, and also suggests that the GEM scale can be used to measure certain domains of empowerment from a women's perspective in this setting.

Introduction Librarians' roles have naturally changed and evolved through time. However, during the past decade, the dramatic transformation in higher education, the ever-shifting research and scholarly landscape, and the unrelenting advances in technology have had a significant impact on the responsibilities of academic librarians. In response to societal changes and financial constraints, universities have established new institutional priorities and have committed to enriching the student experience and supporting their success better. This new academic environment, along with the rise of alternative publishing models, the explosion of digital and licensed resources, the creation of digital content, and the ubiquitous presence of social media, challenge librarians to rethink their roles. Recent demands by government agencies to have publications resulting from funded research made freely available and research data deposited into an accessible repository or database have created new opportunities for librarians and encouraged their involvement in the lifecycle of research data. Librarians are adapting to this new environment by collaborating with faculty in research, teaching, and scholarship and striving to enhance the user experience. Traditional functions such as reference work and collection management are rapidly losing their status as primary responsibilities of librarians, while new functions related to research support, data management, bibliometrics, digital initiatives, scholarly communication, and user experience are increasingly becoming part of the academic librarian's responsibilities. While librarians in many institutions have adopted some of the new functions and are in the process of reinventing their roles, others are in the early stages of doing so. Although the literature abounds with articles on the new and emerging roles of librarians in academic institutions, there is a dearth of research on Canadian academic librarians' changing roles and responsibilities. The present study aims to address this gap by exploring role and responsibility changes as experienced by librarians in Canada's 15 research-intensive universities (U15). 1 This article presents the results of a survey designed to meet the following objectives: identify librarians' new and emerging roles, gauge confidence levels of librarians in new roles, identify librarians' training needs, measure librarians' job satisfaction relative to new roles, and report on librarians' perceived impact of their roles on the academic enterprise. --- Canadian Context The target population for the survey are librarians working in the U15 libraries. These libraries are members of the Canadian Association of Research Libraries (CARL), and 13 of the 15 institutions whose librarians were surveyed are members of the Association of Research Libraries (ARL). These libraries all belong to publicly funded universities that rely primarily on government funding and tuition fees to deliver programs. Academic librarians in Canada enjoy academic status that includes tenure or a form of continuing appointment and the right to participate in university governance. 2 In the Canadian context, research support and scholarly communication are heavily influenced by the three main governmental granting agencies that are referred to as the Tri-Agency. These granting agencies include the National Sciences and Engineering Research Council (NSERC), the Social Sciences and Humanities Research Council (SSHRC), and the Canadian Institutes of Health Research (CIHR). Since 2008, CIHR has had an open access policy, which requires grant recipients to make their final peer-reviewed manuscript available within 12 months of publication. This open access policy was extended to NSERC-and SSHRC-funded research for all grants awarded after May 1, 2015. 3 In 2018, these agencies developed a draft Tri-Agency Research Data Management Policy, which includes suggestions for institutional data management strategies, researcher data management plans, and data deposit. The policy is still under review and is not currently in effect. 4 While this study was conducted in Canadian research intensive universities, the survey results should be of interest to other ARL libraries, as the institutions have many similar functions. The main difference between Canada and the United States is that the requirements for open access and data management by the main granting agencies in Canada is still relatively new and compliance is low. 5 Scholarly communication is an area that has received a great deal of attention from Canadian postsecondary institutions. CARL has been instrumental in addressing issues related to scholarly communication and the role of academic libraries. Much of its work in recent years has focused on open access publishing and the creation of a sustainable scholarly communication system in Canada. 6 In regard to digital scholarship, U15 libraries are at different stages of developing services in this area. While many libraries offer this assistance from multiple service points, others such as McMaster University Library and the University of Alberta Libraries are delivering or planning to deliver these services from a central collaborative space. 7 Teaching is a core function of most Canadian academic librarians. A 2014 Canadian Association of University Teachers (CAUT) survey reports that 93.53 percent of librarians in Canada indicate at least some teaching or instructional activities as part of their workload. 8 In the past decade, Canadian postsecondary institutions have increasingly focused on enhancing the user experience in both physical and virtual spaces. U15 libraries have redesigned and repurposed library spaces, with some having recently launched large-scale master plans to modernize their facilities (examples: McGill University and University of Saskatchewan). 9 Overall, libraries have implemented a wide range of student engagement initiatives and introduced new technology-based services. --- Literature Review The seminal Association of Research Libraries (ARL) publication New Roles for New Times: Transforming Liaison Roles in Research Libraries served as the initial foundation document for this study in that it identified and helped to delineate new and emerging roles of liaison librarians in the areas of investigation. 10 During the past decade, a number of studies have provided snapshots of librarians' roles and activities. Nero and Langley, in their benchmark study, create an open access data set that provides a record of what an academic librarian does in the early 21st century. 11 Gwyer performs a retrospective analysis of published literature looking at how librarianship has changed and projects future trends. 12 Cox and Corrall describe how academic librarianship has evolved in the last two decades and how new academic library specialties have developed. 13 In a systematic review investigating the changing roles of health sciences librarians, Cooper and Crum find "sixteen new roles or activities... and four new twists in traditional roles." 14 The literature reporting on librarians' emerging roles in research support has surged in the last decade, with many earlier publications illustrating the burgeoning discussion. 15 A 2013 study by Corrall, Kennan, and Afzal explores bibliometrics and data support activities in academic libraries in Australia, New Zealand, Ireland, and the UK and finds a skills deficit and low confidence levels among librarians. 16 In 2014, they further analyze their data to find out how librarians will meet the demand for more research support services and develop their skills and knowledge. 17 In their 2012 survey, Cox and Pinfield gauge UK academic libraries' involvement in and challenges of research data management and compare their survey results with those of Corrall et al. and Tenopir,Birch,and Allard. 18 This study by Tenopir et al. reports the results of a survey of ACRL members "to provide a baseline assessment of the current state of and future plans for research data services." 19 Three additional articles by Tenopir et al. focus on research data services provided, librarians' preparedness to deliver these services, and their attitudes toward the importance of this activity. 20 More recently, Tenopir et al. explore the situation in European academic libraries to determine what research data services are currently offered and planned for the future. 21 In 2017, Cox et al. offer an international perspective with a survey on "research data management (RDM) activities, services, and capabilities... in Australia, Canada, Germany, Ireland, the Netherlands, New Zealand, and the UK." 22 In another wide-ranging study, Keller examines the development and sustainability of research support services in Australian university libraries and compares the developments in Australia with those in three European countries. 23 Other studies have a more specific focus. Among these is Auckland's survey of subject librarians and managers in the Research Libraries UK member libraries that examines the role of librarians in meeting researchers' needs and identifies challenges associated with skills gaps. 24 Antell et al. explore the involvement of science librarians providing data management services in ARL institutions and gather information about skills requirements. 25 A few publications that examine teaching functions, knowledge acquisition and application, and confidence in librarians' abilities informed this project. Bewick and Corrall focus on how subject librarians acquire and apply their pedagogical knowledge and examine five teaching activities. 26 Waite, Gannon-Leary, and Carr investigate the tutoring role of librarians in the online environment. 27 A Canadian survey of librarians reveals that the majority of respondents considered teaching an integral part of their professional identity and concludes that, to gain confidence in their teaching, librarians need more formal education. 28 More recently, a revisioning of the teaching role where collaboration and leadership are key components is emerging. To that point, ACRL's 2017 document Roles and Strengths of Teaching Librarians promises to transform the role by proposing a holistic, conceptual model with seven interconnected roles and identifying the strengths required to fulfill each of these roles. 29 A precursor to this critical document is an article by Bowles-Terry and Donovan in which they advocate for a proactive and collaborative role in which librarians achieve their "potential as pedagogical experts and instructional consultants." 30 Studies going back to 2012 promote the role of librarians in digital scholarship and their capacity to engage and become effective partners. Vandegrift focuses on the role of digital humanities in the library, promoting the idea of moving from a "service" model to a "production" model. 31 His later article, coauthored with Varner, continues to make the case that digital humanities and libraries are natural scholarly partners. 32 Sula presents a conceptual model of libraries and digital humanities coming together where librarians can engage in and perform the work of digital humanities. 33 More recently, a 2015 survey of academic librarians and faculty conducted by Cengage Learning and American Libraries provides an important measure in time. 34 The survey identifies support services and challenges, including staffing issues. It establishes a preference for a model where the library is a research partner rather than a service provider. Finally, King proposes a new role that combines digital librarian and digital humanist, underscoring the librarian's capacity to be an equal partner in the process. 35 Until recently, many publications on user experience describe the experience that students and faculty have with online interfaces, websites, and virtual library services. During the past few years, user experience (UX) has become its own specialty encompassing a more holistic view of service. In two related articles, Bell advocates that "Academic librarians should look for ways to improve processes to make using the library more seamless, convenient and time saving" 36 and encourages librarians to adopt a design orientation that will result in "an experience that leverages the library's unique elements that are impossible to obtain elsewhere." 37 To understand the new UX specialization, MacDonald conducted a qualitative study involving interviews with 16 librarians who have "User Experience" in their titles. His report provides a timely snapshot of this developing role. 38 He further expands on this work when he delves into the factors that led to the emphasis on UX and its benefits and challenges. 39 As librarians shift from collecting, organizing, and preserving materials to creating, sharing, disseminating, and curating knowledge, new roles related to scholarly communication are emerging. In a survey of repository managers in Italy, Cassella and Morando assess the roles and skills required to implement and manage institutional repositories. 40 Looking into the future, Chadwell and Sutton see libraries shifting from being "consumers of information to becoming disseminators of scholarship" 41 and envision how open access and library publishing will create new roles for librarians. Not all librarians are ready to assume these roles. An Israeli study by Klain-Gabbay and Shoham finds that approximately one-third of the librarians surveyed appear to be uninterested or underestimate their capabilities to be actively involved in scholarly communication. 42 A large body of literature examines how prepared librarians are and what new skills they require to perform their roles. 43 Researchers such as Riley-Huff and Rholes investigate librarian readiness and methods librarians have used to acquire their skills, 44 and Hess describes job-embedded professional learning. 45 Several articles address the fact that, for librarians to perform their new roles, pedagogic theory needs to be integrated into their training. 46 The one anomaly appears in Bewick and Corrall's study, where the majority of UK librarians report that they have sufficient knowledge to fulfill their roles. 47 There are very few comprehensive studies investigating academic librarians' overall job satisfaction that relate to the current research. One is a 20-year-old Canadian study by Leckie and Brett that explores job satisfaction of Canadian university librarians replicating Horenstein's study of American librarians. 48 Both studies report that the single most satisfactory element of their work is their relationship with their clientele. There is an overwhelming number of articles dealing with the impact of librarians on the academic enterprise. For the purpose of the current study, Robertson's article is relevant. His interview of provosts from nine U15 Canadian universities quantifies their perceptions of their libraries' contribution to institutional priorities. 49 They share their belief that librarians should take on a greater collaborative role with faculty and teaching support units around pedagogical developments. They discuss the changing roles of librarians and the need for librarians to become active as embedded partners in teaching, research, and learning activities of the university. --- Methodology A survey was sent to 743 academic librarians, including archivists, working in Canada's U15 universities. The U15 identify themselves as Canada's leading research-intensive institutions that conduct 80 percent of all competitive university research. They consist of 12 English-language and two French-language universities and one officially bilingual university. These universities were selected to make the project manageable and to obtain responses from librarians employed by institutions with similar missions. Senior library administrators (that is, university librarians, deans, directors, and their associates) were not included in the survey population. The survey is an attempt at a census; therefore, the results are representative only of those who responded and are to be viewed as descriptive in nature. Respondents were assured that their replies would be kept confidential and that the study had been reviewed and approved by the University of Manitoba's Research Ethics Board. SurveyMonkey was selected as the survey software, and SPSS, IBM SPSS Statistics Version 24, and R, RStudio Version 1.1.447 statistical software were used to analyze the data. Cronbach's alpha test was used to measure the reliability of the survey. The following tests were also used for different aspects of the data analysis: ANOVA and Pearson Chi-square tests, Kruskal-Wallis test, Dependent (Paired) two-group Wilcoxon Signed Rank Test, and Independent two-group Mann Whitney U test. The statistical software used were recommended by the University of Manitoba's Statistical Consulting Services. The survey questionnaire and the data are stored in the University of Manitoba's Dataverse repository and are available for use. --- Survey Instrument A 38-question survey was designed in English and French. The survey gathered demographic information and addressed five areas of investigation: Research Support, Teaching and Learning, Digital Scholarship, User Experience, and Scholarly Communication. These areas and the functions related to each of them were identified primarily in the ARL publication, New Roles for New Times: Transforming Liaison Roles on Research Libraries. 50 Additional functions were identified through a review of the literature and job postings. Within each of the areas of investigation, respondents were asked which functions they perform, how confident they are in their abilities to carry out these functions, how they acquired the skills to do their work, and where they require more training. Respondents were also invited to state whether they perform a traditional or a new role and to assess the amount of time they spend on either role. They were then asked how satisfied they are with their position and what impact they believe they have on the academic enterprise. For the most part, the questions were close-ended; the most probable choices were provided, and respondents were invited to check as many as applied. Respondents were also given the opportunity to provide additional possibilities in an "other" option and to submit general comments at the end. Seven librarians and archivists from both English-and French-language institutions piloted the survey. After some adjustments, the final survey was distributed in March 2017, with reminders sent in the following two weeks. The distribution list was created using the CAPAL (Canadian Association of Professional Academic Librarians) membership directory and staff listings on each of the U15 libraries' websites. The Cronbach's alpha was used to measure the reliability of the survey questions, and it was determined that the responses to the librarians' confidence level questions have high reliability with Cronbach's alpha =.735, as do the responses to the questions related to the librarians' job satisfaction in performing traditional and new roles, with Cronbach's alpha =.908 and.934, respectively; and the responses to the questions related to the impact librarians performing traditional and new roles have on the academic enterprise have high reliability as well, with Cronbach's alpha =.842 and.761, respectively. In summary, the instrument is a reliable and valid tool for the survey and study. --- Profile of Respondents A total of 205 of 743 librarians completed the survey, garnering an overall 27 percent response rate. Responses were received from every U15 university, with individual university response rates ranging from 14 to 51 percent. Some librarians did not respond to all questions; hence, there are a small number of missing values. A profile of the respondents reveals the following information: • 52 percent (n = 105) have up to 10 years of experience working in a postsecondary institution; • The largest number of respondents (36%, or n = 73) have been working in their current position between 4 and 10 years; • 36 percent (n = 73) have an additional master's degree and 6 percent (n = 12) have a PhD. --- Results This study focuses on five areas where there has been a significant shift in librarians' roles in recent years: Research Support, Teaching and Learning, Digital Scholarship, User Experience, and Scholarly Communication. --- Research Support The first area of investigation is Research Support, which includes information discovery, systematic reviews, grant application support, as well as various aspects of bibliometrics, and data management. Of the 204 respondents, 173 stated that they provide one or more of the services offered as options with 31 stating that they did not provide any of the services (see Table 1). Overwhelmingly, 75 percent 51 (n=153) of the respondents reported information discovery, e.g. consultations and literature reviews as a service they offer. Respondents reported delivering the other services at comparable rates ranging from 23-28 percent (n=46 to 58). A more detailed analysis of data management and bibliometrics was performed to find out more specifically what aspects of these functions librarians are most likely to provide. The results in table 1 reveal that assistance with the use of technology, infrastructure, and tools at 26 percent (n = 43), support for data deposit in institutional repository at 26 percent (n = 42), and finding external data sets at 22 percent (n = 36) are the top three data management services provided. Respondents currently seem to be providing what can be more closely characterized as traditional assistance and support functions. They are less involved in the development of data management tools and the development of institutional policies. The results show that librarians provide bibliometric services at a higher rate than data management. Bibliometrics training is the highest delivered service at 30 percent (n = 47), followed by citation reports at 27 percent (n = 43), and altmetrics at 25 percent (n = 39). Twenty-two percent of the respondents provide calculation of research impact (n = 35) and h-index calculations (n = 34). --- Teaching and Learning For the second area of investigation, Teaching and Learning, functions beyond the traditional bibliographic instruction and orientation were explored. Twelve services were offered as options. Of the 190 respondents, 168 stated that they provide one or more of the proposed services, and 22 reported that they did not provide any of these services. As table 2 indicates, the two services, classroom teaching to students and one-on-one teaching, selected by the highest number of respondents at 78 percent (n = 149) and 75 percent (n = 142) respectively, could be seen as more traditional than new. However, a considerable number of respondents ranging from 43 to 48 percent deliver emerging services: copyright consultation (n = 82), teaching workshops for faculty (n = 90), and tutorials (n = 92). As for what could be considered newer roles, the highest responses are for instructional design (n = 47), participation in course management systems (n = 69), online learning (n = 73), and short videos, screencasts (n = 74), ranging from 25 to In summary, the results show that the areas of Research Support (n = 173), Teaching and Learning (n = 168), and User Experience (n = 177) garnered the highest response rates, with librarians indicating that they provide one or more of the services offered as options. Scholarly Communication (n = 117) and Digital Scholarship (n = 103) received the lowest rates of response. Overall, most librarians revealed that they perform functions in more than one area. The majority responded to all five areas. --- Librarians' Confidence Levels After exploring what services or functions librarians fulfill in each of the five areas of investigation, the survey participants were asked how confident they are in their ability to perform their duties in each area. The majority of librarians are either confident or very confident in their abilities. The respondents are most confident in the area of Teaching and Learning, with 75 percent (n = 126) of them reporting being confident or very confident, whereas they report considerably lower levels of confidence in the areas of Research Support (62%, n = 102), User Experience (60%, n = 104), Scholarly Communication (51%, n = 62), and Digital Scholarship (50%, n = 53). At the other end of the scale, none of the respondents state that they lack confidence in Teaching and Learning and only 1 percent (n = 2) indicate having no confidence in User Experience (see figure 1). Assuming that there may be a difference between the confidence level and years in current position, five ANOVA Chi-square tests were used to find out if there is a relationship between years in current position and each of the five areas of investigation, pairwise and separately. Based on the testing results and on the significance level set at 0.15, there is no statistically significant relationship between confidence and years in position for Research Support (P = 0.270), Teaching and Learning (P = 0.353), User Experience (P = 0.523), and Scholarly Communication (P = 0.620). However, there is statistically sufficient evidence to conclude that there is a relationship between years in current position and confidence levels for Digital Scholarship (P = 0.106). (See table 6.) Additionally, five nonparametric Kruskal-Wallis tests were used to test the difference between the years in current position and the librarians' confidence levels in each of the areas of investigation, pairwise and separately. Based on the testing results and on the significance level set at 0.15, there is a significant difference in the librarians' confidence levels for Digital Scholarship and years in current position (P = 0.055). Librarians that have worked less than one year in their current position have a higher level of confidence in Digital Scholarship than librarians with one or more years of experience. Similarly, while there is no significant difference in the confidence levels for Scholarly Communication, librarians performing those functions and having less than one year of experience were the most confident in their abilities. In the other three areas of investigation, librarians with less than one year of experience in their current position were less confident than librarians with more experience (see table 7). --- Training and Training Needs Another objective of the study was to examine how the respondents acquired the skills and knowledge that enable them to perform their duties (see figure 2). Overwhelmingly, respon- The respondents were asked to indicate what additional training they require to perform their duties in each area of investigation. The results for each area are displayed in descending order of need (see figure 3). Functions that garner more than 50 percent in each area are data curation skills, 62 percent (n = 99); skills in statistics and quantitative methods, 60 percent (n = 96); knowledge of bibliometric tools and techniques, 58 percent (n = 93); text-mining, 56 percent (n = 58); data management (Digital Scholarship), 55 percent (n = 57); assessment methodology and techniques, 56 percent (n = 95); data management (Scholarly Communication), 57 percent (n = 68); digital rights management, 57 percent (n = 68). None of the functions in Teaching and Learning received a response rate of more than 50 percent. Not all respondents expressed a need for additional training: 4 percent (n = 6) reported that they do not require additional training in Research Support; 7 percent (n = 12) in Teaching and Learning; 12 percent (n = 12) in Digital Scholarship; 13 percent (n = 22) in User Experience, and 7 percent (n = 8) in Scholarly Communication. dents A small number of the respondents indicated needing training in subject or disciplinary knowledge (Research Support). This could be explained by the fact that, in the collection of demographic information at the beginning of the survey, when asked what functions they fulfill as part of their current responsibilities, 150 (74%) of the librarians reported having liaison/ subject specialist responsibilities. --- Traditional vs. New Roles Given that most librarians are not performing new or traditional roles exclusively, a major interest of the study was to determine how many librarians are performing new roles (that is, Research Support, Teaching and Learning, Digital Scholarship, User Experience, or Scholarly Communication); how many are performing traditional roles (such as reference, instruction, cataloguing, collection development, or administration); and how many are carrying out hybrid roles that FIGURE 2 How were your skills and knowledge acquired? --- FIGURE 3 Training Needs are a combination of new and traditional functions. Of the 205 librarians who completed the survey, 165 (80%) answered the new role or traditional role questions with valid responses (Yes or No). Forty respondents skipped both or answered No for both of these questions; they were excluded when calculating the proportions of librarians who perform either of the traditional and new roles. Results reveal that 21 (13%) librarians perform only new roles, 72 (44%) perform only traditional roles, and 72 (44%) perform hybrid roles. The results also show that 45 percent (n = 79) of librarians spend the majority of their time delivering traditional services, 19 percent (n = 33) delivering new services, and 36 percent (n = 62) spending equal time on both. --- Job Satisfaction Having asked the respondents if they perform a traditional or a new role, it was deemed important to ask how satisfied the librarians are with the opportunities that their work provides. A Likert scale with the response options of very satisfied, satisfied, neutral, dissatisfied, and very dissatisfied was used to rate several intrinsic aspects of job satisfaction. 52 For the librarians performing either the traditional or the new roles, the Independent two-group Mann Whitney U Test (W test statistics), with the significance level set at 0.05, was applied to determine significance. The results of the scores (from 1 to 5) for each 5-point Likert scale were ranked and the mean ranks of the new and traditional role groups were computed. The group with the higher mean rank indicates that this group should have a greater number of high scores within it. Table 8 shows that the satisfaction level for both groups is comparable in six of the seven areas presented. The only statistically significant finding is that the respondents performing a new role are more satisfied with their opportunities for challenge (P = 0.01043). For the librarians performing both traditional and new roles, the Dependent (Paired) two-group Wilcoxon Signed Rank Test (V test statistics) was applied (see table 8). With the significance level set at 0.05, the following findings are statistically significant: • The librarians performing a new role are more satisfied with assigned duties than those performing a traditional role (P = 0.009084). • The librarians performing a new role are more satisfied with opportunities for challenge than those performing a traditional role (P = 0.02499). • The librarians performing a new role are less satisfied with opportunities for independent action than those performing a traditional role (P = 0.02904). --- Impact on the Academic Enterprise Another objective of the study was to determine what impact librarians performing traditional versus new roles believe they are having on the academic enterprise. Using a Likert scale with the response options of substantial, moderate, and low, the respondents were asked to rate a number of impact statements. Similar to the measure of satisfaction results, the Independent two-group Mann Whitney U Test (W test statistics), with the significance level set at 0.05, was applied to determine if there is a significant difference as to how librarians performing either the traditional or the new roles view their impact on the academic enterprise. The results of the scores (from 1 to 5) for each 5-point Likert scale were ranked and the mean ranks of the new and traditional role groups were computed. Results indicate that there is no significant difference in the impact level for both groups in any of the six areas presented (see table 9). For the librarians performing both the traditional and new roles, the Dependent (Paired) two-group Wilcoxon Signed Rank Test (V test statistics) was applied (see table 9). With the significance level set at 0.05, the following findings are statistically significant: • The librarians performing a new role perceived themselves to have more impact on contributing to scholarly communication than those performing a traditional role (P = 0.02621). • The librarians performing a new role perceived themselves to have less impact on contributing to student success than those performing a traditional role (P = 0.003686). • The librarians performing a new role perceived themselves to have more impact on supporting researchers than those performing a traditional role (P = 0.0002126). • The librarians performing a new role perceived themselves to have less impact on supporting teaching and learning at the classroom level than those performing a traditional role (P = 0.01473). --- Respondents' Comments At the end of the survey, the respondents were asked if they had any other comments on the new and emerging roles of academic librarians. Thirty-eight (19%) respondents offered a broad range of opinions. Many expressed differing views on the evolution of librarians' roles and the tension that librarians, seemingly liaison or subject librarians, are experiencing in regard to workload, expectations, and sense of value. Some of the concerns expressed follow: • The new roles are interesting and needed but they tend to result in librarians working in "silos" within their own organization. • I worry that the subject specialist role is becoming increasingly devalued over time, despite the need for same. • I believe both the traditional and emerging roles of academic librarians are important. The strength of traditional librarianship model is in the deep knowledge of one's collection and its management.... I appreciate the work of functional specialists (copyright, data curation, scholarly communication) and I would like to get to know their roles better so I can refer my faculty to them when there is need. • It seems that librarians are having to take on new roles in addition to their traditional roles not because they aren't already working at capacity, but because there isn't sufficient funding provided to hire more librarians to take on these newer roles. --- Discussion The study results clearly demonstrate that librarians are still providing many services that relate to traditional rather than new roles: for example, information discovery, classroom teaching, one-on-one teaching, and liaison with staff and faculty garnered among the highest response rates in their respective areas of investigation. This outcome is further reinforced in the area of Digital Scholarship, where results show that, while some librarians are providing digital scholarship services that require more advanced skills, most librarians are still offering their expertise in the more traditional spheres of service. However, the results also illustrate a transition to the newer roles. Copyright and intellectual property consultation and consultation on alternative publishing models ranked very high, a clear indication that librarians are responding to the changing publishing landscape and are providing services in areas like open access publishing. In addition, there are several areas where more than one-third of the respondents reported activity: bibliometrics training, creating short videos, online learning, participating in course management systems, library services assessment, and communication via social media. Technology-based activities such as user-centered design and technology assessment garnered respectable results, further evidence that librarians have adopted new tools to evaluate user needs and transform the delivery of services. High response rates for these User Experience functions as well as others is not surprising, since transforming library services to meet user needs has always been fundamental to librarianship and most librarians are involved at some level in the delivery of library services. Consultation on funder mandates and policies, a service that will likely grow as adherence to the Canadian Tri-Agency Open Access Policy of 2015 increases, was also selected by a fair number of respondents. Nevertheless, results for some of the services provided (for example, mapping and GIS, text-mining, text encoding, and data curation) are very low. This is likely due to the specialized nature of the work and the small number of librarians required by institutions to deliver these services. Overall, librarians are confident in their abilities to perform the new roles. When the areas of investigation are correlated with the number of years the librarians have been working in their current position, there are no statistically significant differences in their confidence levels except in the area of Digital Scholarship, where the librarians with less experience expressed a higher degree of confidence. One would expect an opposite result; however, this may suggest that libraries have hired librarians who already possess these specialized skills. The new roles require new skills and knowledge. The survey results reveal that librarians who perform the new roles acquired their competencies primarily through professional work experience or by self-teaching. Understandably, since nearly half of the respondents have been working as librarians for more than 10 years, well before some of the functions that were listed in the survey emerged, they have not received this type of training in LIS schools or held a position requiring it. Although librarians are confident in performing their new roles, interestingly they also state that their training is clearly insufficient and that they require additional training that will better enable them to provide the new services and to maintain their professional competencies. Very few claim that they require no training. The survey identified many areas in which the librarians require additional training (see figure 3). Data curation skills, statistical training, bibliometrics tools, text mining, data management, assessment methodologies, and digital rights management are the most requested training areas, but there are many other skills that survey respondents identified as being needed. Additionally, in the comments, many of the librarians referred to their subject knowledge as an asset in supporting and in collaborating with faculty and students. They should be offered new and meaningful opportunities to develop the requisite skills that can be used in tandem with their subject expertise. Library associations and other organizations meet some of the demand by offering inperson and online professional development courses for librarians in the workforce; however, this also represents an opportunity for LIS schools to offer postdegree training both on and off campus to the professional community. While the aforementioned have an important role to play to ensure that learning opportunities are widely available, it is imperative that academic libraries, for their part, firmly support the professional development efforts of their librarians to develop expertise for the new roles. Even though only a small percentage of the librarians reported performing new roles exclusively, nearly half of the librarians stated that they fulfill both new and traditional roles, revealing that the new roles are gradually being integrated into current practice. The results demonstrate that Canadian librarians performing new or traditional roles have comparable levels of job satisfaction, the only exception being opportunities for challenge where librarians carrying out new roles reported greater satisfaction. This may reflect the fact that being involved in a new endeavor has a level of excitement that is invigorating and rewarding. Generally, librarians responding to this survey believe that they have a significant impact on the academic enterprise. There is no statistical difference between those performing either a new or a traditional role; however, librarians performing both roles believe their impact is quite different depending on which role they are performing. This study's literature review identifies a few studies on the new roles in the area of research data management that include Canadian participants. Unfortunately, the studies by Tenopir et al. that deal with research data services, practices, and skills development do not separately report the responses of Canadian participants, thereby impeding the

The academic library profession is being redefined by the shifting research and scholarly landscape, the transformation in higher education, and advances in technology. A survey of librarians working in Canada's research-intensive universities was conducted to explore new and emerging roles. This study focuses on librarians' activities in: Research Support, Teaching and Learning, Digital Scholarship, User Experience, and Scholarly Communication. It addresses the scope and nature of the new roles, the skills required to provide new services, and the confidence librarians have in their abilities to perform the new roles. It also reports on librarians' job satisfaction and their perceived impact on the academic enterprise.

efforts of their librarians to develop expertise for the new roles. Even though only a small percentage of the librarians reported performing new roles exclusively, nearly half of the librarians stated that they fulfill both new and traditional roles, revealing that the new roles are gradually being integrated into current practice. The results demonstrate that Canadian librarians performing new or traditional roles have comparable levels of job satisfaction, the only exception being opportunities for challenge where librarians carrying out new roles reported greater satisfaction. This may reflect the fact that being involved in a new endeavor has a level of excitement that is invigorating and rewarding. Generally, librarians responding to this survey believe that they have a significant impact on the academic enterprise. There is no statistical difference between those performing either a new or a traditional role; however, librarians performing both roles believe their impact is quite different depending on which role they are performing. This study's literature review identifies a few studies on the new roles in the area of research data management that include Canadian participants. Unfortunately, the studies by Tenopir et al. that deal with research data services, practices, and skills development do not separately report the responses of Canadian participants, thereby impeding the comparison of their results with those of the present study. 53 The 2017 study by Cox et al. also examines research data management services in seven countries, including Canada. 54 While it surveyed library directors and not librarians, some of the results are relatable in regard to skills development approaches and needs. With a 23 percent (n = 17) response rate from Canada out of a total of 170 responses, it shows support for a wide range of internal and external staff development opportunities that match quite closely the ways the present study's respondents indicate they receive their training outside of professional work experience and self-teaching. It also identifies data curation skills, technical skills, knowledge of research methods, and data description and documentation as high-level needs similar to the current study's respondents who, in relatively large numbers, claim requiring training in these areas. --- Conclusion This study provides a snapshot in time and establishes a baseline on multiple aspects of librarians' roles in the Canadian academic environment including confidence levels, job satisfaction, and impact on the academic enterprise. While librarians continue to deliver services that are viewed as traditional, they are clearly engaged in the new and emerging roles and are anticipating a greater involvement in the five areas of investigation. Canadian librarians are generally confident in their abilities to fulfill their new roles, but those performing functions requiring specialized skills report a higher degree of confidence. Despite this level of confidence, the respondents state overwhelmingly that they require additional training. They have a deep awareness of the skills and knowledge, mostly technical in nature, that they need to further their expertise. Professional development at this critical juncture is imperative. Job satisfaction is comparable among the librarians performing only traditional roles, those performing only new roles, and those performing both roles. The only difference is that those performing solely new roles expressed a higher level of satisfaction in regard to having opportunities for challenge. Overall, the respondents believe that they have a significant impact on the academic enterprise. This is promising, since, with a greater integration of the new roles, one would expect that, in time, they will see their impact increase. While the survey results report on the Canadian context, they have the potential of being of benefit to all postsecondary libraries in that they provide a basis for investigation and integration into their specific environments. What does the future hold? How will the role of the liaison librarian evolve in light of the functional roles librarians are assuming? How will the division between new and traditional roles change over time? What is the actual impact of the new roles that librarians are undertaking? A follow-up study investigating the evolving roles of academic librarians in Canada should be conducted in five to ten years to analyze how librarians have responded to the changing academic environment and reinvented themselves and the profession. The survey questionnaire and the data from this study are deposited in the University of Manitoba's Dataverse repository, which is available online at https://doi.org/10.5203/FK2/RHOFFU.

The academic library profession is being redefined by the shifting research and scholarly landscape, the transformation in higher education, and advances in technology. A survey of librarians working in Canada's research-intensive universities was conducted to explore new and emerging roles. This study focuses on librarians' activities in: Research Support, Teaching and Learning, Digital Scholarship, User Experience, and Scholarly Communication. It addresses the scope and nature of the new roles, the skills required to provide new services, and the confidence librarians have in their abilities to perform the new roles. It also reports on librarians' job satisfaction and their perceived impact on the academic enterprise.

Introduction Compared to the general female population, Female Sex Workers (FSWs) are 13.5 times more likely to be infected with HIV [1]. Globally, FSWs are a high-risk group susceptible to acquiring HIV and sexually transmitted infections (STIs) as well as transmitting the virus to others [2]. FSWs in Nepal differ by different geographical setting and more confined in the urban cities such as Kathmandu and Pokhara and Terai highway districts [3][4][5][6][7]. Kathmandu Valley had highest concentration of FSWs in the country estimated from 10,457 to 11,653 in 2011 [4]. Many young girls get entered into sex work migrating from rural areas to Kathmandu Valley in quest of work. In the urban cities, they are exposed to situations, making then expose to risky sexual behaviors. Being young and new to the profession, FSWs tend to serve a higher number of clients and have a higher number of working days and possess high risk sexual behaviors. Moreover, FSWs in Kathmandu Valley are often from the lower castes, young age, establishment based and are poor, uneducated, and came from rural areas [5]. Because of limited education, poor socioeconomic status, new to profession, young age and poor knowledge of HIV/AIDS, these groups of FSWs are highly vulnerable for HIV and STI infection [8][9][10]. FSWs in Kathmandu Valley are categorized into street-based and establishment based where FSWs solicit their clients [6]. The establishment-based FSWs are based on cabin restaurants, restaurants, massage parlors, hotel where they find their clients. Street-based FSWs worked on streets, markets and roads to solicit their clients. Studies and IBBS surveys have investigated HIV, STI and HIV risk behaviors among FSWs in Nepal, such as unprotected sex work and injecting drugs in relation to category of sex work [6,[8][9][10]. It was found that establishment-based FSWs are lower HIV and STI prevalence than street-based FSWs [6,[8][9][10]. Street-based FSWs have a large number of clients, are less likely to use condoms, charge low for sex, and are involved in sex work for a greater number of years than establishment-based FSWs [8,9,11,12]. Consequently, the vulnerability of street-based FSWs to HIV/STIs is much higher than establishment-based FSWs. Street-based FSWs are also more potential to inject drugs, lacked of consistent condom used and have sex with clients who are drug users, transport workers [6,8,11]. Moreover, street-based FSWs in highway districts have the history of unprotected sexual contact with transportation workers and with migrants who travel from adjacent districts to abroad [5,6]. Understanding HIV related risk behavior between these groups of FSWs is of great importance for prevention. Therefore, HIV risk behaviors among FSWs must be examined in relation to their specific work venues or environments. Moreover, this study also compare the structural risk factors (HIV and STI prevention and treatment services) among street-based FSWs and establishment-based FSWs that have not been analyzed before in Nepal. --- Methodology --- Study design and the participants: A retrospective analysis of Integrated Biological and Behavioral Surveillance of Kathmandu Valley from 2006 to 2015 was conducted. IBBS surveys were cross-sectional in design. FSWs were classified into establishment-based FSWs and street-based FSWs based on their work venues (the places where they solicited or met their clients). The establishmentbased FSWs solicited their clients from hotels, lodges, restaurants, massage parlors and guest houses whereas streetbased FSWs find their clients from the street, roads, squatter settlements and bhattipasals. --- Sample size calculation: For IBBS Survey, sample size was determined by applying the formula 2 1 2 2 2 2 1 1 1 1 ) ( ] ) 1 ( ) 1 ( ) 1 ( 2 [ P P P P P P Z P p Z D n <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> <unk> Where n was required minimum sample size per survey, D was design effect (default value of 2), P1 was the estimated number of an indicator measured as a proportion at the time of the first survey, P2 was the expected level of the indicator either at some future date such that the quantity (P2-P1) is the size of the magnitude of change it is desired to be able to detect, Z<unk> was the Z-score corresponding to the degree of confidence with which it is desired to be able to conclude that an observed change of size (P2-P1) would not have occurred by chance (<unk>-the level of statistical significance) and Z<unk> was the Z-score corresponding to the degree of confidence with which it is desired to be certain of detecting a change of size (P1-P2) if one actually occurred (<unk>statistical power). --- Data Collection Data collection consisted of both biological and behavioral data, including handling of biological data for external quality assurance. IBBS survey used a structured questionnaire to assess background characteristics, sexual risk behaviors, usage of condoms, knowledge and awareness of HIV/AIDS and STIs, violence, exposure to HIV/AIDS programs and drug injecting behaviors, Inclusion criteria: Inclusion criteria was FSWs aged 16 years and above who reported being paid in cash or kind for sex with a male within the last six months. --- Exclusion criteria: Exclusion criteria were FSWs aged 15 years and who didn't provide consent for the survey. Outcome Variable: HIV, syphilis and risk behaviours, structural risk factors comparing street-based FSWs and establishment-based FSWs was the outcome variable of the study. --- Explanatory Variable The independent variables for the study were background characteristics (year, region, education, marital status), sexual behaviors (duration of sex work, age at first sexual contact, average number of the clients, number of working days), consistent condom use with different sex partners and injecting behaviors (the use of drugs, injecting practices), alcohol use, comprehensive knowledge on HIV (ABC, BCDEF) and Exposure to HIV prevention program (HIV test, Met with Outreach Educators/Peer Educators/Community Mobilizer, Visited Drop In Center (DIC), Visited Sexually Transmitted Infection (STI) clinic and Visited HIV Counseling and Testing (HCT) center). Knowledge on ABC was defined to be aware of A (abstinence from sex), B (being faithful to one partner), and C (consistent and correct condom use or use of a condom during every sex act) as HIV preventive measures respectively. Additionally, DEF refer to knowledge that: a healthy-looking person can be infected with HIV (D), a person cannot get HIV from a mosquito bite (E), and one cannot get HIV by sharing a meal with an HIVinfected person (F). The sex partners of the FSW were categorized as clients, regular clients, non-paying partners, and other partners. Clients and regular partners are those partners who pay for sexual contact. Non-paying partners comprised boyfriends, husbands, intimate partners or those who do not pay for sexual services. Partners other than clients, husbands, and male friend(s) were categorized as other partners which comprises of include massage owners and police officials. Other partners mostly don't pay for sexual contact with FSWs. --- Ethical Committee Approval Ethical approval for IBBS surveys were permitted from Nepal Health Research Council. The NHRC approval number for the survey was 1232. Informed consent was obtained from FSWs before the interview. There may be a risk of identifying the FSWs through their signatures if written consent was used. The informed consent was read in the mien of a witness (community motivators or another member of the study team) who then signed the consent form. Study centers with laboratories/clinic were set up at easily accessible locations and individual interviews, clinical examinations and blood collection were carried out in separate rooms. Blood samples were collected from FSWs and were tested for HIV and syphilis. --- Data Management and Statistical Analysis Chi-square test was performed to assess FSW's demographic information, sexual behaviours, injecting behaviours, HIV knowledge, exposure to HIV intervention programs, HIV and syphilis, by their work venues (Street and Establishment). Multivariable logistic regression models was used to examine the association of street-based FSWs and establishment-based FSWs with HIV risk, HIV and syphilis while controlling variables that were significant in the bivariate analyses. A pvalue of less than 0.05 was used to determine statistical significance. Adjusted odd radios (aOR) as well as their 95% confidence intervals (95% CI) were used to depict the independent relationship between predictors and dependent variables. R program was used for statistical analysis. --- Results A total of 2093 FSW were included in the analysis from 2006 to 2015, of whom 39.7% of FSWs (230) were street-based FSWs and 60.3% of FSWs (1261) were establishment-based FSWs. There were significant difference of age, education, marital status and duration of sex work between street-based FSWs and establishment-based FSWs, as shown in Table 1. Establishment-based FSWs (82%) were significantly younger than street-based FSWs (59%). Street-based FSWs were significantly less educated than establishment-based FSWs, as 44% of street-based FSWs had no education whereas 23.5% of establishment-based FSWs had no education. There were significant group differences in marital status; establishmentbased FSWs (28%) were likely to be single than street-based FSWs (14%). Moreover, nearly one third of street-based FSWs were separated. Street-based FSWs (30.2%) who have worked more than three years was significantly higher than establishment-based FSWs (16.4%). --- Discussion: This study compared HIV risk behaviors among FSWs in Kathmandu Valley of Nepal who engage in commercial sex with male clients through different distinct venues (street and establishment). Moreover this study also analyzed structural risk factors (HIV and STI prevention and treatment services) between two groups for first time. [11,16]. Besides this, factors such maintaining good relationships with customers, keeping regular customers, avoiding conflicts with or violence from clients also effect the condom use with clients. Moreover, street-based FSWs are also be forced to exchange unpaid and unprotected sex with some law enforcement authorities in order to escape arrest, harassment, obtain release from prison, or not be deported. HIV awareness targeting FSWs alone will not be enough. FSWs are pressured by clients to engage in unprotected sex indicates that the clients are also unaware of the risks for HIV/STI transmission. Clients of FSWs need to be educated about the risks of engaging in unsafe sex with FSWs. --- Comparison of socio-demographic characteristics, sexual behaviors, drug injecting behaviors, HIV and Syphilis between street-based FSWs and establishment-based --- Alcohol consumption and injecting behaviors Alcohol use is common among establishment-based FSWs owing to their work environment. In Nepal at some bars/clubs, employers expect FSWs to encourage customers to drink [17], alcohol use was part of the routine; that is, drinking with customers at bars/clubs so that customers pay a lot of money. FSWs used alcohol to cope with the stress and violence associated with sex work [13,16,18]. Studies identified that inconsistent condom use with customers among establishment-based FSWs was influenced by their own and their customers' alcohol use [8,18]. It is found that establishment-based FSWs had had sex under the influence of alcohol with customers than street FSWs. Moreover, drug use was also prevalent among establishment-based FSWs. Education about alcohol use and its strong influence on unsafe sex must be taught in the HIV prevention education programs for FSWs. Less than one percent of FSWs had injected drugs, and 7% of FSWs used drugs and it was higher among establishment-based FSWs compared to street-based FSWs. Studies found that FSWs were more risk for HIV if they injected drugs [8,15,16]. --- HIV and Syphilis This study found a relatively high prevalence of syphilis among FSWs, although HIV prevalence among FSWs was less than 2%. Both HIV and syphilis were higher among street based FSWs compared to establishment based FSWs consistent with numerous studies indicating high HIV prevalence among street-based FSWs [8][9][10]19,20]. --- Exposure to HIV intervention programs The study found that exposure to HIV intervention programs was low among establishment-based FSWs than street-based FSWs. Street-based FSWs were more likely to have HIV test, DIC, STI and HCT visit than their establishment-based FSWs in the past year consistent with the IBBS report [6]. These findings suggest the need for targeted interventions for the establishment-based FSWs in addition to the general interventions on FSWs. For establishment-based FSWs, FSWs received more advice from their owners/managers for safer sex, access to information and to health services. The major concern of managers/owners of massage parlors was their business and profits rather than the safety or health issues of the FSWs [8]. Therefore, influence of owners/managers also limits access to HIV intervention services. --- Conclusion The study found that compared to establishment-based FSWs, street-based FSWs more likely to suffer from HIV and Syphilis. Moreover, street-based FSWs had longer duration of sex work, lacked of consistent condom used with clients compared to establishment-based FSWs. However, establishment-based FSWs are also at high risk because drug and alcohol use is pervasive. Also, exposures to HIV programs are lower in these groups. Therefore, HIV prevention efforts in must target HIV risk behaviors among both FSWs specific to their work environment and social and cognitive factors. Moreover, HIV intervention programs for FSWs must incorporate the social and cultural contexts of sex work and target both FSWs and their clients. --- Limitations of the study The limitation of the study is IBBS surveys are cross-sectional in design and cannot provide evidence of permit causal inferences. This study was conducted in three regions of Nepal, so the findings will confine to these districts, and may not be generalized to other districts or any other parts of the country. Moreover, there may be possibilities that same FSWs can participate in multiple rounds of surveillance survey because a survey conducted in the same area among the same group over time. --- Future scope of the study: It is anticipated that this study will help guide policy makers and program managers in identifying useful points and areas to target and focus intervention strategies aimed at different subgroups of FSWs such as street-based FSWs and establishment based FSWs. --- What is already known on this topic: Prevalence of HIV and Syphilis of FSWs is already known on this topic. --- What this study adds: Accessing HIV, syphilis and risk behavior between streetbased FSWs and establishment-based FSWs is needed for intervention programs. The study suggests important implications for designing surveillance and intervention activities among FSWs based on work venues. This study also compares structural risk factors (HIV and STI prevention and treatment services) between street-based FSWs and establishment-based FSWs that have not been explored before.

Background: Female Sex Workers (FSWs) are main drivers of the HIV epidemic in Nepal. The work environment of sex work in Nepal is differentiated into establishment based (e.g. massage parlors, dance restaurants, hotels and lodges) and street based (e.g. streets, parks and markets). The study compares HIV, syphilis and risk behaviours among establishment-based FSWs and street-based FSWs in Kathmandu Valley of Nepal. Materials and Methods: Cross-sectional bio-behavioral surveys in 2006, 2008, 2011 and 2015 aimed to sample 2093 FSWs using two stage cluster sampling in the Kathmandu valley. Statistical analysis used chisquared tests and logistic regression models to assess differences of HIV, syphilis and risk behaviors among street-based FSWs and establishment-based FSWs.The study included 39.7% street-based FSWs and 60.3% establishment-based FSWs. The street-based FSWs had lower education levels, older age groups, separated, longer duration of sex work and inconsistent condom used with clients than establishment-based FSWs (p<0.05). Establishment-based FSWs were lower exposure to HIV intervention programs and pervasive alcohol consumption and use of drugs (p<0.05). The multivariate analysis showed that street-based FSWs were more likely of HIV test (aOR=1.25, 95%CI=1.04, 1.49), HIV (aOR=4.72, 95%CI=2.19, 10.15) and syphilis (aOR=7.96, 95%CI=3.49, 18.15) than establishmentbased FSWs. Conclusion: Street-based FSWs possessed higher risk behaviour and have higher HIV and syphilis prevalence. HIV prevention interventions targeting FSWs should consider risks and vulnerability of street-based FSWs.

Introduction The loss of a beloved person, whether due to death or separation, always causes grief. While the literature on mourning caused by death is now very extensive, there are few studies on mourners suffering because their loved one is missing. For human beings, grief is a natural reaction to loss, though its symptoms vary across individuals. Some exhibit resilient reactions to loss with little psychological distress, whereas others exhibit grief reactions with clinically significant symptoms of depression, anxiety, posttraumatic stress disorder (PTSD) and complicated grief [1,2]. In addition, the experience of loss varies depending on the circumstances of the death. Unnatural, violent and sudden deaths entail a higher risk of psychopathological symptoms [2,3]. The disappearance of a beloved person can be a particularly stressful form of loss. Scholars have observed that grief reactions following a disappearance are a normal response to an abnormal situation [4,5]. If the type of grief experienced by a bereaved family reflects the circumstances of their loss, then an unresolved grief may be the result of an unresolved loss [6,7]. Pauline Boss defined the typical form of unresolved loss as 'ambiguous loss' [8], and she described two basic types depending on the manner of disappearance. In the first type, the missing person is physically absent (or 'physically missing') but psychologically present because their relatives are preoccupied with the disappeared and cannot determine whether they are dead or alive. In the second type, the'missing' person is physically present but perceived as psychologically absent (or 'psychologically missing')-that is, emotionally and cognitively unavailable to those around them-because of depression, addiction, dementia, or the sudden appearance of other severe mental illnesses that cause prolonged disorders of consciousness [3][4][5][6][7][8]. Boss is particularly interested in the effect of these forms of loss on the families left behind, who are commonly concerned with finding coping strategies to deal with the absence of their beloved. Many family members experience relationship conflicts, somatisation and feelings of helplessness, depression and anxiety. These negative effects occur for several reasons: ambiguity is confusing, people cannot make cognitive sense of the situation, and not knowing whether the family member will return prevents the reconstruction of family and marital roles, rules and rituals. Ambiguity destroys the customary markers of life or death, so a person's distress is never validated [9]. The community loses patience with the lack of closure, and families become isolated. Ambiguity causes even the strongest of people to question their view of the world as a fair, safe and understandable place. Finally, ambiguous loss that persists for a long time is physically and emotionally exhausting [4][5][6][7][8][9][10]. With regards to the first type of loss, Boss's research considered the cases of soldiers declared missing, relatives who disappeared during civil conflicts-such as kidnapped people ('desaparecido', disappeared) in Argentina, Brazil, Columbia, Chile, Panama, Peru, Mexico and other countries-and individuals unaccounted for after terrorist attacks, such as ethnic cleansing in Europe (Kosovo) and Africa (Rwanda) or the September 11 attacks in the US [5,10]. In the present study, we consider the kind of mourning provoked by the ambiguous loss of individuals without an apparent cause (that is, in the absence of war, disaster, conflicts and so on). In Italy, the Codice Civile (Civil Code, art 48) indicated that a person's disappearance consists of their withdrawal from home without giving information about their fate. The Decree of the President of the Republic (DPR 31 July 2007) introduced the figure of the Extraordinary Commissioner for Missing Persons, who draws up reports containing a census of missing persons from the previous six months. From 1974 to 2019 [11], the total number of missing persons in Italy was 245,012; the total number of those traced was 183,976; and the total number of those who still need to be traced was 61,036. The main causes of disappearance are: voluntary removal; removal of children from institutions/communities; psychological disorders; child abduction by a parent or other family member; and crime. In Italy, the attention given to this problem is due to the growing interest of media, social networks, and associations aimed at raising public awareness and improving searches for missing people. For example, the television program Chi ha visto l'ha visto? (Who Saw Him/Her), which aired from 1989 to 2006, solved 236 cases thanks to the participation of viewers (65% of total reported missing persons) [12]. These data highlight the importance of community participation in finding the missing person or their corpse. When neither of those events happen, a long search for information begins for the missing person's family members. The type of grief experienced is similar to that of ambiguous loss [4,8,9], which is characterised by the absence of a corpse that permits definitive separation [6]. Because ambiguous loss implies an unconfirmed loss, it defies closure and prevents the resolution of grief [3,6]. In fact, the primary aspect that distinguishes ambiguous loss from clear-cut loss is what Boss initially called 'boundary ambiguity', or the difficulty of establishing the boundary between 'who is in or out of a particular family' [5], p. 553. Both types of ambiguous loss identified by Boss require the family to reconstruct their family system within the paradox of absence-presence [10]. Boundary ambiguity can vary in intensity, and it can threaten individual and relational well-being, preventing stress management [5]. Furthermore, disappearance is a relational loss [6]. The definition of'missing person' assumes the existence of someone who misses the disappeared. To further investigate the phenomenon, it is therefore relevant to understand the meaning of ambiguous loss and the way that it involves the relatives of a missing person [13]. Indeed, even though there are numerous cases of missing persons, there is still scant literature about ambiguous loss related to missing persons, as well as a lack of attention to those 'people left behind' and the ways in which they manage these never-ending losses [14]. The phenomenon of missing persons was first studied by Eric Lindemann in the 1940s. He coined the term 'Anticipatory Grief' [15], which was introduced into the literature with the term 'Anticipatory Mourning', first by Elisabeth Kübler-Ross [16] and then by Therese Rando [17]. Rando's studies on 'anticipatory mourning' and 'anticipatory grief' triggered wide discussions [18], however, for the purpose of our discussion, the second term subsumes the first and describes the ambiguous condition of perceiving someone who is still alive as already dead, causing the loved ones to suffer the loss in advance. In Rando's opinion, anticipatory mourning encompasses seven operations: grief and mourning, coping, interaction, psychosocial reorganization, planning, balancing conflicting demands and facilitating an appropriate death. Such operations characterise a psychological context of adaptational demands, which is caused by experiences of loss and trauma following the awareness that death is near at hand [17]. Indeed, Rando integrated the two definitions following the precedent of Lindemann's epigones [19][20][21], who studied parents' responses to their child's terminal illness. The concept of anticipatory grief/mourning is used both to indicate emotional reactions prior to exitus and those related to a separation not necessarily determined by death. Before Rando, anticipatory grief/mourning had been examined by Elisabeth Kübler-Ross [16], who described the denial, anger, bargaining, depression, acceptance (DABDA) model of coping with death. This model is comprised of five stages: denial, anger, bargaining, depression and acceptance. According to Kübler-Ross and other scholars, this process unfolds in generally the same way regardless of whether the death has already occurred. [22,23]. Hope holds a prominent position in Kübler-Ross's five-phase model because it forms the background to the continuous variation in emotional experiences arising from anticipated loss. Even in the literature on ambiguous loss, hope occupies a fundamental role. The path of hope is not linear, but incessant and flexible: initially, it is based on the idea that the beloved person is located in a safe place; progressively, it acknowledges the condition of disappearance and focuses on achieving closure; concurrently, hope enables those 'left behind' to achieve a peaceful state despite the situation [14,24]. Those left behind need hope because it allows them to ascribe meaning to their loss and, in some circumstances, to maintain a positive connection with the missing person [6,[24][25][26]. The main difference between the academic studies of ambiguous loss and anticipatory grief/mourning is that in the first case, attention is primarily paid to family dynamics, whereas in the second case, attention is paid to individual experiences of suffering and bargaining with the phantom presence of death. In both cases, death is simultaneously present and absent, and the most important difficulty is managing this haziness. This phenomenon has not yet been studied in Italy. Based on these foundational models, we endeavoured to carry out grounded qualitative research to find out which aspects among those described by Boss, Kübler-Ross and Rando are most important. The study of the effects of this form of grieving may be useful when organizing suitable community psychological support interventions. Given the lack of research in this specific field and the opportunity to consider how to help people suffering from this type of loss, we realised the study to better understand the relationship between the different forms in which the concept of anticipatory grief/mourning has been represented, and the ambiguous loss. --- Materials and Methods The Qualitative Study The study followed the American Psychological Association's Ethical Principles and Code of Conduct and the principles of the Declaration of Helsinki; furthermore, it was approved by the Ethics Committee of the University of Padua (Prot. 2868 n. 5A06A9EF69B8970084C83EDB4E2DD3FD). Participants were informed about the study's aims and procedures and they were assured that participation was voluntary and that their responses would remain confidential. Informed consent was obtained from all participants. This study utilised the Grounded Theory perspective and involved qualitative research in psychology with in-depth interviews, because this approach makes it easier to understand subjective stories [27][28][29]. The Grounded Theory offers a practical and flexible approach to interpret complex social phenomena. This qualitative method does not start with testing an existing hypothesis, but uses the empirical data to generate concepts and theories. Thus, one of the benefits of this perspective is the actively reflective position of the researcher while interacting with data, which involves the generation of analytical categories and the identification of relationships between them [30][31][32]. The thematic analysis method was adopted, because it offers an accessible and theoretically flexible approach and it is consistent with the framework of the Grounded Theory [30]. The primary aim was to trace the relationships between ambiguous loss and anticipatory mourning as experienced by people who have dealt with the disappearance of a loved one. We also wanted to understand how these grievers experienced community support. Eight participants (six females and two males; average age: 50; SD 10) were involved thanks to the support of an association dedicated to finding missing persons. The sampling method was not random because we preferred to recruit individuals who were motivated to participate in the project. All the participants used various instruments to search for loved ones, and six participants had asked for help from the Chi l'ha visto TV program through a public appeal reserved for the search of missing persons. One missing person was found alive, three were found dead, and four have not yet been found. The degree of relatedness was: four parents, three children, and one aunt (Table 1). The duration of the disappearances varied from 10 days to 26 years. Before the interviews began, the topics and the focus of the study were explained, and then the participants were asked to sign the informed consent form. The interviews were conducted between June and July 2019 with a mean duration of 40 min. The names used in this text are fictional. The interviewer followed an elastic grid of topics to support the dialogues, and focused on the following: biographical narrations about the missing loved ones and how they disappeared; emotions related to the wait and to the loss; explanations inherent to the disappearance and the search; the main changes in life brought on by the loss; their relationships with their community. The narrations were recorded and transcribed verbatim. The analysis of the text followed the six main phases outlined by Braun and Clarke [30]. Atlas-ti, a computer-assisted qualitative data analysis, was utilised because it permits an examination of the participants' narratives in terms of principal concepts on the basis of both the prior ideas that were inherent to the research questions and concepts that only became clear as the analysis proceeded [33]. In the following phase, the text was segmented into significant quotations to transform it into hermeneutic unities through the creation of codes (basic categories). Then, the codes were transformed into families (hyper-categories) on the basis of the relationships among the codes. Finally, the relationships between families were sorted according to the conceptualization of anticipatory mourning and ambiguous loss [30,34,35]. Data Sharing and Accessibility: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. --- Results The qualitative analysis of the interviews showed, in all of the narratives, five prevailing thematic areas according to the DABDA model. As indicated by Kübler-Ross (1969) [16], these did not follow a predetermined sequence. However, the same phases resulted in quite a peculiar form. The following five areas appeared: 'Incredulity instead of denial'; 'a centrifuge of anger mixed with shame and resentment towards the community'; 'bargaining to resolve shame and self-blame'; 'depression-like mourning without corpse'; and 'the impossibility of closure: Acceptance of the unknown and non-acceptance of the end'. --- Incredulity Instead of Denial All family members, from the very first moment, were in a state of shock, panic, and confusion because of the disappearance. Elisa, who lost her father and found him dead after nine months after he went missing, said: 'I lacked air, I really couldn't breathe. I was desperate...desperate. At night I got all the doubts of what people said. I sometimes got angry because my mother forgot important particulars because of the shock. I thought incessantly if it was possible not to find him at all, if he was alive or dead.' Similarly, Giuseppe, a retired man whose daughter was never found, said: 'It is very difficult to manage the panic following the disappearance. I've often feared becoming confused.' Similarly, Alessandra, who had been waiting 26 years for her missing daughter, said: 'I was shocked and my reaction was to hide myself. Doubts have always macerated me, and even now they torment me that someone has not told me the truth.' This feeling was also described by Luca, a 61-year-old man whose daughter had disappeared but was finally found alive: 'It's like falling into a nightmare and hoping to come out of a really frightening thing. It's as if you were run over by a running train. It's everything absurd.'The incredulity accompanied fear and anxiety, and were linked to the threat of the irreparable. Anna, a 46-year-old woman whose father has never been found, affirmed: 'He disappeared. But what does disappeared mean? It seems so strange that a person can disappear into the air!' Incredulity was the cipher of denial that surrounded all of these experiences. The only way to reduce the uncertainty sprung from the 'absurdity of annihilation' was, for all the participants, to conduct an exhausting search for their beloved. Giulia, a 45-year-old teacher whose father was never found, stated: 'It is impossible that my father was annihilated. This situation is such an absurd thing, he must have gotten lost, he must have been confused, but he's here and so now we go out and look for him. I assumed that soon someone would call and tell us that they have found him.' Such a defensive strategy was activated by the relentless desire to embrace the disappeared again. It ran in parallel with the growing anguish as time went by, as Anna explained: 'I was acting under the action of a mixture of anxiety and desire, hope and hopelessness, confidence in the possibility that others could [go] where I [had not] gone. The moments of inner collapse happened every time I stopped to think and realised that all these feelings and the traces were leading nowhere, but then I started all over again.' Giuseppe described this condition as: 'An eternal and insistent waiting for the bell to ring at any moment. But every time I realised the silence and the time that went by, so I prayed to God they hadn't put my daughter in a bag and thrown her in the trash. I forgave the Lord for taking my daughter away from me, while asking Him to make me sure that she was okay.' Similarly, Luca said: 'This silence is absurd and at the same time frightening, because everything is possible and there is no answer. Exploring everything while you [can] see nothing is what insinuates terror.' --- A Centrifuge of Anger Mixed with Shame and Resentment towards Community Anger appears as a consequence of the absurdity of the situation. The conviction of the impossibility that one's beloved could have become nothing ignites one's anger, as Giulia described: 'Not knowing what caused the disappearance and not finding clues to help you reconstruct the events forces you to continue building scenarios of explanation. If you see the disappearance as a car accident, as much as it is a tragedy, you know that the ambulance arrives, the police arrive, the family are notified. Not being able to give a shape to this falling into nothingness makes everything incomprehensible, and every time you have to change your hypothesis the dismay is accompanied by a deep anger.' The anger burns like a fire, especially when the family members realise that the community does not support them, as Giuseppe pointed out: 'No one, I say no one has been concerned about this tragedy. It was enough to give me a phone call to show solidarity. I don't say they had to help me in the search or give me support, but to at least ask me how the search was going. No one. Nobody cared about this absurd disappearance.' Giulia defined the community's reaction as: 'Not only did no one help me get out of this centrifuge of feelings, as I went from one emotion to another with a strong sense of helplessness, but I was also left alone in managing all the formal aspects that the disappearance of a person entails. People look at you as if you were responsible for something. It's as if they put a mark on you.' Maria, a 69-year-old woman whose daughter was found dead, said: 'If you are alone you can't do anything. Anger is inevitable. Then the association helped me and if it hadn't, I wouldn't have been able to find my daughter's body. Then I could finally mourn her.' However, anger was also characterised by resentment towards the missing person, who is considered responsible for having thrown his family into a no man's land, as Elisa described: 'He put me through nine months of hell, and while I was looking for him my oscillation between hope and despair was interspersed with anger towards him. But my love for him was so strong that I resisted and if I had not found him, now I would still be looking for him.' Anger was also a reaction to impotence, as Alessandra said: 'I feel anger, resentment, and disappointment. My life has [been] spent inconclusively looking for someone I have not yet found and I know that it will continue in the search without success, but I cannot give up this hope. This has been my life.' --- Bargaining to Resolve Shame and Self-Blame The participants developed strategies to solve the problem on their own because the community did not offer any valid support. This caused their thoughts to be transformed into continuous ruminations that focused on the desire to return to the past, so as not to make the mistakes that caused the tragedy. On this basis, recriminations developed from a substrate of guilt, as Anna described: 'From the first moment I never stopped wondering if I was responsible for all this, and that is why I have always tried to do everything possible to find him. Like I could go back and avoid making the same mistakes. The question was what I could or should have done before to avoid all this. However, this quest for atonement for past faults [was] not always clear. My family and I spent months, years looking for clues along the streets, in every possible city, scrupulously checking every signal. In this way we burned our lives. Everything we were and had before was slowly corroded by this exhausting search under the weight of the feeling of guilt mixed with resentment.' Alessandra described her thoughts in a similar way: 'I feel guilty, because even though I have a family of my own, the search and waiting for my missing daughter comes first. I live in resentment towards the community because it corrodes my doubt that someone has not told the truth. But I don't know if I will ever be able to have the truth about my daughter's fate because I believe that God doesn't want to give her back to me, because if she came back I would definitely live only for her and I wouldn't do anything for the others. I always pray to God to let me die when and how He wants. I tell him that He can take my life back, but in return he must let me know something about my daughter.' Giulia continued in this direction: 'Unfortunately, the disappearance of a loved one can divide families that are socially isolated, and so the sense of guilt explodes in recriminations and reprimands of responsibility and blame that trigger angry quarrels and uncontrollable mechanisms. The latent hope is that finding the culprit will also allow us to understand what happened, and therefore to find the missing person. However, these things alienate rather than bring people closer together.' --- Depression-Like Mourning without Corpse The ambiguous mourning was consciously lived and described as a condition of suspension, as Giuseppe said: 'The whole family lived [in] mourning, even though we never found a corpse. But at the same time, not having had a funeral always reminds us that anything could still happen and all this makes the pain unceasing.' Maria expressed similar thoughts: 'The pain is so strong that it doesn't even give you the strength to react. I felt like I was dead... dead. Without my daughter, my life seemed to be over.' Giulia described more or less the same emotional experience: 'I was going on like an automaton. Everything about my father didn't interest me, it just slipped right through me.' Alessandra said: 'Not knowing whether she is alive or dead prevents me from [having closure]. I keep thinking about the last time she said goodbye to me: "Bye mom, see you tonight", and I'm still there. My life stopped that night when I started to worry. Those who find the body of their missing loved one can at least mourn him on his grave. I can't do that either.' Depression occurred within communities that isolated the families in which a person has disappeared, as Elisa said: 'When a person disappears at first it creates great interest, and it seems that relatives and neighbours want to make themselves useful to find the missing person. Then after a few days no one comes forward. Everyone is afraid of having to continue the search and doesn't feel like it. So, you stay alone and the others avoid you and leave you in your darkness. Yes, because it's a dark place, you don't know where to go, you just go on a grope. It's very depressive.' --- The Impossibility of Closure: Acceptance of the Unknown and Non-Acceptance of the End Accepting the reality of loss was an extremely complex task for everyone, a goal that, for those who have never heard from their loved one again, has never ended. As Anna explained: 'It is difficult to put a firm point [on it]. If he died in the mountains, I have to get over it. But the hope is always that he will come back or that we will find him and know what happened. So much time has passed, maybe he is in a dimension where he is better off than here. This is my illusion, which allows me to survive this unconfirmed loss. I think of him as someone who is well.' Acceptance of the situation was expressed on one side as tolerance towards the unknown, an enveloping darkness in which the disappeared is immersed and where they continue to inhabit the life of the family. Giuseppe said: 'Martina is always there. Martina is always there even if she is in the dark and I don't see her. Even when I work and have to think about something else, Martina is with me and my family.'On the other hand, a dimension that allows us to accept the loss is reality, as Giulia explained: 'The problems for those who have to manage the disappearance of a family member are not only psychological. I am referring, for example, to retirement, to properties that cannot be sold until after ten years, once the presumed death has been recognised. I am also referring to employers who do not know whether to proceed with the dismissal or not. If you then add all this to the additional problems of everyday life, such as the illness of another family member, you have to come back with your feet on the ground. When my mother got sick, it was a wake-up call for me and I knew that I had to become concrete.' The 'concreteness' of finding the corpse was underlined by Elisa: 'It was a trauma experienced for the second time, but [it was] different from the first time. When we suddenly found him again, the whole story of waiting and searching became unreal, as if it had been a nightmare that dissolved upon awakening. A tragic awakening, but one that brought me back to reality. An unreal nightmare had ended. I consider myself lucky compared to other people who are still waiting.' Not all families welcomed the concreteness of death, however. Paola, a 53-year-old policewoman and aunt of a boy who disappeared and was found dead at the age of 24, explained how the parents and the sister of the disappeared coped with their loss: I have always been very close to my sister-in-law's family, but on this occasion, I have tried in every way to help them to overcome their grief. They have not overcome the mourning; they continue to suffer and to not talk about what happened. In my opinion, they still live in expectation even if they know that Giampiero is dead. They didn't want to see the corpse when he was finally found. In this way it is as if they have chosen to continue as before, as if they were still waiting for him. In fact, they don't want to talk about this experience, and when someone speaks to them about Giampiero, they suffer profoundly. I would like to help them to solve the problem by talking about it and facing the reality, but I don't know if it is better to let things go like this.... They preferred to stay in the condition of uncertainty that had accompanied them before he was found and to which they had perhaps become accustomed, because anxiety could be dampened by hope. Giampiero wasn't there, but he could have been somewhere. When hope disappeared their habit of suspension remained. That's why talking about Giampiero is painful for them. Because it forces them to talk about the reality of the facts. Alternatively, Maria described her font of resilience: 'For my daughter I did everything I could, even if I didn't get what I wanted. Now, when I do something for others, I tell you the honest truth, I always seem to do something for her. Kind of like a kind of atonement. That's why I collaborate with the association.' Luca, who could embrace his daughter alive, said: 'When we found her again all the effort, the anguish and despair disappeared. The anger disappeared, there was no more resentment. The relationship has improved, it has become more positive. We have learned to be together in a better way by committing ourselves all to go further, without recriminations.' --- Discussion The narratives of all participants highlighted the five phases of the DABDA model of coping with grief in a special way. The five areas of thematic relevance that appeared in the narratives were the following: incredulity instead of denial; a centrifuge of anger mixed with shame and resentment towards community; bargaining to resolve shame and self-blame; depression-like mourning without a corpse; and the impossibility of closure: acceptance of the unknown and non-acceptance of the end. It became clear that, in cases of ambiguous loss, each phase of Kubler-Ross's model must be defined in a different way, while maintaining some key features. Furthermore, many aspects of each narrative could have been classified into more than one theme, which means that the thematic boundaries are permeable, serving mainly as heuristics. There are, in fact, three particular scenarios that differentiated this experience. The first scenario consisted of those who have not found the loved one. The second consisted of those who found their beloved dead, and the third consisted of those who found their loved one alive. The specificity of those who no longer had news confirmed that they are in a constant condition of anticipatory mourning of an ambiguous type. The lack of a funeral ceremony qualifies this experience as a loss without leave [8]. The silence that characterised the absence appears as a void in which doubts, hopes, expectations, searches, and disappointments were constipated, trapping the griever in ruminative thoughts due to the multiplicity of possible scenarios. Rumination kept the families focused on rethinking the causes and circumstances that led to the disappearance. It also amplified the period of mourning, which manifested in flashbacks that evoke the last exchanges of jokes. Their grief management is arranged as a loss-oriented coping [36,37]. This is characterised by a constant questioning of the reasons for what happened, responsibilities, what could still happen and, mainly, the missing person's state of life. The comparison between the narrations of this first group and those of the second allowed us to confirm that, when the corpse is found, this condition of unreality (described as a nightmare) has been overcome. The second trauma, i.e., when there are no longer fantasies regarding discovery, leads to a cessation of the search of the missing beloved. On the contrary, grieving without a corpse to mourn reinforces the disbelief over the loss. This condition prevents the establishment of a process of elaboration of loss through a language of mourning characterised by rituals and symbols that give meaning to the event. This allows for a progressive acceptance of the loss [38]. By celebrating the life of the missing person, the bereaved can consolidate their memories in the present and acknowledge the ambiguity of their mourning within a supportive space reserved for these families. Wayland [26] observed that celebrating the missing person lets the family members feel that the lost person is not resigned to being definitely deceased or gone forever; it allows them to celebrate the beloved one as a person instead of as 'the one who disappeared', an effect confirmed by Giulia. Indeed, Giulia's whole narrative seems to indicate that finding the corpse permits the family to stop their allegations, which continue to oscillate until the fate of the missing person is known. To better describe the form of mourning triggered by ambiguous loss, Wayland [14], following the studies of Boss [6], utilised the dual process model, which refers to an oscillation between mourning the potential death of the beloved and maintaining hope that the beloved may still be alive [6,14,26,36]. We can also recognise this form of oscillation in Alessandra's narrative, especially in the final theme. However, Paola's narrative clearly shows that hopeless waiting may be the preferred solution, freezing the oscillation and the work of mourning rather than confronting reality. Moreover, it turns out that the community is unable to sustain this kind of uncertainty for a long time. It is also unable to support the families living this experience, because it is perceived as destabilizing [4,9]. In fact, the closeness of the community is generally felt only in the first weeks after the disappearance. After this period, the community moves away and isolates the family, which withdraws in a deep sense of shame with experiences of stigmatization and loneliness. The absence of the community binds mourners to the conviction that they will be able to solve the problem on their own at all costs, leading them to constantly undertake new research strategies. We find in this profile something similar to what is described as disenfranchised grief, i.e., those situations in which society does not know how to recognise the suffering of the sorrowful because it cannot give meaning to particular forms of loss [39,40]. In these cases, the community becomes a kind of limbo in which all relationships are characterised by ambiguity. This type of experience can lead to the stigmatization of grieving families, as their grief management practices do not align with people's expectations about loss, and this, in turn, can lead to additional stress amongst family members as their loss is not socially acknowledged [41,42]. Because the phenomenon of ambiguous loss is still poorly understood and susceptible to clichés, families do not often share their emotions with others for fear that they will misunderstand these feelings or minimise the situation. Professionals who support such families must make the therapy space a safe place, like a 'fence' that protects against misunderstanding, but they must also work with families to restore relations with the community, as this can help them to face their situation [26]. A similar type of grief is the traumatic mourning experienced by survivors of a loved one's suicide. These two types of grief share the presence of experiences like guilt, resentment, and anger. In addition, there is a presence of incessant ruminations related to the search for explanations, as well as feelings of shame and the perception of social stigmatization [43]. However, when the lifeless body is found, this corresponds to a further shock for the family because all hopes of finding it are eclipsed. However, the path of complete mourning can begin, as without evidence of death there is no resolution of loss. The work of acceptance within families centers on the condition of ambiguity

This article presents the results of a qualitative study aiming to consider the relationship between ambiguous loss and anticipatory mourning amongst relatives of missing people in Italy. Eight people participated in the research, narrating their experiences of losing a beloved person (one found alive, three found dead, and four still missing). Findings suggest the presence of a particular form of ambiguous loss, characterised by traits typical of both prolonged and traumatic grief. These findings describe how families are faced with an emotional vortex related to a never-ending wait, and how the mourning is solved only when the missing person is found dead or alive. The discovery of a corpse is traumatic but it allows mourners to fully recognise their grief. When a person is found, it changes the relationship in a positive way. When neither of these events happen, mourners have two different kinds of reactions: they experience either a prolonged grief or a drive to solve their suffering by helping other people (post-traumatic growth). In this study, it is highlighted how a community can be useful or detrimental in this process, and the importance of psychological and social support to prevent significant clinical outcomes is stressed.

41,42]. Because the phenomenon of ambiguous loss is still poorly understood and susceptible to clichés, families do not often share their emotions with others for fear that they will misunderstand these feelings or minimise the situation. Professionals who support such families must make the therapy space a safe place, like a 'fence' that protects against misunderstanding, but they must also work with families to restore relations with the community, as this can help them to face their situation [26]. A similar type of grief is the traumatic mourning experienced by survivors of a loved one's suicide. These two types of grief share the presence of experiences like guilt, resentment, and anger. In addition, there is a presence of incessant ruminations related to the search for explanations, as well as feelings of shame and the perception of social stigmatization [43]. However, when the lifeless body is found, this corresponds to a further shock for the family because all hopes of finding it are eclipsed. However, the path of complete mourning can begin, as without evidence of death there is no resolution of loss. The work of acceptance within families centers on the condition of ambiguity: the aim of therapeutic intervention is to help families find ways to develop tolerance for ambiguity so that their relationship with the beloved is not wholly characterised by this traumatic experience [44]. At the same time, professionals must remember that dealing with death in a definitive way can be unsustainable for some patients. As Paola indicated, even when there is the possibility of closure, the family may decide to remain suspended by refusing to witness the concreteness of the beloved's corpse. Giampiero's family has clung to a psychological condition similar to waiting, but without hope. Adequate psychological help could aid in the process of reconstructing the meaning of the loss, which Neimeyer [45] described as'sense-making.' This process, together with a focus on the needs of the family instead of the details of the investigation, helps families to ascribe meaning to their loss. In terms of psychological support, it is also necessary to give families a space in which to celebrate their loved ones. This can be achieved in various ways; the therapist's task is to help the family find the most significant and suitable route for their circumstances. These celebrations can generate creative connections between loved ones and the missing person, celebrating them not to remember their loss, but to honour their life and recognise that they are not present for now [26]. 'Benefit-finding' is the finding of something positive in the lived experience. In both aspects, a community factor that seems to help even those who no longer have news of their loved one is linked to the possibility of allowing them to dedicate themselves to those who live the same experience. In this study, the participants collaborated with an association dedicated to such cases. The resilience that these initiatives activate is the result of the ability to transform uncertainty into an inner strength that gives relief to other people who have to face a similar path [46]. Solidarity becomes the new life project that gives meaning to a disappearance, as well as a new way to feel close to the lost person. The desire to help other families living with the pain of disappearance activates a need to cope by finding a resolution [47]. However, many families find it difficult to perceive this unique loss as an opportunity. It is also worthwhile to help families acknowledge the steps they have taken, or the progress achieved during the person's disappearance, because often they are not aware of this and see no changes. This may also help family members to envision a path together, whereby they may survive their ambiguous loss. Before having family members share their own experiences, professionals may opt to share the experiences of other families to highlight how they reacted to the same situation, thereby creating a context or distributed community to ground their pain [26]. Despite Boss's [7] assertion that mourning is an oscillating process of ups and downs [48], more so than a series of grief stages (as per Elisabeth Kübler-Ross [16]) or a construct of anticipatory mourning (as per Lindemann [15]), our study suggests that ambiguous loss and anticipatory mourning share many qualities, and that research on each of these topics can improve our comprehension of loss without closure. --- Conclusions Our study outlines the need to set up specific interventions aimed at supporting relatives who find themselves having to deal with the disappearance of a family member. This is a highly destabilizing event with the characteristics of anticipatory mourning, which then turns into prolonged and complicated mourning due to the uncertainty that blocks the processing of the loss. From the moment of the disappearance, different scenarios may appear: that the missing person will be found alive; that the relative will receive news of their loved one's death; and that there will be no further news of their loved one. The last situation freezes the experience of loss for the relative of the missing person, triggering an endless exercise in searching for and hoping to find the missing person. The endless waiting for the return of the beloved one and the lack of a corpse does not allow the transition from anticipatory grief to complete mourning. This results in an ambiguous grieving. The complex nature of this undefined loss therefore highlights the need to have an in-depth understanding of this experience. Any support for these grievers must take into account the ambivalent condition of this event. Difficulties in adapting to the loss must therefore be supported by appropriate community and psychological interventions that make it possible to work out the acceptance of a new condition marked by uncertainty. Through adequate psychological support the event of disappearance, as is the case with other traumatic experiences, could then become the starting point for a personal transformation of the individual. This is known as post-traumatic growth, understood as a path of positive change for an individual following trauma. Further investigations will make it possible to recognise more deeply the relationship between different traits of this mourning without closure and its oscillations. It might therefore be useful to better consider its specific expressions of the dual process model, describing how and which kind of loss-oriented stressors interact with the restoration-oriented process. Indeed, it could be useful to specifically describe the relationships between the feelings related to the loss and the tasks that mourners are convinced they have to perform to change the situation and to overcome the suffering. Thus, it would be recognisable functional and dysfunctional psychological strategies that characterize this specific form of loss and its mourning. --- Limits and Future Studies The main limitations of the study are (1) the small number of participants and (2) the unsystematic treatment of the differences between modes of being'missing' (survivors, deceased, still missing). The small number of participants prevents the recognition of sufficiently stable narrative subgroups to describe well-structured, differentiated profiles. Future studies should not only outline these profiles, but also consider the relative effects that television search programmes produce in families. The findings of the present research cannot be generalised; however, they provide a much-needed foundation for future research on missing persons in Italy, thereby filling a gap in the literature. In fact, further studies should better investigate aspects of this kind of loss, such as specific defensive psychological strategies and forms of attribution of responsibility in relation to depression. Furthermore, it could be very useful to analyse the nature of the perceived discrimination, as well as the effects of the media collaboration.

This article presents the results of a qualitative study aiming to consider the relationship between ambiguous loss and anticipatory mourning amongst relatives of missing people in Italy. Eight people participated in the research, narrating their experiences of losing a beloved person (one found alive, three found dead, and four still missing). Findings suggest the presence of a particular form of ambiguous loss, characterised by traits typical of both prolonged and traumatic grief. These findings describe how families are faced with an emotional vortex related to a never-ending wait, and how the mourning is solved only when the missing person is found dead or alive. The discovery of a corpse is traumatic but it allows mourners to fully recognise their grief. When a person is found, it changes the relationship in a positive way. When neither of these events happen, mourners have two different kinds of reactions: they experience either a prolonged grief or a drive to solve their suffering by helping other people (post-traumatic growth). In this study, it is highlighted how a community can be useful or detrimental in this process, and the importance of psychological and social support to prevent significant clinical outcomes is stressed.

Introduction The study will illustrate the plight of women and their role in society. Through the works of Anita Nair, we can see the issue from a new lens -one that is both introspective and thought-provoking. Her unique perspective allows us to delve deep into the heart of this issue and consider its impact on women and society as a whole. It will look at the experiences of women who struggled in a culture that restricted their freedom of movement. The female protagonists of the narratives shatter patriarchal norms and forge unique identities. They yearn to be self-sufficient and to live their own lives. Nair criticizes traditional schooling for promoting patriarchal ideas in both genders in Ladies Coupe. Anita Nair imparts life lessons and portrays household lifestyles while analyzing the many stages of women's existence. Mistress by Anita Nair portrays the evolving social relationships between husband and wife. She exposes the impacts of oppression on women and emphasizes individuality as the fundamental concern of The Better Man. Anita Nair also states that education is only beneficial if it focuses on altering people's ideas, empowering them, and working on the emancipation of women. She understands how society has to work on restoring the male-female relationship and providing equitable treatment to both genders. Society influences the way we exist, perform, and play, as well as how we see ourselves and other individuals. As a part of society, it is highly wrong to differentiate people based on their sex. In a male-dominated household, patriarchy refers to the father's authority over the members. Sylvia Walby describes it as "a system of social structures and practices in which men dominate, oppress, and exploit women" (Walby, 1990). We have witnessed circumstances in which women are not just viewed as submissive to men but also face racial prejudice, shame, abuse, sexism, surveillance, and assault. A woman's quest for identity has made her oppose society's typical system. Women did not have ideas or opinions of their own since they were reliant on men, the system encourages and feeds the fundamental human values of dominance and control in nearly every aspect of life. Those who grow up in a repressive society tend to endorse, associate with, and engage with it as a typical and ordinary life. The methods used to control and subjugate women varied from one civilization to the next, owing to variances in sociocultural practices, class, caste, religion, area, and ethnicity. The culture of male dominance emphasizes the idea of mothering, which limits women's independence and lays the responsibility of parenting children on them. Aristocratic ideologies distort the boundaries of gender and sex and think that all monetary and juridical distinctions involving men and women have a genetic basis. Like socioeconomic strata, ethnicity, caste, or religion, gender must be analysed as a fundamental social difference to understand societal disparities, discrimination, and asymmetrical relationships between men and women. Feminist scholars, philosophers, and novelists have examined women's oppression, arguing that sexual politics and sexism notions have intended similarities with class politics and racist beliefs. Male domination, female subjugation, and male-centeredness are all aspects of discrimination towards women. Male Domination: Men make all the decisions in patriarchy. Women are not permitted to make private choices that affect their families or personal lives. Men are seen as superior because they have authority, whereas women are inferior. In the patriarchal system, men and women are treated differently. Women are perceived as weak, while men are perceived as powerful and logical. Men have a traditional and biased attitude towards women due to these preconceptions. Female subjugation: Women are oppressed and discriminated against in society as a result of male supremacy and their obsession with control. Lack of education, independence, career possibilities, forced marriages, and bearing male offspring are all evidence of prejudice against women. Even if they do acquire jobs, they are inferior to men and are frequently exploited at work. They are not treated with the same dignity as a male in their position. Male-centeredness: The focus of activity and progress in a patriarchal culture is on men and their value to societal advancement. In every patriarchal society, men remain the focus of interest, the inventors of all advances, and the ones who shine. Limited roles: Females and males have different social roles in society. Because a woman's major purpose is to be an excellent mother and wife and to undertake chores at home, she frequently drops out of school following her basic studies. As a result, the autocratic society persuades women that education is pointless. After marriage, many women adopt their husbands' surnames, and half of them quit their employment since they are no longer allowed to work and must care for their new family. Their sad reality is that after marriage, even the parents do not bother to support their side or encourage them to continue their profession because she is married and no longer lives under their roof, a sentence that depicts a classic patriarchal culture. Likewise, many females receive a good education to obtain a respectable spouse rather than a good job. Due to these stereotypes, men have a conventional and biased attitude toward women which startlingly reflects the realities of society. Earlier, women were treated with the same respect as men. The roles of men and women were equal in matriarchal societies. In the fields of martial arts, ayurveda, and statistical philosophy, women were pioneers. Women had a high role in a matriarchal society, and in agricultural science, conventional farming methods were replaced by the use of ploughs and animals. Unfortunately, after this period, the role of man in birthing also became apparent. This led to the abandonment of the idea of the feminine mahatma and the replacement of motherhood with a hierarchical culture. The matriarchal non-Aryan civilization that predominated Indian society was vanquished by the Aryans. It gave rise to caste, which paved the way for the Indian system's introduction of discrimination. There are two different schools of thinking on women in India. One stream advocate for gender equality, while the other merely regards women as subordinate. Based on scripture, Indian life was governed by discrimination, inequality, and a lack of knowledge. Epics founded on scripture served as the foundation of civilization. Women were the most vulnerable to this caste system. Epics such as the Ramayana and Mahabharata were indications of how the position of women underwent a shift at that time. The position of women started to deteriorate in the post-Vedic era. In "Manuvachan," it is made clear that women do not belong in countries where they are in leadership positions due to their social standing. (Patil, 2021) Women's financial and political engagement in such a secure existence started to decrease. Scriptures were written at this time to add religion to women's subordinate and secondary status. Women were subject to a lot of limitations during this time to maintain the subjugation of women. With the aid of several terrible customs, including early marriage, the inhumane treatment of widows, and polygamy, the Arya Samaj attempted to overthrow the matriarchal order. Men and women were subject to a different set of norms about conduct. For her, marriage became necessary. In the Brahmin social structure, the rigour of the hierarchy of castes, the absence of females, education, and shared families contributed to the dismal situation of women. This era of women's lives is believed to be a bleak period because of the transition of the system of castes into an economic hierarchy in the medieval period. To prevent girls from getting married outside of their caste, child marriage was created. Women were subjected to intellectual servitude and denied the right to an education. Widow remarriage was prohibited to prevent interracial marriages among widows. Hindu women were forced to remain within four walls, while Muslim women faced a similar fate. They were denied any rights and were forced to spend their life behind a burka. They had a very low quality of life as a result. Mr. Bhide Patil claims that the missionaries' activity in Maharashtra and India contributed to the development of a new generation of social reformers. (Patil, 2021) In the nineteenth century, both Raja Ram Mohan Roy and Mahatma Phule contributed significantly to the discussion of women. Despite minimal attempts, it seems like change has begun. Pre-independence and postindependence are the two distinct eras of women's growth in the modern era. The British introduced a new concept of capitalism and colonialism to the Indians at the start of the nineteenth century. The British attempted to demonstrate their moral superiority at this time by supposing that a group of Indian women was under oppression. Women were adored as mothers and goddesses in Indian civilisation but considered second-class citizens. Women had a secondary role within society and at home throughout the nineteenth century. Later, the activism was given little scope recognizing that the seclusion of women was the primary cause of Indian backwardness, the first school for girls was established in Pune in 1848. It aided in the transformation of women's lives. Women took part in the liberation movement. In addition, women's engagement in the economic, political, social, and educational spheres began to rise. However, in a male-dominated system, the position of women remained unchanged. The Indian government established equal rights for women and men in society after the country attained independence. The Hindu Code Bill was submitted to Parliament to establish gender equality, but it was rejected by the male-dominated politicians of the period. Later, a large number of organizations advocating women's emancipation were created. These organizations work to develop women holistically by raising awareness and a sense of self-worth. In the domains of sociology, politics, literature, and education, women have successfully demonstrated their abilities. The twentieth and twenty-first centuries were crucial for Indian society. This period has seen several drastic developments in the daily lives of Indian women. Women's attitudes in society are evolving. Women's social and cultural environments are evolving. Women have demonstrated their existence in every situation that has arisen. The position of Indian women began to improve throughout the British era. Women tried to advance their position by improving their skills. However, a patriarchal culture often fails to recognize the talent and contributions of women on the same level as men. Education facilitated the removal of patriarchy from society. It helped in raising public awareness. Women underwent personal change and development via education, becoming more conscious of their rights. It assisted women in empowering themselves and overcoming the obstacles the institutions had placed before them. The socioeconomic circumstances of women were changed with the aid of education as well. Women's participation in the market has two positive effects. One of the reasons they engaged more and were less reliant on men for their own needs was that they were talented. Second, women with greater levels of education received preferential treatment and better salaries. Women needed to be liberated from the orthodox culture, and education provided them with the chance to succeed. Education not only aids an individual's involvement and decision-making in life, but it also helps in the growth of the nation and around the world. We witnessed many educated women in the past who contributed to India's and the world's liberation movements. For instance, Sarojini Naidu paved the way for women's involvement in the Indian movement. She rekindled the villagers' sense of freedom via her poems. Yet another woman with a gift for words was Madam Bikaji Cama. She travelled to Europe to advocate for India's independence. India has seen the emergence of the "New Woman." The Victorian era marked the start of everything. The Victorian era brought about several improvements that benefited women. The Irish author Sarah Grand (1854-1942) used the term "New Woman" in 1894 to refer to the independent women seeking radical change. After the 20th century, conditions changed as there were more female writers, a few of whom even gained respect and acclaim for their contributions globally. The shift from a conventional self-effacing lady to an educated woman emerged in Indian English literature of the 1960s following the arrival of a new generation of authors. Several female writers are addressing the humiliating state of women in contemporary society to combat gender injustice. Writers who are concerned about the current state of women's affairs utilize their literary platform to awaken people's consciences and break the taboo of their deplorable treatment of women. These female authors rebelled against the idealized portrayal of women. Writers such as Anita Desai, Jhumpa Lahiri, Bharati Mukherjee, and Namrata Verghese not only rebelled against literary conventions but also challenged the accepted view of the Indian woman. They revealed who contemporary, educated middle-class women were and what they envisioned themselves to be. --- Subjugation of women in the works of Anita Nair Literature has always served as a reflection of society, reflecting its people's culture, traditions, and lifestyles. Many works of literature illustrate the paradox of an Indian woman's existence. Indian women's authors' early works portray women in a conventional light. The portrayal, however, got more authentic as time went on, emphasizing her sense of despair and estrangement. They portrayed characters caught between the two worlds. Anita Nair is a modern Indian writer of the twenty-first century. Her writings mostly depict the pitiful fate of women who writhe in the hands of patriarchy. Our culture's dominant values limit women's rights and marginalize their existence as human beings. Anita Nair, in her interview with Indian Express, states patriarchy works in equally visible and deceptive ways, Nair goes on to say it is what she had wanted to concentrate on in each of her literary novels. (Pepper, 2013) Anita Nair's primary concerns consist of gender inequality and women's cultural upbringing, as well as the abuse of women, both within and outside of the marital framework. She exemplifies women's servitude within conventional Indian culture. She insists on equal opportunities for both men and women. She believes that it is only right that women in India be given the same opportunities as men. Education, financial independence, and employment opportunities, among others, have enhanced the condition of Indian women. The process of self-discovery is portrayed in Anita Nair's Ladies Coupe. This work serves as an identity for women in modern India. The book's characters talk about how women were taken advantage of in a society that was ruled by men. Ladies Coupe features the narrative of six distinct ladies, highlighting various stages in the life of a woman. The protagonist of the novel is Akhila, also known as Akhilendeswari. Nair uses the persona of Akhila to illustrate the predicament of Indian women, who are typically expected to devote their time to performing the roles of daughter, mother, sister, and family earner to meet their needs. Akhila in her journey, met five women: Janaki, Margaret Shanti, Prabha Devi, Sheela, and Marikolanthu. Through their personal stories, they all depicted various stages of life. The French word "coupe" indicates a confined region. It is ideal for Akhila, who is likewise bound to her family, hampering her independence in every way possible. The majority of Anita Nair's books explore the lives of women who endure trauma and oppression in their families. The other five ladies are constrained by their social and familial bonds. The coupe's restricted environment represents an Indian woman's life. The Ladies Coupe depicts how society expects and values conventional and pious ladies. As a result of needing a spouse to provide for the family, Akhila's somewhat avaricious family forbade her from getting married. Her mother anticipated that she would be a subservient daughter. She was a girl who paid attention to everything around her. Akhila, like every other girl her age, had ambitions. But whenever there was disagreement in the house, she would be the one to make sacrifices. Because of her traditional family, she was expected to have a member of her family with her anytime she went out. The irony here is that even when Akhila was the family earner, she had to seek approval from the rest of her family. Akhila chooses to embark on this journey as she reaches her limit and believes she hardly has control over her life. She is about to embark on an experience that will turn her into a new woman to evade her family's obligations and commitments. Ultimately, she was a resolute lady who, by the evening, resolved to get on the train and flee: "She felt her lips stretching into a smile.... will board a train and allow it to lead me into a horizon I will not recognize" (Nair, 2005) The work explores awakenings, traversing the liminal zones of self-discovery, and transformational change. It also discusses restrictions. This train was more than just a mode of transportation for her; it was a new universe where she would be liberated to conceive fresh opportunities in her future. Akhila, who had always done "what is expected of her," fantasized "about the rest" and collected "epithets of hope like children collect ticket stubs" (2) before her important excursion. The mother of Akhila is a devoted, traditional woman who believes a wife is never truly equal to her husband. She is the kind of woman who is convinced that "he knows best." She never makes decisions for herself and instead always defers decision-making to her partner. The mother of Akhila desires that her daughter adopt her perspective and values. She said that a good woman knew how to prioritize the requirements of her husband before her own. A good woman did what she was told and paid attention to her husband. According to her, there is nothing like equal marriage. Thus, for a considerable amount of time, despite all the advancements, the patriarchal family unit maintained typical norms. The idea of the perfect "housewife" evolved into the dominant paradigm. Before embarking on the journey of self-discovery in Kanyakumari, Akhila began to question whether a woman needs a man to complete herself and be an acceptable citizen in this society. The personal experiences shared by the five women on her train provided answers to all of these concerns. For example, Janaki was the coupe's eldest member. She was barely aware of her obligations as a woman when she entered into an arranged marriage at the age of eighteen. She did precisely what she saw around her; she was the epitome of a typical woman. In society, she was submissive to men. She adds how her father and brothers came first, subsequently by her husband, and later by her son. She automatically moved in the same cycle that started with her father. Her husband was equivalent to God, according to the ideals she followed, and she was entirely committed to him. She quickly learns that she never lived her life solely for herself. Another example is Margaret Shanti, who entered a love marriage with Ebenezer Paulraj, the man she adored. Margaret works at the same school where Paulraj is the principal. She has also won a gold medal. She intends to undertake a PhD after finishing her M.Sc.; however, her husband, Ebenezer Paulraj, advised her to first earn a B.Ed. It is challenging to live in a conventional culture when everything, even career choices, is determined by the men in your life. There is no sense of individuality. "How a good wife never says 'No,' even when she is not in the mood," her mother said a day before her marriage. ( 102) Margaret, a successful chemistry teacher, is the prisoner of an unpleasant marriage with an insensitive autocrat and a selfish husband who neglects her. "What else could I do?" she asks. Hadn't I done everything he asked? She was clueless about his expectations of her. "And suddenly, I felt much too weary to care." (LC 109) This depiction personifies the effects of patriarchy. (Nair, 2005) She tries everything to woe him, but nothing works. She is mentally and emotionally drained. Simone de Beauvoir was a French essayist and philosopher who lived from 1908 to 1986. The Second Sex ( 1949) is a well-known analysis of women's situations. She discovered that men saw themselves as subjects and women as objects. Simone de Beauvoir answers through The Second Sex that he wants her 'all' to himself and does not want to live as one of the two and become alone. Therefore, she is betrayed from the day he marries her. (LC 465) (Nair, 2005) The most common fate provided to women by society is marriage. In India, in marriages that are arranged, the wife is obliged to serve the desires of the man her whole life. Later on, he compelled Margaret to have her first child aborted when she became pregnant. She finally gives up after several arguments, but she remains solitary. She had no regard or adoration for her partner, and it all evolved into hatred. She felt comfortable hurting her ex-husband's pride in his athletic appearance because he was essentially obsessive and unaware of her needs. She wanted revenge for the discomfort she felt in life because of her husband. In exchange for making him appear overweight, she prepared oily food for him. She commented while mocking society: "You'll discover that once you stop worrying about what the world thinks of you, your life will become that much more" (136). Anita Nair portrays gender discrimination in Indian culture in Ladies Coupe via the portrayal of Prabha Devi, where a girl child is still regarded as inferior to a boy child. Prabha Devi is a beautiful young lady who was neglected by her biological father shortly after she was born. When her mother informed her father that she had given birth to a girl, he said, "A daughter is a bloody nuisance." He could not accept the fact that he had a girl because he had always desired a son. It is heartbreaking to witness how patriarchy operates throughout generations. The irony is that she is both the goddess one worships and the gender one despises when she is born into the household. In due course, she married Jagdeesh, a diamond merchant's son. As part of his business travel, they both relocated to New York. Prabha Devi has transformed into an entirely different lady. She walked confidently in high heels. She did not want to be her former self, who was never good enough. Prabha Devi was not planning to have children soon after her marriage. She informed Jagdeesh of the same thing, expecting him to agree with her decision. But after learning of the decision, he became ashamed and began to talk about how his parents planned to have their first grandchild. She understood it was not something she wanted. She abandoned her husband. Learning to swim is one of Prabha Devi's post-marriage accomplishments since it gives her a sense of empowerment. Nair depicts Indian husbands' obstinate conduct towards their wives, as well as how everyone tells them their biological clock is ticking and they should conceive sooner. Anita also demonstrates how families compel women to carry children even when they are unwilling to do so. To sacrifice oneself for the benefit of one's family and husband is precisely the lesson that women raised in patriarchal societies are taught. Out of the six women, Marikolanthu is particularly miserable; she is an unmarried mother who falls prey to a man's desire. She belongs to a lower-caste community. She serves as an accurate representation of impoverished and hungry rural women subjected to male dominance. Marikolanthu, like Akhila, was never treated well at her residence. While growing up, she suffered from gender prejudice. She never attended the same school as the other children in town. Her mother never let her go to school and instead assigned her to care for Akka's child. Since Sujatha Akka was the only person who treated her like a human, she felt a strong bond with her. When Marikolanthu grows into an adult woman, Akka gets her a job and transfers her to Vellore to keep her safe from the unwanted attention of her family's males. She works as a maid for two foreigners, Miss K, and Miss V. They were doctors at the same hospital. Her early innocence was shattered into pieces when Murugesan, an upper-class guy and a relative of her employer, raped her. Murugesan is a family member in the home. He is the brother of the family's eldest daughter-in-law and despises Marikolanthu, as she appears to be more prominent in the house than his sister. He rapes Marikolanthu, reminding her that slaves must know their proper place. When a girl gets raped, she is embarrassed and constantly reminded by society. Upon Marikolanthu's rape, rather than evoking compassion, everyone places the blame on her. Nair attempts to characterize the psyche of all members of society, male and female, who find fault with the woman who has been unfairly abused because she is held accountable for her misfortune. In her work, D. Silvia Flavia (Langyan, 2021) outlines a prevalent patriarchal notion in the novel Ladies Coupe. It portrays how a woman is limited by conventions to be reliant on men and handicapped to see her abilities. She has shown her ladies being oppressed by patriarchy and fighting side by side. Her female characters have been presented as clever, inquisitive, and rebellious against the injustice done to them. As they emphasize a connection between inequality and injustice, colonialism and the idea of patriarchy are inextricably linked. Although the colonial master is no longer present in the conquered nations, the legacy of colonialism lives on in the form of patriarchy. Men alone can be seen enjoying the blessings of freedom, while women continue to be oppressed by men. The decolonized male demonstrated his dominance by treating women unfairly. Therefore, Anita Nair's female characters highlight the issue of their lives, which has been reinforced by patriarchy, and perceive it as both the source of their subjugation at residence and within the community and a place where they may fight to defeat those who oppress them. Akhila decided to see her younger boyfriend, Hari, after getting to know the five female characters onboard and learning about their experiences. Previously, she was concerned about how her connection with Hari would be seen by society. These stories, however, encouraged her, and she quickly saw that a woman needed a partner with whom she could express her thoughts and feelings. Following the life lessons of the ladies in the coupe, Akhila rediscovers herself. In the novel "Mistress" by Anita Nair, the book explores complex relationships between married and unmarried people and the challenges women face in society. Additionally, it delves into the beautiful and intricate art of Kathakali. The work goes thoroughly into the social standards of married Indian women and the decisions they make in their marriages. The novel's main character is Radha, who represents a modern Indian woman. Her husband, Shyam, failed to provide her with a sense of security or independence, leaving her feeling unfulfilled. As a result, she becomes involved with Chris, a travel journalist who recently arrived in India. Radha feels a strong connection and affection towards Chris, whereas she feels suffocated and enslaved in her relationship with Shyam. Anita Nair's writing showcases the struggles of women who attempt to be submissive wives but ultimately fail to maintain their happiness. The male-dominated culture's pride hurts the sentiments and desires of these women, leading to unhappiness in their married lives. For instance, Radha expresses how she feels like a possession to her husband, Shyam, despite her efforts to love him. She says he thinks she is "a possession for Shyam," and she adds "a muchcherished possession." Radha claims that it is her only role in his life as he does not want an equal; all he wants is a mistress. (Nair,2005) This section emphasizes Radha's need for love and company. Radha decides what to do and accepts the circumstances. This also highlights the need to challenge traditional gender roles and the importance of equal partnerships in marriage. Nair portrays the need to understand the challenges faced by women in male-dominated cultures. By using the character Radha, the author challenges gender inequality and attempts to go beyond prevailing stereotypes by illustrating Simone de Behaviour's theory that men consider women like objects. Shyam alleges he treats his wife like a sexual commodity. Shyam may have thought he owned Radha, but he did not. She declares she was "never truly his", and she continues to say, "And I'll never be." (Nair, 2005) Chris and Shyam are ultimately rejected by Radha. She is free of the burdens of being a wife and mistress. By separating from both men in her life, she gives her child a motherly identity only via maternal custody, leaving him "fatherless." Radha, who has been Chris' mistress and Shyam's wife, is now on her way to becoming the "mistress" of herself. In her novel "The Better Man," Anita Nair portrays the struggles of women pursuing independence in marriage and facing gender inequality, ultimately leading to self-realization. Anjana and Valsala, are the female leads of the narrative. Anjana, the spouse of Ravindran, was a self-reliant young woman before her marriage, and her parents gave her the chance to reach her full potential. Everything changed after her marriage. She craved her individuality. She yearns for love and independence. Anjana and Ravindran were growing apart. His business was always shifting, and he lacked stability in his finances. His inability to communicate effectively was the main problem in his business. When he would get home from work, he would beat Anjana. Her father warned him about the domestic abuse as well as his not being at home saying, when he gave her daughter's hand marriage, it was with the "hope" that you would "love her." But all he did was hurt her. He insists on saying his daughter can "manage very well without a husband" like him. (Nair,BM: 232) Her father helped her in getting a suitable teaching position to spare her husband's violence. She enjoyed her work. She is now free from her marriage. She realizes her value in life. Anjana is now a mature lady. The author investigates the patriarchal structure that is to blame for women's plight in Indian culture. The narrative also follows the character's development from vulnerabilities to wisdom. Valsala, who married Prabhakaran, a schoolteacher, was dissatisfied with her marriage and eventually developed feelings for her neighbour, Sridharan. She could not care less about becoming a part of traditional society. Valsala finds her true self and accepts his proposal to be her mistress. This episode, via morality, exemplifies Valsala's feminism. She acknowledges that sex, freedom, love, and gender equality are fundamental revitalizing energies for all women. She validates it by saying she is "just forty years old." She believes she does not want to be "pushed into old age before it is time." She was a newly free woman, fiery, and wanted to love with full passion. She states "I want to know ecstasy." She continues to repeat the same "night after night" (Nair BM: 130). Valsala inquires and asks questions about established conventions in Indian society. She raises new questions regarding women's sexuality and gender identity. --- CONCLUSION Women in literature have long been portrayed as paragons of passive sufferers globally. The subjugation of women is common in patriarchal cultures. They must serve their husbands, as marriage is their only fate. Women were expected to keep their thoughts to themselves and were not allowed to express their ideas. According to Gayathri Chakraborty Spivak, the marginalized were silenced not only by imperialism but also by those of us who look on while injustice occurs all around the world but do nothing against it. According to her, "the figure of the woman moving as a daughter, sister, wife, mother, and clan member to clan and family member structures patriarchal continuity even as she is herself drained of proper identity." ( In Other Worlds) (Spivak,220) Social suppression of women has a long, dynamic history, and sadly, it still exists today. Anita Nair's selected writings illustrate the hardships of women who battled in an environment that limited their rights to freedom. Nair's female characters desire to find the truth and be free from oppression; therefore, they battle it in their own way. Anjana and Radha, for example, both abandoned the men in their lives and began to value themselves. Valsala finds her inner consciousness, and Akhila realizes she is no longer a prisoner to her own family. Anita Nair's writings depict women and their challenges in a conventional society, with women finding solutions to them. She portrays both the rebellious and resilient nature of women and also highlights how education is critical to empowering women. Anita Nair portrays how today women are free from patriarchal constraints and forging new identities. Women have changed over time, and today they exhibit an exquisite combination of past and modern aspects. When a woman is pushed to the limit, separated from society, and trapped, she becomes subjugated. It is a rigorous procedure. It is only by acknowledging and understanding this issue we can begin to work towards creating a better, more equal world for all. --- Declaration of Conflicts of Interests The author(s) declared no potential conflicts of interest. --- Funding Disclosure/Acknowledgement This research received no specific grant from any funding agency.

This study will investigate how patriarchy works as a vehicle for women's subjugation. Many female authors were born within a predominately patriarchal environment, where women have historically been subservient to socially imposed norms. Anita Nair has emerged as one of India's most committed modern authors. She freely expresses her views about women in autocratic Indian culture. She also offers insight into how society views women and what it expects of them. The paper will portray women's sufferings and the status of women in society. It will also shed light on the importance of education. The idea of 'half' by Simone De Beauvoir in her work The Second Sex will illuminate the concept of self. The paper will highlight the shifting scenarios of women and how new women transcend the confines of patriarchal setup and create new identities through Anita Nair's novels-Ladies Coupe, Mistress, and The Better Man.

I. INTRODUCTION Popularity of online social networks allows us to investigate dynamics of social interactions on a scale that was previously unattainable [1]- [8], while at the same time raising ethical concerns not previously encountered [9], [10]. One particular type of social interaction is an information cascadea spread of information between individuals in a social network [11], [12]. Information cascades are instrumental in investigating social influence, which can be defined as the degree to which the behavior of individuals changes the behavior of their peers [13]. Although mathematical modeling of social influence and information cascades is an active field of research in sociology for decades [11], [12], it only recently became technologically feasible to apply it to wide range of domains such as viral marketing [14], The associate editor coordinating the review of this manuscript and approving it for publication was Xiao Liu. information diffusion [15], behavior adoption [16] and epidemic spreading [17]. Presence of exogenous factors is particularly problematic in estimation of social influence as it confounds with the endogenous factors, and can be hard to differentiate using observational data alone [18]. Still, it is instrumental for understanding the information spreading as information can propagate through multiple channels simultaneously, many of which are exogenous to the online social network itself -news media websites, direct communication via email and instant messengers, and even offline word-of-mouth transmission. In addition, external events such as political unrest [1], [19] and natural disasters [20] are often strong mediators of information cascades. These exogenous influences are usually not directly observable in the online social network itself, although they can be inferred from the available data. Understanding how endogenous and exogenous forces influence the information diffusion in online social networks could help us estimate to what extent are these vulnerable to manipulation FIGURE 1. Collected Facebook friendship networks. Visualization of Facebook friendship networks of users who registered on three of our Facebook online survey applications: referendum2013.hr (11538 registered users), sabor2015.hr (6909 registered users) and sabor2016.hr (3818 registered users). Network nodes are colored according to the user's votes, and node sizes correspond to the number of their Facebook friends that also registered on the survey application. Clustering of users into communities based on votes shows a homophily effect -users are more likely to associate with other users that share their political preferences. This suggests a potential for endogenous influence. by various interest groups such as organized individuals, news media and government agencies [21]. In this paper we present a new methodology for estimation of endogenous and exogenous influence in online social networks. Our current model is conceptually similar to the unified model of social influence [22] which was shown to be generalization of many popular influence models, including complex contagion model [4], independent cascade model [23] and generalized threshold model [23]. In our previous work [24] we proposed a simpler method for inference of endogenous and exogenous influence that exploits statistical differences between the way the two types of influence act on users. The underlying assumption is that the endogenous influence is dependent on the current state of the social network and which users are already active or not, while the exogenous influence is independent on these. By incorporating these assumptions in a statistical model we can infer magnitude of endogenous and exogenous influence from empirical data. Here, we develop a likelihood-based approach which is expressive enough to accommodate many different microscopic models of influence, and propose a maximum likelihood inference method to estimate the parameters. The inference problem is the following -given a single activation cascade and a friendship network between users, and assuming a particular form of endogenous influence, infer parameters of endogenous and exogenous influence and estimate magnitudes of these influences in time and on a global and user level. We evaluate our methodology on activation cascades collected via three online survey applications related to three distinct political events in Croatia (Fig 1 andFig 2, and Table 1). First survey, which is related to the referendum on the definition of marriage in 2013, we already used in our previous work [24]. Other two surveys are related to Croatian TABLE 1. Collected online survey data. Collected online survey data include demographic information, friendships between users, and referral links through which users visited our applications. Time period refers to the period when surveys were active. Depending on whether these referral links originated within Facebook or some external website they could be used as indicators of endogenous and exogenous influence respectively. parliamentary elections in 2015 and 2016 and we collected them exclusively for this research. In all of our surveys the activation cascades are a series of user registrations through time. Surveys were active one week prior to actual elections and through them users were able to express their vote on the upcoming elections, see summary statistics for all users as well as for their online peers, and share the link to the survey through Facebook. Besides votes, we also collected Facebook friendship connections between all users that participated in our survey. In 2013 survey we also collected demographic data and in other two we obtained referral links through which users visited our survey website. These referral links originate either from Facebook, which indicates endogenous influence, or from some external website, which indicates exogenous influence. This classification of referral links served as a proxy for ground truth influence and allowed us to evaluate our inference method. During data collection we followed Facebook's Platform Policy which provides guidelines and regulations for the usage of Facebook Graph API in thirdparty Facebook applications. The main contributions of this paper are the following: 1) We collected data on social engagement of over 20 thousand Facebook users that participated on three Time series are annotated with times of major news events which reported on our online survey application, and which are used as a proxy for exogenous influence. Time series for sabor2015.hr and sabor2016.hr datasets are additionally separated based on the type of the referral links. distinct online political surveys. Datasets where users have to provide an informed consent to collect their data are usually much smaller, and so researchers have to rely on simulated datasets in order to validate their models. 2) We estimate magnitude of endogenous and exogenous influence in social networks by using only a single activation cascade of users and their friendship network. Most previous research relies on the availability of multiple information cascades and rarely tackles exogenous influence directly by either leaving it as an option [22], devising experiments where it is negligible [25] or simply treat it as a nuisance [26]. 3) We show how can our methodology be used to estimate collective influence of various groups of users and characterize to what extent was their activation endogenously or exogenously driven. These estimates agree with both the simulated activation cascades and three realistic use cases where user's referral links served as a proxy for the ground truth labels on whether users were endogenously of exogenously activated. --- II. RELATED WORK The most commonly used information diffusion models were inspired by epidemiology which model how a disease spreads in a population [27]- [29]. However, their utility is sometimes hindered by their use of latent states which are unobservable in data. For this it is more appropriate to use Independent Cascade (IC) model [30] and Linear Threshold (LT) model [11], [23] which feature two observable statesactive and inactive that denote whether an user was already exposed to the piece of information or not. These are popular for their simplicity that facilitates theoretical analysis [31], statistical inference from data [26], and can also be used as building blocks for more complex applications such as influence maximization [32], [33]. In this work we use two variants of the IC model (Eq 1 and 2). However, there are several crucial differences between epidemic spreading and information diffusion [34]. Epidemic spreading is better modeled with simple contagion model where endogenous factors play a dominant role, and the activation probabilities are independent of the neighborhood structure and the state of activated users in it. On the other hand, information diffusion is better modeled with complex contagion due to the common presence of exogenous factors [25] and more complex forms of endogenous influence which include various social reinforcement mechanisms such as reciprocity [35], social feedback [36] and homophily [37]. These additional factors are often neglected in modeling, which is reasonable if there is enough evidence that some of them, for example exogenous influence, is negligible [25]. When this is not possible the exogenous influence has to be explicitly accounted for [38]- [40]. In our work we rely on an explicit modeling of exogenous influence through a likelihood-based approach. Many likelihood-abased approaches for modeling influence exist in literature, including peer and authority model [41] which, however, requires explicit modeling of authorities responsible for exogenous influence, while in our case this is not necessary. Many of the other approaches rely on the availability of multiple activation cascades [39], while we use only one. Also, we use the social network structure, based on final state of activation cascade, directly in our inference rather than using it implicitly [8] or relying on a network statistic such as degree distribution [42]. --- III. METHODS Crucial components of our methodology are explicit microscopic models of endogenous and exogenous influence with which we expand the Independent Cascade (IC) model. We then use these models in a log-likelihood function which gives us probability of observing particular activation cascade as a function of the model's parameters. Formulating our inference problem in a probabilistic way allows us to optimize for the maximum likelihood parameters and to estimate the magnitude of endogenous and exogenous influence. We apply our methodology on several simulated and empirical activation cascades in order to characterize the activation of users as being more endogenously or exogenously driven. The simulated case is easier because we know both the functional form and the parameters of the model that generated simulated information cascade, which allows us to perform evaluation in a straightforward manner. For the empirical cases we use three Facebook datasets obtained from an online political survey applications. In the end we estimate collective influence of three groups of users -those who registered by following link from within Facebook, those that registered by following link from an external website, and those that followed a link from a Facebook advertisement. --- A. MODELS OF ENDOGENOUS AND EXOGENOUS INFLUENCE We assume that an activation of an user in an online social network is mediated by two influences (Fig 3): (i) endoge-FIGURE 3. Endogenous and exogenous influence. Our assumption is that information propagation in an online social network is mediated by two types of influence -endogenous (peer) which acts between the users of the social network and exogenous influence which is external to it. The estimated endogenous influence on the newly activated user i = 1 should be higher because more of his peers are already active, as compared to user i = 2. nous influence p peer which depends on the network structure and users that are already active or not, and (ii) exogenous influence p ext which is modeled as a time dependent random variable and is constant across all users. An additional assumption is that parameters of endogenous influence are constant throughout the period of observation, while parameters of exogenous influence may change in time. Both sets of parameters are equal for all users. This allows us to use a very simple model for the exogenous influence -a single probability of activation p ext (t) with a suitable closed form, we chose to evaluate it at each time step independently [39]. The benefit of such nonparametric estimate of exogenous influence is that it minimizes assumptions on the influence's functional form. For example, we do not have to explicitly incorporate decay of exogenous influence into our model as we will do with the endogenous influence later on (Eq 2), but our model is still able to infer this decay if it is supported by available data. An example of this is visible in the experiment in Fig 6. For the endogenous influence we choose two commonly used Independent Cascade (IC) models: (i) Susceptibleinfected (SI) model p EXP (t). IC models are an example of simple contagion -activation of users happens due to a direct influence of one of their peers, independently of the rest of the system, including the neighborhood structure and which other users are active or not. EXP model has an added condition that peers that activated recently carry more influence than the ones that activated farther away in time, which is commonly incorporated in endogenous influence models [43], [44]. Probability of endogenous activation for user i at time interval [tt, t] under the SI model is defined as follows: p (i) SI (t) = 1 - j<unk>N (i) active at t (1 -p 0 ) = 1 -(1 -p 0 ) a i (t) (1) where N (i) is a set of peers of user i, a i (t) designates how many of them are active at time t, and p 0 is a probability of user i's being activated by each of its peers. Assumption of the SI model is that probability of activating one's peers does not change in time, so once user is activated, every subsequent step he has the same probability p 0 of activating any of his peers. This assumption is more appropriate in epidemiological setting, from where SI model originated, than in information propagation setting where we would expect the influence to decay in time. This could be achieved by adding a parameter for influence decay, which leads us to the EXP model: p (i) EXP (t) = 1 - j<unk>N (i) active at t (1 -p 0 e -<unk>(t-t j ) ) (2 ) where t j is the time of activation of user j. p 0 and <unk> are parameters of endogenous influence which define the shape of exponential decay of influence, with p 0 being the probability of user j activating user i at time t = t j and <unk> being the half-decay of influence. Both SI and EXP models feature independent cascades -each individual user can independently activate any of his peers. However, in social contagion it is more realistic to add a requirement of multiple interactions for the activation. This effectively models social reinforcement mechanism which is a known driving force for product adoption [25]. One of the simplest examples of such complex contagion models is the threshold model where the probability of endogenous activation is related to the number of already active peers N (i) of user i. We define one such threshold model in the Eq S11 of the Supporting information and show that it can also be effectively incorporated into our inference methodology. We now define a likelihood function L which gives us probability of observing data D (network and activation times) at a particular time t given some functional forms for endogenous and exogenous influence p peer and p ext. Due to typically small probabilities involved in these processes we actually use log-likelihood for maximum likelihood estimation of parameters, where product of probabilities is replaced with the sum of log-probabilities: log L(D; p peer, p ext, t) = i<unk>activated at [t-t,t] log(1 -(1 -p (i) peer (t))(1 -p ext (t))) + c(t) i<unk>inactive at t log((1 -p (i) peer (t))(1 -p ext (t)))(3) First term on the right-hand side quantifies the agreement for the users that did activate in a given time period [t -, t], as this had to be due to either endogenous or exogenous influence. Second term quantifies the agreement for the users that did not activate up to time t, neither through endogenous nor through exogenous influence. The time enters our inference only through the activation time of users and is used in two ways -i) to determine which users were active or inactive in time window [tt, t] (Eq 3), and ii) to calculate endogenous influence decay in EXP model (Eq 2). However, in principle it is possible to use a temporal network where friendship connections between users change in time. This can be encoded into the expression for endogenous influence p peer, for example in equations for the SI and EXP models (Eq 1 and 2) by making N (i) -a set of peers of user i, a timechanging quantity. We can remove explicit dependence on time t from the Eq 3 by evaluating L nonparametricaly -at each time increment t. One issue still needs to be addressed -on which users does the exogenous influence actually acts? We know that our friendship network does not contain all possible users, and so the true number of yet inactive users is probably much larger than what we actually observe. This observer bias could lead to the overestimation of the exogenous influence as we approach the end of the activation cascade and the number of eventually observed inactive users decreases towards zero, while the true number of inactive users which could possibly activate (but do not during our observation period) stays large. We correct for this by artificially increasing the part of our log-likelihood which is responsible for inactive users by factor c(t) = 1 + <unk>(N all /N inactive (t)), where N all is the number of all users in the social network, and N inactive (t) the number of all yet users inactive users at time t (more details in Section S6 of Supporting information). --- B. ALTERNATING METHOD FOR INFERENCE Our two main assumptions during statistical inference are: (i) both endogenous and exogenous influence are equal for all users at any given time, and (ii) endogenous influence does not vary in time while exogenous influence does. This leads us to the inference algorithm where we seek a single set of parameters for the endogenous influence p peer and a set of parameters for the exogenous influence <unk>p ext <unk> t for each time step t. This would make the dimensionality of our loglikelihood proportional to the number of time steps we use for inference, which would be hard to optimize numerically. Instead, we use an alternating method [39] where we alternatively fix either p peer or <unk>p ext <unk> t and optimize for the other. Algorithm 1 gives the pseudocode of the alternating procedure for inference of endogenous p peer and exogenous <unk>p ext <unk> t influence that we use in our experiments. In the first part of the algorithm (steps 2-4) we optimize p peer and p ext for every time window separately, which then serve as initial values for the alternating procedure. Optimization procedure is designated with a generic MAP (Maximum A Posteriori) procedure which takes as arguments the parameters which are held fixed and outputs values of the remaining parameters so that the log-likelihood (Eq 3) is maximized. The actual MAP optimization is performed with a truncated Newton algorithm that is Hessian-free and uses conjugate gradients to iteratively compute parameter updates [45], although in principle any suitable optimization algorithm could be used. Second part of the algorithm is the actual alternating procedure (steps [5][6][7][8][9][10][11] where we first optimize for a single set of endogenous parameters p peer, conditioning on the exogenous parameters <unk>p ext <unk> t we obtained for each time window (step 6). We then optimize exogenous parameters for each window separately <unk>p ext <unk> t, conditioning on a single set of endogenous parameters p peer we obtained in the previous step (step 7). We then alternate between the step 6 and 7 until values for p peer and <unk>p ext <unk> t converge. The difference between the values for the current and previous iteration are calculated in steps 8 and 9 and the convergence itself is checked in step 5. --- C. INFERENCE OF ACTIVATION TYPES Because our model gives us probabilities for endogenous and exogenous activation for each user individually, we can use this information to estimate activation type for each of the users. For this we define a single measure of exogenous responsibility R (i) which quantifies to what degree is an activation of user i due to the exogenous (external) influence: R (i) (t) = p ext (t) p ext (t) + p (i) peer (t) (4 ) where t is the time of activation of user i. Values close to zero indicate dominating endogenous influence, and values close to one indicate dominating exogenous influence. An extreme value of zero is achieved for users who activated during time when there was no exogenous influence acting in the network. An extreme value of one is achieved for users who, at the time of their activation, did not have any active peers. Note that it is not possible for both p ext (t) and p (i) peer (t) to be 0, and consequently that the value of responsibility is undefined, because that would mean the activation of this user is evaluated as impossible by our model in Eq 3. In principle, we could also use pure activation probabilities p (i) peer or p (i) ext as measures of influence, but experiments on simulated data showed that exogenous responsibility is the most sensible (more details in Supporting information). --- D. INDIVIDUAL AND COLLECTIVE INFLUENCE OF USERS Our assumption is that each user is, to some extent, responsible for endogenous activation of all of his peers that activated after him. This influence extends beyond user's immediate peers. However, as we do not have a deterministic activation path (we do not know who shared information with whom) it is not straightforward to transitively incorporate influence from far away users as it is usually done [46]. This is why we express the influence I (i) of user i (Eq 5) as the extent to which user i is responsible for activation of his peers j: I (i) = j<unk>N (i) I (i<unk>j) m<unk>N (j) I (m<unk>j) p (j) peer (t j )(5) where I (i<unk>j) is the fraction of the endogenous influence that user i can claim for user j. In our case we define it as I (i<unk>j) = 1 if i and j are peers, and 0 otherwise. This means that all user's are credited equally for the activation of their peers, regardless of how far away in time they themselves activated. For an alternative formulation which involves time see Eq S8 in the Supporting information. As shown on Fig return p (i) peer, <unk>p (i) ext <unk> t The parameters of endogenous and exogenous influence. 13: end procedure FIGURE 4. Individual and collective influence. In this simple example we estimate influence I 1 of user i = 1 as the extent to which he is responsible for endogenous activation p (j ) peer of all of his peers j = <unk>3, 4, 5, 6, 7<unk> which activated after him. Only three of his peers j = <unk>4, 5, 7<unk> activated due to endogenous influence, but he has to share part of this claim with two users i = <unk>0, 2<unk> which are their shared peers. The total individual influence for user i = 1 in the above example is I 1 = 1/2 p (4) peer + 1/3 p (5) peer + p (7) peer. Type of activation (endogenous or exogenous) for each user can be estimated with our methodology or taken from raw data by using referral links from which users visited our application, in which case p just a potential for responsibility and so the user has to share part of his claim to I (i<unk>j) with all other m peers of j. For the SI model we can set this to 1, meaning that we consider all peers equally responsible regardless of the time of their activation. Each user would then be assigned 1/m of the peer activation probability p (j) peer for each of his peers that activated after him, where m is the number of user's j peers that activated before him. For the EXP model we can weight this with the times of activation -users can claim larger part of the influence for peers that activated close in time to their own activation (more details in Section S4 of the Supporting information). The collective influence for a group of users G is just an average influence of all users in the group 1/|G| i<unk>G I (i). --- E. EVALUATION Instead of using a single threshold for the exogenous responsibility to classify users into endogenously and exogenously activated we calculate the entire receiver operating characteristic (ROC) curve and associated area under the curve (AUC) score. This allows us to compare different endogenous influence models regardless of the chosen threshold. In order to calculate the ROC curve and AUC score we also need some sort of a gold standard label for each user, for which we use referral links available for sabor2015 and sabor2016 datasets. Depending on the referral link we classify users in one of the three categories: (i) strong endogenous influence for users whose referral link originates from a Facebook share, (ii) potential endogenous influence for users whose referral link originates from Facebook and (iii) strong exogenous influence for users whose referral link originates from an external web site. Users who do not have a referral link are considered as unknown. For the purpose of evaluation we consider users from category (i) as endogenously activated and users from category (iii) as exogenously activated. --- F. DATA COLLECTION Our online survey applications were actually web applications which used Facebook Graph API [47] for authentication of users. Some sort of user authentication was necessary to prevent multiple voting. Facebook Graph API allowed us to collect Facebook friendship relationship between users registered on our application. In addition, with referendum2013.hr we collected basic demographics information such as age and gender. With other three applications we used our own web server directly to collect referral links through which users visited our web application. In all applications we also collect exact registration times of all users. Users provided informed consent on two levels. First, initial web page of survey application displayed a disclaimer next to the registration button describing the type of data we collect and the purpose we intend to use it. This was visible to both registered and unregistered users, before any data was actually collected. Second, upon authorization with their Facebook credentials, but before any data was collected, users were presented with a link to both Facebook's Platform Policy and our own privacy policy, and were given an option to opt out from the survey. In addition, we also provided detailed terms of use, Frequently Asked Questions (FAQ) and privacy policy web pages which complied with the Facebook's Platform Policy [48], all of which were available to both registered and unregistered users. More details on the data we collected and the methodology of eliciting informed consent is available in Section S2 of the Supporting information. Facebook's Graphs API assigns application-specific ID's to each user, so it is not possible to associate users from different datasets. After they registered users were able to see summary voting statistics of their friends as well as for all registered users. These statistics were displayed after the user cast his vote in order to minimize the influence on his choice. We also provided an additional incentive to share the link to the application through Facebook and other social media by displaying to each user a number of users which registered to the application after following the referral link from their share, and comparing this to other users. Our data collection procedure complies with the Facebook Platform Policy [48] and was approved by the Ethics committee of the Faculty of Electrical Engineering and Computing, University of Zagreb. --- G. CODE AND DATA AVAILABILITY Due to Facebook's Platform Policy https://developers. facebook.com/policy regarding user's data privacy we are not allowed to publicly release any Facebook-derived data, including personal information and friendship relations between our users. Friendship networks, registration times and analysis code needed to reproduce the results of this paper are available upon a request after signing the data access agreement on https://goo.gl/forms/IxINFkeBSJpDuzRv2. The agreement states that the requester: (i) Will only use the dataset for the purpose of reproducing and validating the results of our study; (ii) Will not attempt to deanonymize the dataset or in any other way compromise the identity or privacy of users contained in it; and (iii) Will not further share, distribute, publish, or otherwise disseminate the dataset. This data access agreement complies with the Facebook Platform Policy. Facebook online survey applications through which we collected referendum2013 and sabor2015 datasets are available on public Github repositories: https://github.com/devArena/referendum2013.hr, and https://bitbucket.org/marin/sabor2015.hr. More information is available in Sections S1 and S2 of the Supporting information. --- IV. RESULTS AND DISCUSSION --- A. MAXIMUM LIKELIHOOD INFERENCE FOR ENDOGENOUS AND EXOGENOUS INFLUENCE We want to compute a single set of endogenous influence parameters for the whole period and a separate set of exogenous influence parameters for every time window. Our assumption is that endogenous influence parameters do not change over time, but that exogenous do. A direct way to do this is to perform a joint optimization of a log-likelihood that contains a single set of endogenous influence parameters and a separate set of exogenous influence parameters for each time window [t + t]. Our log-likelihood would then be t + 1-dimensional in the case of SI model, and t + 2-dimensional for the EXP modelt parameters of exogenous influence for each time window we are considering in our inference plus the parameters of endogenous influence (p 0 for SI model and (p 0, <unk>) for EXP model). This makes the number of parameters proportional to the number of time windows, which makes a joint optimization of log-likelihood unfeasible. Instead, we use an alternating method [39] described in Algorithm 1 where we alternatively fix either endogenous influence parameters or exogenous influence parameters and optimize the other until both values converge. In addition, we never optimize all of the t parameters of the exogenous influence jointly but do it one by one. This yields a nonparametric estimate for exogenous influence, meaning that we have a separate estimate of exogenous influence p ext (t) at each time step t. Although the number of parameters we have to infer is still proportional to the number of time windows we are considering in our inference, this strategy is much more efficient then joint inference and provides reliable estimates even though there is no formal guarantee that the estimates will actually converge. However, in our experiments we did not experience any problems with the convergence. Fig 5 shows the initialization step of the alternating procedure on a simple simulated activation cascade, where parameters for endogenous and exogenous influence are inferred separately for each time step t. Using efficient optimization routines allows our method to scale to networks of over 10000 users with resolution of 100 time steps. In our experiments we use a truncated Newton algorithm [45] for maximum likelihood estimation, although in principle any suitable optimization algorithm could be used (more details in Methods section). Total number of users activated due to endogenous and exogenous influence is calculated through the exogenous responsibility measure (Eq 4) which is derived from the inferred parameters and quantifies the extent to which is each user's activation is due to endogenous or exogenous influence. This estimate is normalized with the total number of user activations in a given time interval, which is an observable quantity. --- B. INFERENCE OF ENDOGENOUS AND EXOGENOUS INFLUENCE ON SIMULATED DATA Our simulations are designed to approximate, as well as possible, the conditions in which real data were collected. However, instead of using one of the empirical social networks which we collected, we decided to simulate on a configuration model of referendum2013 Facebook friendship network so that our results are reproducible using only a degree sequence. This technique is similar to generating a synthetic representation of a Facebook social network [49] with respect to compactness and anonymity. Configuration model of a network preserves the number of connections each user has, but these connections are permuted randomly across all users. This destroys mesoscale structures such as communities, but is still preferable to other permutation methods where FIGURE 5. Maximum likelihood inference of endogenous and exogenous influence. Plots of the normalized likelihood function (similar to Eq 3 which shows log-likelihood) at two distinct time steps in the simulated activation cascade using SI model for endogenous influence. SI model features only two parameters at each time step -parameter of endogenous influence p peer (p 0 in Eq 1) and a parameter of exogenous influence p ext. Shape of the likelihood function suggests that these two parameters are correlated as each provides part of the explanation for the observed data, and if one is weaker the other most compensate. Also, when we have more data (time 21) the shape of the log-likelihood function is more concentrated than when we have less (time 50), resulting in more confident estimates. In this simulation we are estimating parameters of endogenous and exogenous influence at each time step separately, which corresponds to the initialization stage of our actual inference procedure which we use on simulated (Section IV-B) and empirical (Section IV-C) data. In our full inference procedure we infer a single set of endogenous influence parameters for the whole observation period instead of having a separate estimate for each time step like in this example (more details in Section III-B). Here we are using a truncated Newton algorithm [45] for optimizing a log-likelihood function in order to obtain a maximum likelihood solution, although in practice any suitable optimization method could be used. either times of activation are permuted (destroying order of activity) or connections themselves are permuted between the users (destroying degree distribution by changing it to binomial) [50]. The simulation starts with a small number of active users and progresses in discrete steps following one of the endogenous influence models (Eq 1 and Eq 2). Fig 6 shows the results using the EXP model (Eq 2) for endogenous influence. At three distinct times we also simulate an exponentially decaying exogenous influence which acts equally on all inactive users. This resembles a typical situation when a distinct exogenous information source activates some of the users [51], which we also observe in our dataset (Fig 2). However, our methodology works equally well for other shapes of exogenous influence (Fig S8 and Fig S9 in the Supporting information). Using just the activation times of all users and their friendship network we are able to estimate the parameters of the assumed endogenous and exogenous influence models as well as the absolute number of users activated predominantly

Information propagation in online social networks is facilitated by two types of influence endogenous (peer) influence that acts between users of the social network and exogenous (external) that corresponds to various external mediators such as online news media. However, inference of these influences from data remains a challenge, especially when data on the activation of users is scarce. In this paper we propose a methodology that yields estimates of both endogenous and exogenous influence using only a social network structure and a single activation cascade. Our method exploits the statistical differences between the two types of influence -endogenous is dependent on the social network structure and current state of each user while exogenous is independent of these. We evaluate our methodology on simulated activation cascades as well as on cascades obtained from several large Facebook political survey applications. We show that our methodology is able to provide estimates of endogenous and exogenous influence in online social networks, characterize activation of each individual user as being endogenously or exogenously driven, and identify most influential groups of users.

obtain a maximum likelihood solution, although in practice any suitable optimization method could be used. either times of activation are permuted (destroying order of activity) or connections themselves are permuted between the users (destroying degree distribution by changing it to binomial) [50]. The simulation starts with a small number of active users and progresses in discrete steps following one of the endogenous influence models (Eq 1 and Eq 2). Fig 6 shows the results using the EXP model (Eq 2) for endogenous influence. At three distinct times we also simulate an exponentially decaying exogenous influence which acts equally on all inactive users. This resembles a typical situation when a distinct exogenous information source activates some of the users [51], which we also observe in our dataset (Fig 2). However, our methodology works equally well for other shapes of exogenous influence (Fig S8 and Fig S9 in the Supporting information). Using just the activation times of all users and their friendship network we are able to estimate the parameters of the assumed endogenous and exogenous influence models as well as the absolute number of users activated predominantly due to the one or the other. In addition, using a measure of exogenous responsibility (Eq 4) we are able to infer, for user, the extent to which endogenous or exogenous influence was responsible for activation. Instead of using a single threshold to classify users we calculated the whole receiver operating characteristic (ROC) curve and the corresponding area under the curve (AUC) score to evaluate the performance (Fig 6). We compare our method to a simple baseline commonly used in previous work [39], [52] where an activation is considered exogenous if activated user had no other active peers at the time of the activation. However, as more and more users becomes active, it becomes increasingly likely that a user is connected with at least one other active user by pure chance. This underestimates the number of users activated by exogenous influence and consequently underestimates overall exogenous influence. We obtain similar results (Fig S6 in the Supporting information) for the SI endogenous influence model and an additional threshold model we define in the Eq S11 of the Supporting information. The inference itself is fast and scales well to networks of over ten thousand users (Section S5 in the Supporting information). --- C. INFERENCE OF ENDOGENOUS AND EXOGENOUS INFLUENCE ON EMPIRICAL DATASETS In order to investigate social interactions between users of a large online social network we developed three online surveys that use Facebook API for collection of data. Surveys were related to three distinct political events in Croatia: 1) referendum2013.hr for referendum on definition of marriage, 2) sabor2015.hr for parliamentary elections in 2015, and 3) sabor2016.hr for parliamentary elections in 2016. 1 shows summary statistics for each of the datasets. The referral links provide information whether each user followed a link originating from a post on Facebook which indicates endogenous influence, or some external website reporting on our survey which indicates exogenous influence. We use this information to evaluate our estimates of endogenous and exogenous influence acting on users. More details on the datasets and the methodology of data collection is available in Section III-B and Sections S1 and S2 of the Supporting information. Fig 7 shows the results of applying our inference methodology to estimate the magnitude of endogenous and exogenous influence during these three activation cascades. In this experiment we use the EXP model as endogenous influence model because it performed best on average over all three empirical datasets, with and without correction for the observer bias. Inference on a simulated activation cascade. We use our methodology to infer which users activated due to endogenous or exogenous influence in a simulated activation cascade following exponential decay (EXP) endogenous influence model. In real world applications only total number of activated users (black line) is actually observed, along with the friendship network between users (Fig 6). We use a configuration model of referendum2013 social network to make our results reproducible even without the whole empirical network. We see that our measure is able to differentiate absolute numbers of endogenously and exogenously activated users throughout the whole cascade period and to correctly infer the parameters of endogenous influence -p peer and <unk>, and exogenous influence p ext (t ) for every time period t. We also infer activation type for each user individually by using the exogenous responsibility measure R (i ) (t ) (Eq 4) as shown on Fig 6 and achieve AUC of 0.93. We compare this with the baseline method where, instead of exogenous responsibility, we use number of active peers at the time of activation. A special case of this baseline is where we consider users without any active peers as exogenously activated, which is a baseline that we use in Fig 6. This baseline method underestimates the exogenously activated users towards the end of the observation period, which is due to the fact that more and more users are active and it is increasingly likely that at least one of the peers is active by chance alone. On As our methodology operates in discrete time (Eq 3) we discretized the activation times of users into 30 minutes time intervals to determine which users were active or inactive during each specific interval. Considering the duration of the data collection for each of the surveys, this corresponds to 333 time intervals for refer-endum2013 dataset, 327 intervals for sabor2015 dataset and 328 intervals for sabor2016 dataset. Each user that registered on one of the online survey application using his Facebook credentials is considered activated in the given time period. The referral link from which we visited the website of the survey application will be used as a proxy of endogenous and exogenous influence -referral links from Facebook are considered as endogenous and those from external websites as exogenous. We later use this information for evaluation of our methodology. We estimate magnitudes of endogenous and exogenous influence and characterize each user as being endogenously or exogenously activated. We use the AUC score to evaluate the predictive performance of our inferred model on sabor2015 and sabor2016 datasets for which we had data on referral links from which users visited our survey application. This served as a proxy for ground truth labels which we needed for calculating the AUC scores. The purpose of the model is to estimate the magnitude of endogenous and exogenous influence on each given user, given available data and provided that underlying assumptions of our statistical methodology are satisfied. Similar as in simulated experiments, we compare our methodology with a baseline method that simply estimates the number of exogenously activated users as all those who did not have any active peers at the time of their own activation, and again we observe that it underestimates the number of exogenously activated users, especially near the end of the observation period. Our estimates of endogenously activated users (Fig 7) closely resemble the true number of users activated by following another user's share, which is the strongest indication of endogenous influence we have. On the other hand, it might seem that our method overestimates exogenously activated users by declaring many of the users originating from Facebook as exogenously activated. However, relying on Facebook referrals alone is not a reliable proxy for endogenous activation, as many users might be activated through other means of indirect communication available through Facebook -by following an advertisement, or by directly visiting a Facebook page of the survey application. We observe that the magnitude of exogenous influence increases as we approach the end of the activation cascade period. This effect is due to the fact that we only observe the friendship network of users that eventually registered on our application, which is only a small subset of the whole Facebook network. However, one of our assumption is that exogenous influence acts uniformly on all users in the friendship network, not just the subset of them, and this manifests in the increased exogenous influence as the activation cascade approaches the size of the network. This observer bias can be corrected by adding a correction factor c to our log-likelihood function (Eq 3), which is regulated with parameter <unk>. The results of applying the correction term on the empirical data are shown on Fig 7, while more detailed experiments are available in Fig S5 of the Supporting information). However, because less and less users got activated near the end of the observation period this observer bias does not influence our final estimates by much. However, we still believe that correction is warranted and useful, especially for estimates near the end of the observation period, and in other use cases where observation period is shorter and observer bias might be more pronounced. For evaluation (Fig 7 ) we again calculate the corresponding AUC score which uses exogenous responsibility measure R (i) (t) (Eq 4) to classify users into endogenously and exogenously activated. The achieved AUC scores for our method (AUC our ) for sabor2015 and sabor2016 datasets are 0.76 and 0.82 respectively. This is higher than the baseline measure which uses number of active peers at the time of activation which achieves AUC scores (AUC base ) of 0.68 and 0.78 for the sabor2015 and sabor2016 datasets respectively. Using exponential decay model for endogenous influence allows us On the bottom panels we see the effect of correction for the observer bias (<unk> = 0.1) as compared to no correction (<unk> = 0) -it reduces the overestimate of exogenous influence near the end of the observation period. AUC scores for using exogenous responsibility as a measure for classifying users into endogenously and exogenously activated (AUC our ) for datasets where we have information on referral links for evaluation -sabor2015 and sabor2016, are 0.76 and 0.82 respectively. This is higher then those achieved with a baseline measure of number of active friends, which are 0.68 and 0.78 for sabor2015 and sabor2016 datasets respectively. A more direct comparison with the baseline is available in Fig S14 of the Supporting information. Facebook referrals alone are not discriminating enough as there are multiple possible ways by which Facebook users might reach our application, including visiting the webpage of our application directly or through an advertisement, both which are more similar to exogenous rather than endogenous influence. --- FIGURE 8. Comparison of influence estimates. Comparison of influence estimates obtained from our methodology and raw data for different groups of users -those activated due to endogenous (peer) influence, exogenous (external) influence and advertisements (ads). Ads are similar to exogenous influence as they are targeting large number of users independent of their friendship connections, but within the Facebook social network itself. to calculate the half-decay of endogenous influence which is 10.1 hours for the sabor2015 dataset. This value is consistent with what we could expect, as it means that endogenous influence diminishes to a fraction of a value in the span of a day or two and requires influx of new users to keep it sustained. --- D. COLLECTIVE INFLUENCE Once we characterized activation of each user as being endogenously or exogenously driven, we can estimate the extent to which each user contributed to the activation of its peers by excluding the portion of the influence attributed to exogenous factors. We do not have a deterministic propagation path for our activation cascade -we do not know who influenced whom directly, so we cannot deterministically incorporate influence of all users in a transitive manner [46]. Nevertheless, our measure of influence simply incorporates all possible endogenous propagation paths to estimate an influence for each user (Fig 4 and Eq 5). If we then average this influence over a group of users we get their collective influence. Instead of using our estimates of endogenous and exogenous activation for each user we could also estimate influence directly from data by using the referral links from which users visited our application. Fig 8 shows the comparison of our methodology with estimates of influence obtained from raw data for different groups of users that activated due to: endogenous factors, exogenous factors, advertisements. Our question was: Which channel of communication is the most influential, that is, recruits users with higher collective influence? The results of our experiments on two datasets for which we had data on referral links, shows no clear pattern of influence. Different groups of users are more influential depending on the dataset. However, regardless of the model of endogenous influence (SI or EXP) our estimates are robust and are proportional to the ones obtained from raw data. It is important to emphasize again that our methodology does not use any information on referral links or external influence whatsoever, but rather infers this from the dynamics of the user activations. More details is available in Section S4 of the Supporting information. --- V. CONCLUSION Unlike traditional survey methods where data is manually entered either by a respondent or experimenter [53], online social networks provide an opportunity to collect much larger amounts of data on user activity. However, due to their nature they provide challenges to experimental design [54]. Observational studies without explicit consent are regularly performed within companies for marketing purposes, which is regulated by company's privacy policy, and in some cases this research can be used for academic purposes [36]. Still, academic publication of such research could raise ethical concerns [2], [55]. On the other hand, conducting a study where explicit consent is mandatory heavily restricts the amount of data that can be collected, even when researchers have a direct access to the whole online social network and are in position to present their experiment automatically to the large number of users. For example, a study from Aral and Walker [56] on a sample of 1.3 million Facebook users managed to collect responses of only 7730 users. However, major publicized events such as elections and referendums can serve as catalyzers for mobilizing users. Users are usually willing to participate in a study if through it they receive an information or a service which they perceive as valuable and which could not be easily obtained in some other way. Despite inherent difficulties in collecting data, we decided to conduct several online surveys using our own web applications and Facebook's API, which allowed us to collect activation cascades and friendship connections of over 20 thousand users in total. Although computational social science is in its infancy, with standards and practices still taking shape, we tried to keep the privacy of the users and follow current recommended ethical practices [9], [10]. Conducting a survey through an online social network means that the recruitment happens organically from person to person as a form of snowball sampling and not through some unbiased randomized procedure, so it's the most eager persons that are recruited first. Number of mobilized users mostly depends on highly connected and willing individuals, that mobilize less wiling users. This effect might easily dominate the one from mass media [57]. Using this data we demonstrate how to estimate exogenous and endogenous influence using only information on the friendship connections between users and a single activation cascade which corresponds to the times of user registration. Our methodology exploits the different ways of how exogenous and endogenous influence propagate -endogenous influence propagates between users and as such is dependent on the friendship structure, while exogenous influence acts uniformly on all users regardless of the social network structure. Our method is not able to reconstruct an exact propagation pathway, as these inevitably include pathways external to the particular online social network as well as pathways that are inherently unobservable such as word-of-mouth communication. Still, our method is able to give a probabilistic estimates of these two influences given minimal assumptions. Any additional information on the activation cascade or the social network could be included in our methodology, most probably along the lines of the unified model of social influence [22]. The advantage of such likelihood-based approaches is that inference is performed in a probabilistically-consistent manner, instead of relying on aggregated statistics to choose among competing models of influence [58]. The availability of efficient numerical solvers means our method can easily scale to large networks of over 10000 users. Computational scalability was already addressed for the unified model [59], however, only for the modeling and not for inference. Our methodology could be applied for characterizing the types of influence in information spreading, for example the role of external factors in the fake news spreading occurring over online social networks such as Facebook or Twitter [60]. Also, there might also be applications outside the domain of social networks as the paradigm of endogenous and exogenous effects could be applied in the wider context of dynamical systems modeling [38]. Our methodology suffers from several limitations, which also indicate potential paths for future research. First, we do not elucidate the mechanisms by which endogenous and exogenous influence arise. The form of the endogenous influence is predefined, and choosing between several possible candidates is possible. In our case, we evaluate different endogenous influence models by their prediction on empirical data, but other methods are possible, including information-theoretic approaches. Second, we assume exogenous influence acts equally on all users, and that parameters of endogenous influence are equal for all users. This was necessary in our case because we only have one activation cascade available for inference [40], and without imposing additional constraints our statistical inference would be infeasible [61], [62]. In cases where multiple activation cascades are available, it should be possible to relax these assumptions and allow for different values of endogenous and exogenous influence parameters for various groups of users. Third, we do not try to correct for the confounding effect arising from unobserved or observed characteristics of users. For example, it is expected that users respond differently to influences, both exogenous and endogenous, from entities that share their political orientation as compared to those that do not. Again, including additional parameters in our model would increase the uncertainty of our estimates. Fourth, we assume friendship connections do not change during the activation cascade. In our case this is justified as the duration of our information cascade is relatively short, only a week, during which we do not expect many changes in friendship connections. For longer observation periods it might be necessary to introduce a possibility of changing friendship connections, which can be incorporated into our model by introducing time-changing quantity N (i) (t) -a set of peers of user i in a particular time step t, in equations for endogenous influence (Eq 1 and 2). --- ACKNOWLEDGMENT We would like to thank the people with whom we had fruitful discussions and who helped in various stages of manuscript preparation and experimental design: Nino Antulov-Fantulin, Vinko Zlati<unk> and Sebastian Krausse. Also, we greatly appreciate the effort of people who actively collaborated in the development of the Facebook online survey applications with which we collected the data: Bruno Rahle, Iva Miholi<unk>, Tomislav Lipi<unk>, Vedran Ivanac, Matej Mihel<unk>i<unk> and Mladen Marinovi<unk>. --- degree. He is also a Research Associate with the Laboratory for Machine Learning and Knowledge Representation, Rudjer Boskovic Institute, Zagreb, and is a member of the Centre of Excellence Project ''DATACROSS''. His main research interests are in the field of machine learning and complex systems, with special emphasis on inference of dynamical processes on social networks. He is also interested in building web services related to data analysis and visualization. TOMISLAV <unk>MUC received the Ph.D. degree. He was a Mentor of a dozen of master's and Ph.D. degrees students with the University of Zagreb, involved in organization of international conferences (ECML-PKDD, Discovery Science) on several occasions. He is currently a the Head of the Laboratory for Machine Learning and Knowledge Representation, at Rudjer Boskovic Institute, Zagreb. He has published more than 100 articles in journals and proceedings of international conferences. His research interests are in the area of artificial intelligence, in development and use of machine learning, and data mining techniques for knowledge discovery in different domains of science and technology, for last twenty years. In this period, he has been participating in, or leading, a number of research projects financed by Croatian, European, and other international funding agencies. He is an Evaluator for several research funding agencies. He also serves as a reviewer for a number of scientific journals in the fields of computer science, computational biology, and interdisciplinary science. MILE <unk>IKI<unk> received the Ph.D. degree in computer science from the University of Zagreb, in 2008. For the first seven years of his career, he was a System Integrator, Consultant, and Project Manager on the projects with industry in the fields of computer and mobile networks. In 2009, he became an Assistant Professor of computer science. He is currently a Professor with the Faculty of Electrical Engineering and Computing, University of Zagreb, Croatia. He is also spending his sabbatical year with the Genome Institute of Singapore. His scientific work is focused on the development of new algorithms and machine learning methods for genome sequence analysis and analysis of dynamics in networks.

Information propagation in online social networks is facilitated by two types of influence endogenous (peer) influence that acts between users of the social network and exogenous (external) that corresponds to various external mediators such as online news media. However, inference of these influences from data remains a challenge, especially when data on the activation of users is scarce. In this paper we propose a methodology that yields estimates of both endogenous and exogenous influence using only a social network structure and a single activation cascade. Our method exploits the statistical differences between the two types of influence -endogenous is dependent on the social network structure and current state of each user while exogenous is independent of these. We evaluate our methodology on simulated activation cascades as well as on cascades obtained from several large Facebook political survey applications. We show that our methodology is able to provide estimates of endogenous and exogenous influence in online social networks, characterize activation of each individual user as being endogenously or exogenously driven, and identify most influential groups of users.

Introduction According to the definition given by the dictionary, parenting style is "a constellation of parents' attitudes and behaviors toward children and an emotional climate in which the parents' behaviors are expressed" [1]. Parenting is universally important in shaping child and adolescent well-being. Research consistently shows that parenting practices and styles are linked to the behavioral and emotional development of adolescents [2]. The importance of parenting arises from its role as a buffer against poverty and delinquent influences, and a mediator of damage [3]. Diana Baumrind divided parenting styles into three typologies: authoritative, authoritarian, and permissive. These were categorized based on two dimensions of parenting behavior and style: (1) demandingness (parent control and demand) and ( 2) responsiveness (parent acceptance of developmental needs) [4]. Authoritative parents have high expectations for achievements, but they are also warm and responsive. Authoritarian parents have a high level of parental control and only allow one-way communication. These parents often imply harsh punishment as a way to control children's behavior, and they are not responsive to their children's needs. On the contrary, permissive parents set very few rules and boundaries. These parents are warm and have high engagement with their children's needs [5,6]. Socioeconomic status is a multifactorial variable that plays a primary role in learning and developing a foundation for child well-being and positive lifelong behaviors [7,8]. Socioeconomic status directly and indirectly influences the young child's cognitive, language, social, physical, and emotional development [9]. Diana Baumrind identified those three main styles in the 1960s. Later on, a fourth type of parenting style, "neglectful style," was added in the 1980s by Eleanor Maccoby and John Martin [10]. In this study, we focused only on Diana Baumrind's three main styles (authoritative, authoritarian, and permissive); the neglectful parenting style will not be discussed [4]. Our main call in this study was to estimate each parenting style frequency among adolescent children's parents as per Diana Baumrind's classification [4] and determine the relationship between the sociodemographic characteristics of the participants and parenting styles. --- Materials And Methods --- Study design, setting, and population This was a descriptive cross-sectional facility-based study conducted among adolescents' parents in Buraidah City, Qassim, Saudi Arabia. The Saudi parents who participated in this study were selected randomly from 40 primary healthcare centers (PHCCs) in Buraidah City. Out of 570 distributed forms, 549 responded. Fifty-three forms were excluded as they did not meet our inclusion criteria, which were Saudi parents, living in Buraidah City, and voluntary participation. Four hundred ninety-six were suitable for analysis, giving a response rate of 90.3%. --- Sampling and data collection procedure Data was collected using a pre-tested questionnaire consisting of two parts. The first part addressed the study participants' demographic and family socioeconomic status. The second part of the questionnaire measured the use of the participants' parenting styles according to the Parenting Style Dimension Questionnaire (PSDQ) [11][12][13] based on Baumrind's parent typology: authoritative, authoritarian, and permissive [14]. Parents were asked to rank the occurrence of each statement from 1 to 5 as follows: 1 = never, 2 = once in a while, 3 = about half the time, 4 = very often, and 5 = always. The rank from 1 to 5 displayed how often parents exhibited the behaviors mentioned in each question. As we could not retrieve the original forms, nor an Arabic translation, the questionnaire was retrieved from an open source [13] and translated by the principal investigator. A copy of the used questionnaire is presented in the Appendices section. The principal investigator and data collectors collected the data from parents who were voluntarily willing to participate in this study. They were directed to help participants with low literacy levels to complete the questionnaire and supervise independent participants. Data collectors waited for eligible attendees with the receptionist. They frequently alternated between male and female sections to collect the study sample equally. They conveniently approached adult attendees, inquired whether they have adolescent children, and invited them to voluntarily participate in the study by completing the study questionnaire. Participants were given a hard copy or a direct link to the questionnaire as per their preference. Data collectors supported study participants as per their needs. Participants completed the questionnaire with simple or partial supervision or had to rely on data collectors if they faced major difficulties. --- Data analysis Data were analyzed using the Epi Info software version 7.2.5 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Frequency tables and percentages were presented for categorical variables, including parenting style. Mean and standard deviation or median and quartile range were used for numerical variables and the final score. The overall score of the Parenting Style Dimension Questionnaire (PSDQ) was used to identify the parenting style of each participant. Parents were categorized into one of the three parenting styles. We collected the overall mean score for each parenting style category and took the highest score as it determined the dominant parenting style of the parent. To identify the dominant style while having a different number of items for each style, we divided the total score for each item by its number of items. Authoritative and authoritarian style sores were divided by 13, while the permissive style score was divided by 4. For each participant, different parenting styles composed a total of 100. The largest segment determines the dominant style for every given participant. Parenting style proportions were plotted in a pie chart expressing their frequency as the dominant style. The chi-square test was used to compare final scores for categorical variables, while Mann-Whitney or Kruskal-Wallis tests were used to compare medians, as appropriate. --- Ethical considerations The study proposal was reviewed and approved by Qassim Regional Bioethics Committee (approval number: 1442-2185738). Permission for data collection was also taken from Primary Health Care Director Buraidah. Informed consent was obtained from all the participants. The confidentiality of the participants was ensured at all stages of the research. --- Results Out of 496 respondents, there were 250 (50.4%) males, and the mean age of the participants was 36.7 (+10.6) years. Most of them (454, 91.5%) were currently married. The majority of Saudi parents had secondary and high school education (257, 51.81%). The median number of participants' children was two. One-quarter of parents have only one child, and another quarter of parents have more than three children. Around half of the participants were living in apartments (240, 48.4%), followed by villas (158, 31.9%), and the majority of the families (343, 69.2%) owned houses. The median number of household inhabitants was five, ranging from two to 14 members. Nuclear family was the most frequently reported type of family (390, 78.6%). However, 46 (8.3%) were extended families. The majority of our participants and their partners were currently working (360 (72.6%) and 314 (63.3%), respectively). The husband's income was the main source of family income (358, 72.2%); however, in around one-quarter of families, the wife does participate in family earnings. Around one-quarter of husbands had a monthly income of 7,000 Saudi Arabian Riyals (SAR) or less, and only 66 (13.3%) had more than 15,000 SAR, while around half of wives had no income at all. Only 69 (13.9%) of our participants had other income resources, mostly from private businesses (Table 1). The most common parenting style used among the study population was authoritative (380, 76.6%), followed by authoritarian (62, 12.5%), while only 54 (10.9%) used the permissive style (Figure 1). --- Item --- FIGURE 1: Frequency of parenting styles based on Baumrind's classification (n=496) Table 2 shows the comparison of each style frequency with respect to the sociodemographic characteristics of the participants. There was no statistical difference in parenting style with respect to gender, education level, occupation, or family type. There were no parenting style differences based on income contribution from spouses (P=0.23). However, the husband's income was significantly associated with parenting style. The husband's income of more than 10,000 SAR was associated with authoritative style (P=0.012). Those who lived in traditional houses had less authoritative style frequency than those who lived in other housing types (59.4% and 79.2%) (P=0.002). There was a small but significant difference between the mean age of each dominant parenting style: authoritarian, 34.5 (<unk>10.9); authoritative, 37.5 (<unk>10.2); and permissive, 33.7 (<unk>12.0) (P=0.01). At the same time, there was no difference in the median number of participants' children for each parenting style as each group had a median of two (P=0.388). Similarly, the median for household members was quite similar, 4, 5, and 4, for authoritarian, authoritative, and permissive, respectively, and the difference was statistically significant (P=0.014) (Table 2). --- Item --- Discussion In this study, the authoritative parenting style was found to be the most commonly used style among participating families. This finding matched four previous studies that described a similar observation [11,[14][15][16].On the contrary, one of the previous studies done in a junior high school in Surabaya in 2018 found that authoritarian was the most widely applied parenting style according to the perception of adolescents (49.9%). Permissive was the least applied parenting style (12.2%) [17]. Another study done in the USA revealed that the permissive style was the dominant parenting style [18]. In our study, the percentage of male gender regarding authoritative parenting style was slightly higher than females; this could be due to the Eastern community culture as the father usually is the head of the family [18]. Inconsistently, in another study conducted on Middle Eastern parents by Dwairy et al. [14], the percentage of females who had an authoritative parenting style was higher than males. Moreover, the study revealed that the authoritarian parenting style came in second rank among other parenting types, and the percentage of female parents who used the authoritarian style was slightly higher than males. These findings were inconsistent with the results from two previous studies conducted in the USA and Middle East countries, in which the percentage of female parents was lower than males [14,18]. Similarly, our study found that the least used style was the permissive parenting style as in previous studies [1,11,15]. Female parents used this style more than male parents. Additionally, a study done in 2019 among parents living in the Western suburbs of Limassol in Cyprus found that an authoritarian parenting style was more common in fathers than in mothers. Also, older parents were more authoritative than younger parents. Younger parents have a more permissive parenting style [19]. The objective of this study was to test the influence of sociodemographic characteristics of the study participants on their parenting styles. We did not find any statistical association between gender type, education level, occupation, or family type and parenting style. However, a significant statistical relationship was found between the effect of the husband's income and authoritative parenting style; this finding was inconsistent with the results of the study by Dwairy et al. [14], where the economic level was positively correlated with the permissive style. Another study conducted by Hadjicharalambous and Demetriou [19] found that mothers with low income were more authoritarian than fathers with low income. There are some limitations that should be considered while interpreting the findings of this study. We cannot generalize the results of the study to other communities since the study population was mostly from middle or high social classes and was selected from one city only. Convenience sampling used in the methodology disrupted the representation of study participants to the general population. The collection of data using a self-administrated questionnaire may affect the quality of the data obtained from illiterate parents compared to the quality of data from educated parents. However, the data collectors explained the questions to illiterate parents to minimize this bias. There is a possibility of social desirability bias. However, we assume it to be of less importance as the data was collected without personal identification and judgment. --- Conclusions This study highlighted the parenting styles used by parents in the Qassim region of Saudi Arabia. The authoritative parenting style was the dominant type among younger parents. Statistically, no factors affected the parents' style except family size and husbands' income, which shows a significant statistical correlation. This can be due to the local culture where fathers were usually supporting and heading their families. It is important to develop a policy and parenting education program to provide the necessary skills and abilities for parents to deal with their children. --- Appendices --- • Written informed consent was obtained individually from every participant after clearly mentioning the objectives, risks, and benefits of the study. 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: Payment/services 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.

Three parenting styles still form the foundation for today's research into childhood development. The natural mode of parenting falls somewhere among Baumrind's parenting styles (authoritative, authoritarian, and permissive). Due to the lack of research that integrates the relationship between parenting styles and socioeconomic status in Saudi Arabia, we decided to study different types of parenting styles and their relationship with sociodemographic status.This study aimed to estimate the frequency of parenting styles among adolescent children's parents in Buraidah City, Qassim, during the year 2021.A descriptive cross-sectional community-based study was conducted among 496 parents. A structured questionnaire was used to collect data. The Parenting Style Dimension Questionnaire (PSDQ) was used to identify the parenting style of each participant. Data were analyzed using the Epi Info software version 7.2.5 (Centers for Disease Control and Prevention, Atlanta, GA, USA).Among the surveyed parents, there were 250 (50.4%) males, and the mean age was 36.7 (±10.6) years. The majority (390, 78.6%) live in a nuclear family with a family size ranging from four to six members (285, 57.5%). A total of 451 (90.9%) parents were educated in secondary school and above. In this study, the common parenting style was the authoritative style (380, 76.6%). The two sociodemographic factors found to be statistically correlated with authoritative style were big family size (P=0.014) and the husband's income (P=0.012).The study revealed that the authoritative parenting style was the dominant type among younger parents. However, no factors affect the parents' style except family size and the husband's income. It is important to develop parenting education programs to provide parents with the necessary skills and abilities to deal with their children.

Introduction Countryside, as an important carrier of Chinese culture and history, has long played an indispensable role in the country's economic, cultural and social development. But in recent years, faced with problems such as brain drain, cultural forgetting and lagging economic development, rural revitalization has become an important part of the national strategy. Rural talents are the key force to promote rural revitalization, and how to train and retain these talents has become the core issue of rural revitalization. At the same time, intangible cultural heritage -referred to as "intangible cultural heritage" -as the cultural essence of the Chinese nation, is also facing the risk of being forgotten and lost. Therefore, intangible cultural heritage education and rural talent training have become the two major focuses of rural development at present. However, in practice, intangible cultural heritage education and rural talent training are often separated and lack of effective combination between them. And Party building, especially the construction of grassroots party organizations, provides an effective combination point for the two major priorities. Through party building, intangible cultural heritage education and rural talent training can promote each other and jointly promote rural revitalization. In this context, this paper puts forward a new perspective, that is, the integration of intangible cultural heritage education with ideology and politics, to explore how party building can help the revitalization of rural talents. We believe that intangible cultural heritage education is not only a tool for inheriting culture, but also a way of ideological and political education. Through intangible cultural heritage education, rural talents can better understand and accept the Party's ideology, thus becoming a strong force for rural revitalization. Intangible cultural heritage, as the essence of Chinese culture, is the core of rural culture. If intangible cultural heritage education can be effectively combined with ideological and political education, it can not only cultivate rural talents with red genes, but also provide strong cultural support for the long-term development of rural areas. In addition, the role of party building in rural areas is not only to organize and lead, but also to guide values. In the cultivation of rural talents, Party building can provide the right value orientation for talents and make them more determined to work for rural revitalization. At the same time, in intangible cultural heritage education, Party building can ensure that the inheritance of intangible cultural heritage is positive and beneficial, and avoid the intangible cultural heritage being distorted or distorted. To sum up, the integration of intangible cultural heritage education with ideology and politics, and the revitalization of rural talents through party building are important directions for current rural development. From this perspective, this paper will conduct an in-depth discussion on relevant issues to provide theoretical support for rural revitalization. --- The status quo and value of intangible cultural heritage education Intangible cultural heritage, or "intangible cultural heritage", represents a nation's history, culture and tradition. Under the influence of globalization and modern lifestyle, these traditional cultures are gradually facing the crisis of being marginalized or even disappearing. Therefore, intangible cultural heritage education has gradually become the main method to save and pass on these valuable cultural heritages. The Chinese government has attached great importance to the protection and inheritance of intangible cultural heritage in recent years. From the central government to local governments, a series of policies and measures have been introduced to promote the inheritance and development of intangible cultural heritage. The Ministry of Education works closely with the Ministry of Culture and other institutions to incorporate intangible cultural heritage knowledge and practices into school education, so that generations of students can understand and value their cultural heritage [1]. However, despite the remarkable results that have been achieved, intangible cultural heritage education still faces some challenges in practice. For example, the deep cultural value of intangible cultural heritage is still relatively shallow in some regions; For some important intangible cultural heritage projects, it is difficult to get long-term and systematic education promotion due to the shortage of resources; And the combination of intangible cultural heritage and modern education, etc., are all issues that need to be discussed and solved in depth. The value of intangible cultural heritage education is multi-layered. First of all, non-heritage works are the cultural genes of a nation, which contain rich historical and cultural memory. Through intangible cultural heritage education, these valuable cultural heritages can be passed on continuously and will not be forgotten by time. Secondly, the philosophical thoughts and life wisdom contained in intangible cultural heritage provide students with valuable thinking and inspiration, helping them to form solid values. For rural students, through understanding and learning intangible cultural heritage, they can establish a deeper emotional connection with their hometown, which is of great significance for the cultivation and retention of rural talents. In addition, although intangible cultural heritage is traditional, it is not isolated or closed. Studying intangible cultural heritage not only gives students a deep understanding of tradition, but also inspires them to combine tradition with modernity and find new paths for developing innovation in the future. In general, the value of intangible cultural heritage education lies not only in the inheritance of traditional culture, but also in the positive role it plays in the cultivation of rural talents [2], rural revitalization and future development. --- The relationship between party building and rural talent revitalization As a long-term strategic task, Party building has a far-reaching impact on the country's politics, economy, culture and other aspects. Rural revitalization is an important strategy in the new era. Its core goals are agricultural modernization, rural beauty and rural prosperity. In this context, talent has become a key driving force. To this end, we will delve into the intrinsic connection between party building and the revitalization of rural talents. Party building ensures the correctness of the strategy and direction of rural revitalization. Rural revitalization involves not only the economic level, but also cultural, educational, ecological and other dimensions. In this process, the Party's organizational strength and policy guidance have ensured that rural revitalization has always moved in the right direction. For example, in the face of some poor areas with backward infrastructure, party building helps formulate key development strategies and ensure the rational allocation of resources [3]. At the same time, Party building is also deeply involved in the cultural and ideological construction of the countryside, focusing on cultivating correct values and world views, thus promoting the harmony and stability of rural society. Furthermore, Party building has also played an important role in the cultivation and retention of rural talents. Through various forms such as training courses and study groups, Party organizations provide rural residents with the opportunity to study and further their education, so as to improve their cultural quality and professional skills and build a talent pool for rural development. At the same time, facing the problem of brain drain in rural areas, the Party has created a more livable and developing environment for rural talents through a series of policy measures, including preferential policies, financial support and project cooperation. Combined with improved infrastructure, rich cultural activities and quality public services, this has enhanced the attractiveness of rural areas and encouraged the return of rural talents. More core, the values and beliefs advocated by the party building have provided a strong spiritual pillar for rural talents. When they believe that their efforts have been affirmed by the Party and society and supported by the broad masses of the people, they will be more determined to devote themselves to rural construction and make greater contributions to rural revitalization. In general, there is a natural connection between party building and the revitalization of rural talents. Strengthening the party building work can undoubtedly better promote the cultivation and retention of rural talents, and then inject strong impetus into the overall revitalization of rural areas [4]. --- Frontiers in --- The importance of intangible cultural heritage education and ideological and political integration Rural revitalization is not only a matter of economy and technology, but at a deeper level, it is a matter of culture and values. Rural revitalization needs talents with deep cultural heritage and the support of red genes. This is exactly what the integration of intangible cultural heritage education and ideological and political education can provide. Intangible cultural heritage education emphasizes the traditional culture and history of the Chinese nation, which covers our customs, crafts, arts, customs and so on. It is the root and soul of the Chinese nation as well as the cultural basis for rural revitalization. Ideological and political education, from a larger perspective, provides us with an interpretation of the country, society and history. It is our belief and direction. When the two are integrated, what we get is a rural talent with deep cultural heritage and firm beliefs and values. They can not only cherish and pass on our traditions, but also be clear about their own historical mission and future direction. First of all, what rural talents learn in intangible cultural heritage education is to respect and identify with tradition. They understand that no matter how The Times develop, we should never forget our roots. This respect and recognition of tradition makes them cherish every inch of land and every tradition in the countryside more. In ideological and political education, rural talents also learn a firm belief in the Party and the country. They understand that it is precisely because of the leadership of the Party that our country can stand up from poverty and weakness and go to such a height today. This faith and loyalty makes them all the more determined to work for rural revitalization. More importantly, the integration of intangible cultural heritage education and ideological and political education also provides a more open and inclusive way of thinking for rural talents. They have learned to respect tradition while daring to innovate and change; And the ability to think independently and critically while holding firm to their beliefs. To sum up, the importance of intangible cultural heritage education and ideological and political integration is self-evident. Only through this integration can we cultivate rural talents with real red genes, deep cultural accumulation and high comprehensive quality, so as to provide solid support for the comprehensive revitalization of the countryside [5]. --- The strategy of Party building assisting intangible cultural heritage education to promote the revitalization of rural talents --- Strengthen the ideological and political curriculum integration of intangible cultural heritage resources In the cultivation of rural talents, the integration of intangible cultural heritage resources and ideological and political education is the key. Intangible cultural heritage is the root and soul of a nation, while ideological and political education is the thought and action orientation of rural talents. In order to realize the organic combination of the two, the strategy should pay attention to the integration of intangible cultural heritage resources in the ideological and political curriculum, combine the core values of traditional culture with the core values of socialism, and form a distinctive ideological and political education content. This requires the cooperation of education departments, intangible cultural heritage protection institutions and party organizations at all levels to sort out the ideological and political elements in intangible cultural heritage resources, formulate corresponding courses and textbooks, and combine them with practical activities, such as visits and field trips, so that rural talents can deepen their understanding of intangible cultural heritage and ideological and political theories in their actual experience. Known as a "living epic", the Yao ethnic group's Grand Song is a true portrayal of their history, culture and life. In a village school, educators combined ideological and political courses to introduce the Yao Songs into the teaching. In the course of teaching, experts first introduced the historical background, cultural connotation and artistic characteristics of the Song to students in detail. Then, some passages in the song correspond to socialist core values, so that students can realize that although the song comes from ancient traditional culture, the values of justice, harmony and patriotism conveyed by the song are highly consistent with contemporary socialist core values. In addition, the school also organized students to go to the Yao inhabited areas to communicate with local residents and experience the singing and learning of the Yao songs on the spot. Such practical activities make students more deeply feel the charm and depth of the intangible cultural heritage, and also make them more firmly believe in the core socialist values. Frontiers in Educational Research ISSN 2522-6398 Vol. 6, Issue 19: 67-71, DOI: 10.25236/FER.2023.061912 Published by Francis Academic Press, UK -70- --- The deep cooperation between rural cultural inheritors and ideological and political educators has been steadily promoted In order to combine intangible cultural heritage education with ideological and political education, the key is to realize deep exchanges and cooperation between rural cultural inheritors and ideological and political educators. Strategically, we can consider establishing a long-term and systematic training and exchange platform, so that cultural inheritors can understand the importance of modern ideological and political education, and ideological and political educators can have a deep understanding of rural culture and tradition. Through regular seminars, workshops and field trips, the two sides can learn from each other and exchange ideas. Further, a teaching model of "two teachers in one" can be considered, in which a rural cultural inheritor and an ideological and political educator jointly teach, so that intangible cultural heritage content and ideological and political theory can be integrated into one, providing students with a three-dimensional and rich learning experience. In a mountainous county town, the local Party committee and the education bureau jointly launched a "red intangible cultural heritage" education project. The project invited famous local handicraft inheritors and middle school teachers with rich experience in ideological and political teaching. In the teaching, the handicraft inheritors first introduced the unique local handicraft skills and the cultural traditions behind them to the students. Then, the ideological and political teachers combined these cultural contents to explain the history of the Party, the heroic deeds of revolutionary martyrs and the core values of socialism, so that students can understand the deep red genes behind these traditional cultures. The program has been well received by students and their parents. Many students said that through this teaching method, they not only learned about the local intangible cultural heritage, but also deepened their understanding of the Party's history and theory, and their feelings for the Party became firmer in their hearts. --- The construction of a digital intangible cultural heritage education resource bank in rural areas helps the innovation and popularization of ideological and political education With the increasing development of digital technology, rural education should also keep pace with The Times, and use digital means to contribute to the integration of intangible cultural heritage and ideological and political education. Strategically, education departments at all levels and intangible cultural heritage protection institutions should join forces to build a rural digital intangible cultural heritage education resource bank. This resource bank not only collects all kinds of intangible cultural materials, such as video, audio, text, pictures, etc., but also combines ideological and political content to form a complete teaching module. The digital resource library allows rural educators and students to study and explore anytime and anywhere, and it is more convenient to combine intangible cultural heritage with ideological and political education, providing a richer and three-dimensional teaching experience. Huashan rock paintings, as a precious heritage of ancient Chinese civilization, have rich historical and cultural value. An education department in a certain place, in cooperation with the intangible cultural heritage protection institution, has incorporated them into the digital intangible cultural heritage education resource bank, and integrated them with the ideological and political education content. During the teaching, educators first show students the spectacular scenes and details of Huashan rock paintings through high-definition video materials. Then, combined with the content of the rock paintings, they explained the excellent traditional culture and historical process of the Chinese nation. Finally, ideological and political educators combine with the rock paintings to derive ideological and political theories such as loyalty to the Party and the country and pride of the nation from the rock paintings. Through this digital teaching method, students can not only get close contact with the precious intangible cultural heritage, but also deepen their understanding of the Party's history and ideological and political theory in the study, so as to realize the perfect combination of intangible cultural heritage and ideological and political theory. --- Conclusion In the great journey of building a socialist modern country in an all-round way, the rural revitalization strategy is undoubtedly an important part of it. Behind this strategy, the role of talents has been highlighted, and the deep integration of intangible heritage education and ideological and political education has laid a solid foundation for the cultivation of rural talents. This paper deeply discusses the Published by Francis Academic Press, UK -71-close relationship between party building and the revitalization of rural talents. Through the Party's strong organizational ability and policy orientation, rural revitalization has always been able to move steadily in the right direction. At the same time, the integration of intangible cultural heritage education and ideological and political education not only enriches the connotation of rural culture, but also injects red genes into the cultivation of rural talents and improves their comprehensive quality. Several strategic practices, such as the curriculum setting of local intangible cultural education combined with ideological and political education, and the construction of rural digital intangible cultural education resource bank, have provided strong support for rural revitalization. Practical examples prove the effectiveness and prospect of these strategies. Looking back, the Party has always been the most solid backing for rural China, and today's rural revitalization is also inseparable from the Party's leadership. Looking into the future, we have reason to believe that with the further integration of intangible cultural heritage education and ideological and political education, the quality and quantity of rural talents will usher in a new leap forward, and the goal of rural revitalization will be realized step by step.

With the deepening of the rural revitalization strategy, the education of intangible cultural heritage (referred to as "intangible cultural heritage") has been paid more and more attention. From the perspective of intangible cultural heritage education and ideological and political integration, this paper discusses how Party building can help the revitalization of rural talents. Firstly, we analyze the status quo of intangible cultural heritage education in rural areas and its value to rural talents, highlighting its important role in cultivating rural talents, inheriting culture and improving the effect of ideological and political education.

Introduction Currently, economies around the world are being challenged by massive asymmetric shocks generated by the COVID-19 outbreak, even though its symmetric character is well recognized in the literature in the field [1]. Due to the high degree of existing interdependencies between countries, mediated through the flow of goods, services, technologies, people, and ideas, the negative effects of this critical public health emergency have spread at an unimaginable speed. The responses of various countries have been aligned with a multitude of information disseminated by institutions and governments, using both traditional methods of communication, as well as the new, revolutionary channel of social networks. Previous articles in this area have recognized the powerful role social media plays in sharing and obtaining information, especially during the COVID-19 pandemic [2]. Moreover, social networking sites (SNSs) have become extremely popular, not only during critical global situations but also more broadly, due to their general communication features that allow both online interpersonal interactions to occur, as well as providing the opportunity to engage in conversations with people who share the same interests. Many scientists from the fields of sociology, communication, informatics, and so on have been focused on online social network research [3]. In recent years, SNSs have expanded from computer sites to smart-phone applications, beginning to exert an even more profound influence on the social lives and economic activities of many people [4]. The use of social networking sites has seen a significant increase, both among adolescents and adults. As indicated by Lenhart et al. [5], 73% of American teenagers use social networks, with an upward trend from year to year. According to Ilakkuvan et al. [6], young people spend an average of three hours per day on SNSs. There are several advantages to using social networks; most notably, the opportunity to share information with a large audience at a low cost [7]. Also, especially when it comes to the young generation, there is a strong need for acceptance and a powerful desire to be considered valuable and worthy by other members of the community; these urges can be satisfied through the use of SNSs [8]. With the rapid development of information networking technology, social networks such as Facebook, Twitter, and YouTube have emerged as an alternative to the traditional, face-to-face communication, especially in the case of young individuals, enriching and broadening people's social activities. Since the popularity of social networks is reaching a peak [9], the theories developed around this topic are becoming more and more complex [10]. Using matrix theory in social network analysis, Paul and Friginal [11] established a dichotomy concerning the two most widely used online platforms, namely Facebook and Twitter, i.e., considering Facebook as a symmetric social network and Twitter as an asymmetric one. This view was shared by the study of Conejero et al. [12], who consider Facebook and LinkedIn as symmetric social networks and Instagram and Twitter as asymmetric ones. SNSs permit users to connect to each other by creating profiles through which they can provide a variety of personal information. Personal profiles can include a series of information and information types, including photos or videos. According to Kaplan and Haenlein [13], "the higher the social presence, the larger the social influence that the communication partners have on each other's behavior". Moreover, many organizations use SNSs to build communities for professional collaborations to share knowledge and learning materials among their employees [14]. SNSs represent nowadays a new innovative trend [13] whose framework is characterized by complexity, continuous transformation, and adjustment to world dynamics. Understanding the components of the architecture of this system requires panoramic introspection. The "social" aspect invokes its existence in a social space that can be used for individual, professional, and/or entertainment purposes, and can be linked to the level of satisfaction an individual may experience. Furthermore, social networks have allowed users to be permanently connected, engage in content creation, or be updated with the most relevant information, without having to take a closer look at them. According to Kaplan and Haenlein [13], there are two key elements that social media embodies, namely, self-presentation and self-disclosure. The concept of self-presentation states that regardless of the type of social interaction, people manifest the tendency to seek to control the impressions others develop about them. In a study elaborated by Schlosser [15], it was acknowledged that to manage others' perception about themselves, individuals often present an edited version of their life on social media, that might, contrary to their expectations, reduce the level of enjoyment they actually experience in their daily life. This action is triggered by the desire to create an image that is consistent with personal identity. Usually, such a presentation is by self-disclosure, namely, the conscious or unconscious disclosure of personal information (for example, thoughts, feelings, pleasures, and dislikes). Self-disclosure is consistent with the image of themselves that people want to present and is an essential step in the development of close relationships. In light of the increasing impact that social networking sites are having on our lives, especially among young people, it is important to acknowledge the fact that SNSs make a valuable contribution in shaping individuals' beliefs and to the construction of self-identity [16]. Taking these points into consideration, the main objective of the current study was to investigate the relationships among user online activities (looking at what friends have posted, posting different things, commenting on other users' photos or posts, receiving updates, chatting with others), usage intensity (number of friends or hours spent on SNSs) on specific social networks (Facebook, Instagram, Twitter, LinkedIn, and YouTube), importance, and level of satisfaction. First, the study extensively investigates all possible lower-level associations among items (correlation analysis). Second, several conceptual links among compound factors (constructs) are examined via SEM analysis. Even though the influence of social media on individuals' behavior has captured the attention of researchers for many years [17], the novelty of the current study consists of its developing a relational model for a better assessment of users' social activities and their influence on the level of satisfaction users experience with SNSs. The conceptual model includes constructs that reflect private activities on social networks, public activities on social networks, and the perceived importance of various social network sites. To our knowledge, this model has not been previously examined by other researchers in this respect. All correlations were studied both from professional (e.g., job/internship searching, or looking for instructive videos) and personal points of view (chatting, connecting with other people that share the same interests). Moreover, a relational model was developed to assess user social activities and their influence on the level of satisfaction experienced by SNS users. The remainder of the paper is structured as follows: Section 2 offers a comprehensive presentation of the related literature in the field; Section 3 details the research methodology, providing a short description of the survey framework and research model, and continuing with the elaborated hypotheses, as well as describing the data collection and measurement process. Section 4 presents the data analysis and results, while Section 5 comprises a discussion and notes the main limitations of the present study. The final part of the paper presents the main conclusions. --- Literature Review According to the definition elaborated by Boyd and Ellison [18], social networking sites are web-based services where individuals may create different public or semipublic profiles in order to find and interact with other users. Since SNSs emerged, numerous studies have been published to provide a more in-depth understanding of user behavior. The research conducted by Shane-Simpson et al. [19] examined the social network framework by exploring questions such as who is attracted to social media sites, why they prefer a given site, and what are the social consequences of each site preference. After analyzing data collected from 663 students, Instagram was found to be the most frequently used platform among students, especially women. It was also found that most participants who preferred Twitter had both a public profile and a private one, and reported higher levels of self-disclosure. Participants who favor Facebook reported lower levels of self-disclosure, but a higher level of social ties. Uses and gratifications theory (UGT) was put forward by Phua et al. [20], and the main SNS platforms like Facebook, Twitter, Instagram, and Snapchat were examined. The influence of several variables on the relationship between frequent use of each SNS and the bonding of social capital was analyzed. It was found that Twitter users had the largest bridging social capital, followed by Instagram, Facebook, and Snapchat users, while Snapchat users had the largest social-equity bonding, followed by Facebook, Instagram, and Twitter users. The effects of engaging in different SNS activities (broadcasting activities, directed communication including private messaging, commenting) by older users, compared to younger adults, were studied in an article by Kim and Shen [21]. The authors found that compared to younger adults, older adults benefit less from having a large network and more from engaging in directed communication activities. Although the literature in the field describes a multitude of advantages associated with the use of social networking sites, some studies also emphasize the negative aspects these platforms may embody. SNSs are seen-especially by adolescents-as a universal solution for the vast majority of dilemmas. They are a continuous source of enjoyment, entertainment, social support, and well-being, even while humanity is facing a severe global health emergency threat, like the COVID-19 outbreak [22]. Moreover, it is important to note that SNSs give rise to negative behaviors. Paradoxically, SNSs are considered the point of origin for a wide variety of disorders like anxiety, loneliness, depression [23], and anger [24]. Therefore, there seems to be a growing number of social networking users who feel overwhelmed by the use of social networks [4], and it was found that social interaction overload and intrusion into work and private life were significant contributors to technology stress. Consequently, using a group of 180 college students, the study of Tafesse [25] confirmed the hypothesis according to which the use of social networking sites negatively affects students' performance. Also, the perceived satisfaction with SNSs and technostress have been found to have a significant positive impact on rational use. The relationship between consumer socialization within SNSs, the consumer's need for uniqueness, and consumer satisfaction was examined by Abosag et al. [26]. Their findings showed that satisfaction with SNSs is enhanced by friend liking and is undermined by the need among users for uniqueness. The dynamics of employee behavior and motives for using a variety of social media platforms, for personal and professional reasons, were explored by Lee [27]. The results demonstrated that employee communicative behaviors on social networking are unique, i.e., individual, interpersonal, and organizational-level factors collectively and jointly affect employees' positive and negative intentions. Also, social interaction overload negatively impacts performance perception, and the intrusion of private life affects performance and happiness. More and more studies similar to that of Moqbel and Kock [28] reveal that the degree of SNS dependence is growing and that this may have consequences on personal and work environments. SNS dependence reduces positive emotions that enhance performance and improve health. Also, it stimulates distraction, which is a performance inhibitor. The relationship between social media and employee innovation via the mediation of organizational learning and knowledge sharing was studied by Khan and Khan [29]. Their results provided insights by demonstrating that knowledge sharing and social media can help facilitate employee innovation in the public sector. --- Research Methodology --- Research Model and Hypotheses Development The research methodology applied in this paper is based on exploratory studies, with primary and secondary research being anchored on data collected through questionnaires, a literature review, and on specific statistical analyses and tests. The study investigates different aspects, e.g., how individuals are using SNSs for professional purposes vs. personal reasons. For each category, some examples were provided in the introduction section. Moreover, the correlations between the number of friends, hours spent, SNS usage and the level of satisfaction, importance, and SNS activities are assessed. Also, a relational model that evaluates social behavior, the impact of SNS activities on SNS importance and the level of satisfaction, is developed. A graphical representation of the model is illustrated in Figure 1. The logical assumption that drives the research hypotheses is that user activities on social networks influence the importance of, and satisfaction with, social networks. The popularity of SNSs and their use have increased in recent years, especially among young people [5]. Engagement with SNSs provides satisfaction, social support, and increased perceived importance [30]; however, exaggerated behavior in this direction or a selfish attitude [31] regarding peers (i.e., using chat instead of broadcasting opinions or just looking for "like" updates, having poor reactions or no reactions at all) may have the opposite effect on satisfaction [28] and can lead to negative mental outcomes [4,23,24]. Based on these considerations and an intensive literature review, the following hypotheses are put forward: Hypothesis 1 (H1). Private activities on social networks (PRASN) positively impact the importance of the social network (SNI). --- Hypothesis 2 (H2). Public activities on social networks (PUASN) have a positive influence on the importance of social networks (SNI). --- Hypothesis 3 (H3). Private activities on social networks (PRASN) are correlated inversely with satisfaction with social networks (SNSa). --- Hypothesis 4 (H4). Public activities on social networks (PUASN) have a negative influence on satisfaction with social networks (SNSa). --- Hypothesis 5 (H5). The importance of social networks (SNI) alters the degree of perceived satisfaction with social networks (SNSa). Private activities on social networks (PRASN) largely comprise two items (e.g., "I spend a lot of time receiving updates from liked pages"). Public activities on social networks (PUASN) were measured using three items (e.g., "I spend a lot of time commenting on other users' posts"). Perceived social networks importance (SNI) was measured using two items, taking into consideration professional and personal life (e.g., "Social networks are important for my professional life"). The overall perceived satisfaction with social networks (SNSa) was measured using two items, taking professional and personal life (e.g., "Social networks bring professional satisfaction") into consideration. The constructs used in the model, as well as the used items, are detailed in Table 1. --- Data Collection and Measurements In order to fulfill the main objectives of the current research, an anonymous online questionnaire was developed and disseminated via Google Forms in November 2018 to nontechnical students Private activities on social networks (PRASN) largely comprise two items (e.g., "I spend a lot of time receiving updates from liked pages"). Public activities on social networks (PUASN) were measured using three items (e.g., "I spend a lot of time commenting on other users' posts"). Perceived social networks importance (SNI) was measured using two items, taking into consideration professional and personal life (e.g., "Social networks are important for my professional life"). The overall perceived satisfaction with social networks (SNSa) was measured using two items, taking professional and personal life (e.g., "Social networks bring professional satisfaction") into consideration. The constructs used in the model, as well as the used items, are detailed in Table 1. --- Data Collection and Measurements In order to fulfill the main objectives of the current research, an anonymous online questionnaire was developed and disseminated via Google Forms in November 2018 to nontechnical students enrolled in the e-learning platform at one of the most prestigious faculties in Central and Eastern Europe. The questionnaire integrated a total of 26 items of various types, i.e., short answer questions, multiple-choice questions with one or n answers, or single or two-dimensional questions; all items were measured using a five-point Likert scale. To capture behaviors that could be extrapolated to a wider user community, we avoided respondents with technical profiles. Using students as a sample group is a widely applied practice in academic research. Nonetheless, Sitar and Mican used managers and site owners [32]. Student sampling, also used in our research, is a reliable technique, as observed by Pollet and Saxton [33]. Since our potential subjects have different backgrounds in terms of family, environment, and previous exposure to SNSs, they were deemed to be sufficiently diverse to provide generalized results. Acknowledging that a 100% response rate is unrealistic, a sample was used. The representativeness aspect was not neglected; thus, the minimum sample size was computed with Cochran's formula [34], based on a confidence interval of 5% and a confidence level of 95%. The simple random sampling method was used to ensure the same probability of being chosen during the entire sampling process for each individual [35]. Each student was chosen randomly, but that student could then choose to respond or not. Our survey pool consisted of 153 subjects enrolled in our courses, and the size of the computed representative sample was 111. The survey was distributed randomly and gradually to a subset from which 111 students ultimately agreed to fill in the questionnaire. This sample size is above the minimal threshold described by Bonett and Wright [36] for correlation analyses and is satisfactory for PLS-SEM [37]. A total of 111 individuals responded to this questionnaire, all of whom were undergraduate students, aged 18-22. The gender distribution was as follows: 67.6% women and 32.4% men. They connect to the Internet through the following types of mobile devices: smartphone 83.8%, tablet 22.5%, notebook/ultrabook 11.7%, laptop 52.3%, and desktop 55.86%. The average reported weekly social networking time is 12.847 h, i.e., 110 min per day. The descriptive statistics (mean and standard deviation which shows the spread of the values) of the items related to the constructs from the questionnaire included in the model are presented in Table 1. The rest of the variables included in our survey are illustrated in Tables 23456. --- Data Analysis and Results The collected data were analyzed using the statistical software SPSS to measure the correlations that describe the relationship between the variables. Before performing the correlations, the normality Kolmogorov-Smirnov test was used with the quantitative data to decide whether parametric or nonparametric tests needed to be further applied. Because data series do not follow a normal distribution, Spearman's rho coefficients were computed. Also, ANOVA tests were considered to identify or reject behavior similarities among groups. For the second analysis type, SmartPLS [38] was considered. This approach employs partial least squares structural equation modeling (PLS-SEM) and has become a quasi-standard method used in marketing and management research for analyses of the cause-effect relationships between latent constructs [39]. PLS-SEM is appropriate when the research goal is prediction oriented and/or when the research is exploratory in nature, i.e., researchers developing theories by doing multivariate analyses and focusing on explaining variance in the dependent variables [37]. PLS-SEM was suitable for the present research because the authors evaluated the relationships among several latent variables; this method combines the advantages of path analysis, factor analysis, and multiple regression analysis, and at the same time, helps researchers to examine relationships among variables in terms of explained variation. Due to the exploratory nature of the present study and the scarcity of previous research on the topic, and considering the predictive nature of the current research goals, PLS-SEM was considered a suitable and adequate data analysis method. --- Correlation Analysis The analysis of the correlations among the activities carried out on SNSs is presented in Table 2. There is a strong direct correlation between posting things and commenting on other users' content (e.g., photos, posts) (rho = 0.519, p <unk> 0.001), and between looking at what friends have posted and commenting on other users' content (photos, posts), (rho = 0.509, p <unk> 0.001). Both are highly significant. In the case of receiving updates from pages you like, there are three correlations, namely, a weak one with looking at what friends have posted (rho = 0.237, p <unk> 0.05), another with posting things (rho = 0.379, p <unk> 0.001), and a third with comments on other users' content (photos, posts), (rho = 0.292, p <unk> 0.001). Between chatting with others and receiving updates from pages you like, there is a weak but significant link (rho = 0.324, p <unk> 0.001). The ANOVA test did not confirm any significant gender differences regarding chatting or receiving updates. Additionally, the same analysis type indicated that even if the younger users spend more time on social networks, no significant age or gender variances in this behavior were observed. The data regarding correlations between time spent on social media sites for professional and personal purposes are presented in Table 3. Even if, in general terms, there are no significant differences between the time allocated to private and professional activities, there is a slight distinction between each used SNS. Thus, there is a good correlation between the frequency of Facebook usage in professional activities and use in personal activities (rho = 0.501, p <unk> 0.001). As for Instagram, there is a very high and highly significant correlation between the two usage types (rho = 0.786, p <unk> 0.001). In the case of Twitter, we observed a strong link between the two usage types (rho = 0.647, p <unk> 0.001), and a weak link between using Twitter for personal purposes and Instagram (rho = 0.200, p <unk> 0.05) or LinkedIn for professional activities (rho = 0.295, p <unk> 0.05). In the case of LinkedIn, there was a correlation between the two sides of LinkedIn use (rho = 0.755, p <unk> 0.001) and a weak link between using LinkedIn for personal purposes and using Twitter for professional purposes (rho = 0.238, p <unk> 0.05). For YouTube, there was a strong correlation between the frequency of use for the two domains (rho = 0.400, p <unk> 0.001) and a weak one between using YouTube for personal use and LinkedIn at work (rho = 0.233, p <unk> 0.05). Table 4 illustrates the correlations between the number of current friends, the number of hours spent on SNSs, and the frequency of SNS use for professional and personal purposes. There are several weak and highly significant inverse correlations between the number of current friends and the frequency of Facebook use for professional purposes (rho = -0.325, p <unk> 0.001), Facebook for personal purposes (rho = -0.249, p <unk> 0.01), or Twitter for personal purposes (rho = -0.265, p <unk> 0.01), and a weak and inverse relationship with the frequency of Twitter use for professional purposes (rho = -0.237, p <unk> 0.05). In terms of the number of hours spent on SNSs, three weak but significant inverse relationships were found with frequent use of LinkedIn for professional activities (rho = -0.249, p <unk> 0.01), frequency of use LinkedIn for personal activities (rho = -0.195, p <unk> 0.05), and the frequency of YouTube usage for personal purposes (rho = -0.203, p <unk> 0.05). The correlations between the current number of friends, the number of hours spent on SNSs, and satisfaction, importance, and SNS activities are presented in Table 5. Two weak and inverse correlations were observed between the current number of friends and comments on other users' pages (rho = -0.245, p <unk> 0.01) and receiving updates from pages you like (rho = -0.198, p <unk> 0.05). Regarding the number of hours spent on SNSs, there was a weak but significant link with chatting with others (rho = -0.246, p <unk> 0.01). Observed correlations between professional and personal satisfaction and importance are presented in Table 6. Concerning satisfaction with SNSs for professional reasons, there were three correlations. The first one is a strong and highly significant correlation with satisfaction with SNSs for personal use (rho = 0.611, p <unk> 0.001). The other two correlations were weak and negatively correlated with SNS importance for personal reasons (rho = -0.278, p <unk> 0.01) and SNS importance for professional reasons (rho = -0.194, p <unk> 0.05). In terms of satisfaction with SNSs for personal use, this was correlated weakly, but with high significance, with SNS importance for personal use (rho = -0.326, p <unk> 0.001). We also noticed that SNS importance for professional use is strongly correlated with SNS importance for personal use (rho = 0.713, p <unk> 0.001). Regarding the mechanisms through which satisfaction with SNSs is influenced by SNS activities, the following correlations were established. Satisfaction with SNSs for professional reasons correlated poorly, but significantly, with posting things (rho = 0.252, p <unk> 0.01) and comments to other users' (photos, posts) (rho = 0.233, p <unk> 0.05). In the case of satisfaction with SNSs for personal use, the same weak and significant correlations with posting things (rho = 0.259, p <unk> 0.01) and commenting on other users' material (photos, posts) (rho = 0.258, p <unk> 0.01) was identified. SNSs importance for professional reasons correlates poorly, inversely, and significantly with chatting with others (rho = -0.242, p <unk> 0.01). Also, SNSs importance for personal reasons correlates poorly, inversely, and significantly with posting things (rho = -0.192, p <unk> 0.05) and comment on other users' (photos, posts) (rho = -0.225, p <unk> 0.05). --- Structural Equation Modeling Analysis In order to reveal more regarding the immense complexity of the social network phenomenon and user behavior, a new approach is proposed. The degrees of importance and satisfaction with social networks were analyzed concerning activity types, i.e., public or private. To build the model and test the research hypotheses, the statistical software SmartPLS version 3.3.2 (SmartPLS GmbH, Boenningstedt, Germany) was used [38], which applies modeling using the partial structural equation with the smallest squares PLS-SEM, also called PLS path modeling. It requires two sets of validation procedures, i.e., for the outer and also for the inner/structural model. --- Reflective Measurements Assessment An assessment of the reflective measurements is presented in Table 7, which contains the model constructs with latent reflective variables and reflective indicators. The reliability and convergent validity results of the model can be observed by looking at the outer loadings, Cronbach's alpha, composite reliability, and average variance extracted (AVE). The outer loadings indicate the relationships between constructs and indicator variables in reflective measurement models and are computed for all measurement model constructs. For the outer loadings indicator, the values were higher than the minimum score of 0.70 [40], which infers adequate levels of indicator reliability. The indicators SNI2 (outer loading: 0.949) and SNSa2 (outer loading: 0.929) had the highest reliability, while the indicators ISN1 (outer loading: 0.712) and PUASN1 (outer loading: 0.703) had the lowest reliability. Regarding the internal consistency reliability, Cronbach's alpha was considered as the lower bound and composite reliability as the upper bound [41]. In this respect, almost all the values for the Cronbach's alpha coefficient were considerably above the recommended value of 0.70 [41]. The highest values were for SNSa (0.822) and SNI (0.821). On the other hand, for composite reliability, all the values could be considered adequate. In this case, the highest values were for the same constructs as in the case of Cronbach's alpha coefficient. The average variance extracted (AVE) is a traditional measure to prove the convergent efficacy of the construct level. It is calculated as the grand mean value of the squared loadings of the indicators linked with the construct [42]. Regarding the convergent validity, the AVE was far above the minimum threshold of 0.5 [42], which indicates that convergent validity was confirmed for all the constructs. In this model, the highest values were for constructs SNSa (0.849) and SNI (0.844). The heterotrait-monotrait ratio (HTMT) has been proven to be a reliable basis for the statistical discriminant validity test [43]. For the current case, as presented in Table 8, all HTMT values were lower than the conservative threshold value of 0.85 [43], and discriminant validity was confirmed among all pairs of constructs. --- Collinearity Issues Assessment To further evaluate the structural model, a collinearity assessment was needed among the values of all sets of predictor constructs (Inner VIF values) [40]. Table 9 shows the inner VIF values of all combinations of endogenous constructs and their corresponding exogenous constructs. As can be observed, all values were below the ideal conditions threshold value of 3 [40], which means that collinearity between the predictor constructs did not represent an issue in the present structural model. --- Structural Model Relationships To evaluate the structural model, the significance level of the relationships established between the constructs was analyzed. Figure 2 shows a graphic representation of the structural model, while Table 10 presents a summary of the results. We can see that 3 out of the 5 hypotheses that we developed were confirmed by this custom model. According to the p-values, H2 and H5 were supported with p <unk> 0.01, and H3 with p <unk> 0.05. --- Predictive Relevance To evaluate the predictive relevance [40] of the current model, R 2 and Q 2 values for the target variables were calculated and the PLSpredict algorithm was employed. The R 2 value for the final dependent variable in the model (SNSa) had a value of 0.142, which denotes a low predictive To evaluate the predictive relevance [40] of the current model, R 2 and Q 2 values for the target variables were calculated and the PLSpredict algorithm was employed. The R 2 value for the final dependent variable in the model (SNSa) had a value of 0.142, which denotes a low predictive accuracy. Similarly, regarding the Q 2 value, the final dependent variable in the model (SNSa) had a value of 0.0824, which equally denotes a weak predictive power. The PLSpredict algorithm [44] was employed to achieve a better assessment of the model's predictive power. The method uses training and holdout samples to generate and evaluate predictions from PLS path model estimations. As the data included in Table 11 reveal, all the Q 2 values were positive and the prediction error of the PLS-SEM results (RMSE and MAE) was smaller than that obtained by simply using the mean values; this indicates that this model offers better predictive performance. Taking into account the RMSE and MAE, in comparison with the LM results, the PLS-SEM results had lower prediction errors in terms of RMSE and MAE than the LM for all the items, which indicates that the model has high predictive power. Note: PLS = prediction using PLS-SEM; LM = prediction using a linear model; RMSE = root mean squared error; MAE = mean absolute error. --- Discussion and Limitations --- Discussion Existing studies by economists, psychologists, or sociologists agree on the significant role that the quality and quantity of social relationships have on the well-being of individuals [45]. Previous work confirmed the positive correlation between the density of social networks and the level of life satisfaction [46]. This link is explained by the fact that a larger number of social networks is positively correlated with a high degree of stability and security, and therefore, with a high level of life satisfaction [47]. As we experience a continuous evolution in the area of social networks, new forms of interconnections with other people are emerging day by day. The appearance of social media has substantially modified the range of criteria people use to evaluate their own well-being and life satisfaction [48]. Increasing the level of life satisfaction is an overall goal people want to achieve; such an undertaking reflects a subjective and global evaluation of the personal quality of life [49]. In this research, we investigated the link between the use of SNSs by students and the level of satisfaction they experience, both professionally and personally. The elaborated research model took into consideration the fact that SNS use by young people is increasing exponentially, day by day, and therefore, that it requires a further assessment of the channels of dissemination regarding the attributed importance or the satisfaction/dissatisfaction it may provide. The purpose of social networks is to extend the general framework of traditional communication channels. Many scholars have expressed concern regarding the fact that online interaction techniques, such as the use of SNSs, are slowly becoming a substitute for face-to-face connections, and as a result, we may be confronted with a decline in individual social capital [18,50]. Moreover, it was argued that online interactions are less social than face-to-face ones; many studies in the field have confirmed this assumption. In particular, Kross et al. [51] observed that an increase in the number of hours spent on SNSs such as Facebook correlates with a decline in the level of life satisfaction over a certain period. These results were also supported by a study of Sabatini and Sarracino [52], which argued that the effect of SNSs, especially Facebook and Twitter, on individual well-being is negative. Interesting results are to be found in the work of Burke and Kraut [53], which suggests a positive link between online communication and well-being, as long as such communication includes people who are significantly important in the individual's life, or it incorporates characteristics which the individual considers to be suitable to their personality. In the current research, the correlation coefficients denote positive significant relationships among all of the SNS activities depicted in Table 2, with the most powerful being between posting and commenting on other users' posts or photos. The behavior of students may also be transposed in the consumer community, where peers are strongly connected to a specific cause-like sharing food safety information-and trust each other [54]. Concerning these activities, we found there were no significant gender differences in terms of chatting or receiving updates, contrary to other studies that confirmed a higher involvement in this respect among males than females [55]. The time spent on social media sites for professional use is highly correlated with the related time spent for personal use on the same platform for the case of Instagram, followed by LinkedIn, and Facebook. The correlation among time spent on the same SNS but for different purposes is always positive; however, if both SNSs and purpose are different, inverse associations may be observed (e.g., Twitter for work and Instagram for private use). Overall social media intensity-i.e., number of friends and time spent on SNSs-is not quite a straight indicator for the time spent on a given SNS for professional/personal activities. In fact, our study indicates that this intensity correlates inversely with each of these times. The most prominent gap is between the number of friends on SNSs and the time spent on Twitter. Surprisingly, similar or inconclusive behavior was observed between social media intensity and satisfaction with SNSs, SNS importance, and activity type. There is an inverse correlation between the hours spent and chat activities, followed closely by number of friends and receiving updates from the liked pages. Going further, we noted a highly positive interdependence between the importance of SNSs (for professional and personal uses) and satisfaction. Surprisingly, importance was shown to correlate inversely with satisfaction, and possibly-although most were not significant-with all SNS activity types. Satisfaction was is positively impacted by public

Social networking sites (SNSs) are now ubiquitous communities for constant online interpersonal interactions that trigger symmetric or asymmetric effects on our everyday life. Recent studies advocate in favor of the significant role that SNSs have in promoting well-being and, more importantly, in disseminating reliable information during a global crisis, such as the current COVID-19 pandemic. Based on the growing importance of SNSs to the global framework, the main purpose of this study is to empirically assess the link between the use of symmetric social networks such as Facebook, or asymmetric social networks, like Instagram, and the level of satisfaction, employing the methodology of structural equation modeling. The results of the research validate the hypothesis that SNS activities increase the level of satisfaction, and therefore, that there is a direct link between the number of posts and comments and the level of satisfaction. Furthermore, based on the reversible and significant link between the level of satisfaction and the importance attributed to SNSs, the main conclusion of the study is that the higher the importance of the SNS, the greater the level of dissatisfaction experienced by users. Also, public activities on social networks positively affect social network satisfaction, while private activities have a direct negative relationship with the importance of social networks.

; however, if both SNSs and purpose are different, inverse associations may be observed (e.g., Twitter for work and Instagram for private use). Overall social media intensity-i.e., number of friends and time spent on SNSs-is not quite a straight indicator for the time spent on a given SNS for professional/personal activities. In fact, our study indicates that this intensity correlates inversely with each of these times. The most prominent gap is between the number of friends on SNSs and the time spent on Twitter. Surprisingly, similar or inconclusive behavior was observed between social media intensity and satisfaction with SNSs, SNS importance, and activity type. There is an inverse correlation between the hours spent and chat activities, followed closely by number of friends and receiving updates from the liked pages. Going further, we noted a highly positive interdependence between the importance of SNSs (for professional and personal uses) and satisfaction. Surprisingly, importance was shown to correlate inversely with satisfaction, and possibly-although most were not significant-with all SNS activity types. Satisfaction was is positively impacted by public SNS activities (posting, commenting, and looking at posts) and indefinitely so by private ones (chatting and receiving updates from favorite pages). Since these results were not quite conclusive, they were studied further at a higher conceptual level by using a different technique. After applying structural equation modeling, our results showed that public activities on social networks positively affect user satisfaction with social networks. Also, private activities on social networks have a direct negative relationship with the perceived importance of social networks. The perceived importance of social networks has a direct negative relationship with user satisfaction. Socialization mediated through technology means that bidirectional social capital is exchanged between individuals and the network. Active public behavior on SNs contributes positively to increased perceived satisfaction (H2) since it is considered irrelevant for perceived importance (H1 infirmed). Selfish behavior on a SN, i.e., using it purely as a private communication channel (chatting) or to obtain only personal benefits (receiving updates from favorite pages), alters the perceived importance of the social network, since the obtained satisfaction is unquantifiable (H4 infirmed). Even if the social networks appear to be a panacea for both personal and professional concerns, their misuse may generate the opposite effect [23]. A higher level of perceived importance regarding a social network tends to yield lower perceived satisfaction (H5 confirmed). This relationship may look paradoxical, but it was also confirmed by Yao and Cao [4]. The proposed model confirmed three relationships with similar strengths in terms of effect, but only one, i.e., between public activities and satisfaction, was positive. Social networks offer social support, satisfaction, and a sense of well-being in day to day life, but also during word emergencies, like the current one created by the COVID-19 virus [56]. On the other hand, they may play a negative role by creating or reinforcing mental health problems or radical ideas [57]. These contradictory aspects reveal how vast, complex, and unpredictable this phenomenon is, and how far the literature has to go to completely understand it. Moderation, as in anything with addictive potential, may be the key to optimizing the positive-negative balance. --- Limitations and Future Directions of Research Despite the overall implications of this study, certain research limitations should be mentioned. First of all, even though the number of students that participated in the survey fulfills the minimum size requirements of both the analysis methods and the representativeness of the studied population, the sample could have been extended to students enrolled in other programs of study for more complex analysis. However, we must acknowledge that this sample size was severely reduced due to the GDPR constraints regarding the number of students enrolled in our e-learning system. Even if the student sampling method is widely used in research, our model and analyses may lack generalization. Region, gender, age, timing, profession are the main factors to be considered in larger samples relying on a multi-strata sampling method. Nevertheless, sophisticated models/analyses may fail during emergency crises, such as the COVID-19 lockdown, social distancing, or post-social distancing. Considering the current crisis, one future direction would be to study and model the effects of the media during periods in which social distancing measures are implemented. Another would be to investigate more deeply how the complexity of the magnitude of social network use and social capital types facilitate transitional social support/satisfaction during lockdown for all involved parties [17]. --- Conclusions Social networks are part of the everyday lives of people around the world; they are used for a multitude of purposes, considering the typology of the industry, from communication to informatics, and other fields [3]. As mentioned, the primary objective of this study was to assess, by using structural equation modeling, the link between SNS use and the level of satisfaction, in particular among young people. The obtained results indicate that the average amount of time students spend weekly on SNSs is 12.85 h, with no significant discrepancies between men and women. The dominant positions in terms of usage are attributed to Facebook and YouTube, with LinkedIn and Twitter being situated at the opposite end of the pole. Generally, there are no significant differences in terms of time spent for professional activities versus personal ones. The most popular and time-consuming activities that users carry out within SNSs are talking privately to others and tracking the news posted on their favorite pages, without revealing any significant differences between males and females. The present study provides insights into social networking site use and the effects that this may have on an individual's life, in particular, in the case of students. As users spend more time looking at their friends' posts, they also spend more time posting things themselves and commenting on other users' content (photos, posts). Therefore, the current research also contributes to the existing literature by identifying correlations between these three activities. Similarly, as users spend more time receiving updates from pages they like, they spend more time chatting with others. SNS activities bring satisfaction, both in the professional and personal lives of most of the respondents. Of all the activities, posting things and commenting on other users' content (photos, posts) are statistically significant and correlated, i.e., the higher the number of posts and comments, the higher is the level of satisfaction, both professionally and personally. Similar results can be found in the work of Valenzuela et al. [58]. Paradoxically, following the analysis of the correlation between importance and satisfaction, it turned out that there is a reversible and significant link between these two. Therefore, if the importance of SNSs increases, satisfaction decreases. In other words, the higher the importance, the more the discontent grows. The model derived from structural equation modeling analysis confirms more intuitively a part of the correlation analysis findings. Public activities (posting things, commenting on other users' posts, and looking at posts) positively impact satisfaction, but the effect on the importance of SNSs is inconclusive. On the other hand, the output offered by the private activities (chatting with friends and receiving updates from favorite pages) is asymmetric; these variables have an indefinite effect on satisfaction and a negative one on importance. SEM analysis confirmed the negative effect that importance has upon satisfaction due to the overuse of social networks. Nowadays, the young generation, which is permanently exposed to social media, has to distinguish between the positive and negative effects that this channel of communication may engender. Despite some mainstream opinions on this topic, the role and use of social networks is an endless subject of discussion and the literature is far from reaching a consensus.

Social networking sites (SNSs) are now ubiquitous communities for constant online interpersonal interactions that trigger symmetric or asymmetric effects on our everyday life. Recent studies advocate in favor of the significant role that SNSs have in promoting well-being and, more importantly, in disseminating reliable information during a global crisis, such as the current COVID-19 pandemic. Based on the growing importance of SNSs to the global framework, the main purpose of this study is to empirically assess the link between the use of symmetric social networks such as Facebook, or asymmetric social networks, like Instagram, and the level of satisfaction, employing the methodology of structural equation modeling. The results of the research validate the hypothesis that SNS activities increase the level of satisfaction, and therefore, that there is a direct link between the number of posts and comments and the level of satisfaction. Furthermore, based on the reversible and significant link between the level of satisfaction and the importance attributed to SNSs, the main conclusion of the study is that the higher the importance of the SNS, the greater the level of dissatisfaction experienced by users. Also, public activities on social networks positively affect social network satisfaction, while private activities have a direct negative relationship with the importance of social networks.

Background Despite the growing numbers of migrants in China, the local governments in urban cities have mainly addressed only three health problems for rural-to-urban migrants: infectious diseases, reproductive health, and occupational diseases due to the effects of these problems on local residents [1]. As a result, prevention and control of non-communicable disease for rural-to-urban migrants continues to receive inadequate attention. The National BPHS is one of very few programs that cover non-communicable disease prevention and control for rural-to-urban migrants. These services, mainly provided by community health centers (CHC), are available to all residents free of charge. BPHS are the most basic preventive health service program provided by the Chinese government to current urban and rural residents and focus on children, maternity services, the elderly, and chronic disease conditions [2]. In order to promote the development of BPHS in China, the National Health Commission issued its first detailed set of regulations and standards in October 2009. In 2019, after several revisions, the BPHS program included 31 services, with 6 of 31 services specifically for women: (1) the establishment of health records, (2) health education, (3) basic contraceptive services for married couples, (4) breast and cervical cancer screening in rural populations, (5) prenatal diagnosis evaluations, and (6) maternal health care record establishment, at least five prenatal visits, timely care within the first 12 weeks of pregnancy, and postnatal care. Historically, rural-to-urban migrant workers have been affected by the hukou system [3]. In China, hukou defines a person's rights for health care services, and social welfare within a specified locality [4], services are provided to citizens according to their hukou location and classification (rural vs. urban). For example, one study demonstrated that rural-to-urban migrants showed lower basic public health services (BPHS) utilization (30.37%) compared with local residents (43.23%) [5]. Additionally, the long-established hukou system is the basis for implementation of many public policies and social welfare programs [1]. A change of hukou status is difficult when people migrate from rural to urban settings or from one place to another [3]. Thus, social welfare and healthcare benefits in urban areas are not available to the rural-tourban migrants, only for residents with an urban and locally registered hukou. However, rural migrants can now apply for a resident permit, thus allowing them to have the same rights as a local resident in an urban city; for example, they may now have the same access to BPHS and health insurance. Although rural-to-urban migrants' basic rights while living in cities have been progressively improving by actions of the Chinese government, resident permits still cannot guarantee all rural-to-urban migrants will have the same rights as city residents. There are requirements for applying for resident permits. For example, migrants need to have lived in the city for more than six months and have a steady work contract [6]. For a cosmopolitan city like Shenzhen, the application requirements are more restricted since migrants need to have lived in the city for more than 12 months and have made 12 months of social insurance payments [6]. Therefore, there is still a gap between migrant workers' access to the same rights as urban residents in China. According to the annual survey of rural migrant workers, there were 288.36 million rural laborers working in China in 2018 (an increase of 1.84 million compared to 2017), and 79.7% of rural migrants are married [7]. Among all rural migrants, female migrant workers accounted for 34.8%, which is a slight increase compared with 2019 (34.4%) [7]. As a result of the large and increasing population of female migrants, understanding factors associated with their health service utilization will ultimately impact the health of the nation. At present, China is actively developing the BPHS program and making significant progress. However, due to the imbalance of economic development in various regions of the country and large geographic gaps between urban and rural areas, BPHS equalization in China is relatively slow. For example, although health care record establishment is crucial for disease prevention and treatment, only 25.2% of female rural-to-urban migrants had established health care records in 2013 [5]. The establishment of health care records is still far lower than the 2013 National Health Commission goal of 65% [9]. Additionally, only 52.7% of female rural-to-urban migrants had received health education in 2014 [10], and a survey in Fujian province showed that the rate of breast and cervical cancer screening was only 38.2%, which was far below the rate for local residents (79.4%) [11]. Previous research has looked at several factors associated with health service utilization, but with inconsistent results. Compared to education below a primary school level, higher education was significantly associated with more health records establishment, health education utilization, adequate health literacy, maternal health service utilization, health examination and reproductive health consultation [12][13][14][15]. However, Liu et al. reported that education showed no significant association with reproductive health education and reproductive health examination for migrants [16]. This was corroborated by Wang et al. who reported that migrant education level had no association with utilization of health education [17]. Social support refers to the perception and status of a person being cared for and receiving help from others [7]. High levels of social support are hypothesized to encourage utilization of preventive services [10,18]. Hou et al. reported that participating in social organizations and activities was associated with significantly more health record establishment and health education utilization by migrants compared to those who did not participate in these activities [10], which indicates that social connections may have a positive influence on BPHS utilization. Migrants who followed migrating family members were significantly more likely to establish health records [19] than those who traveled alone to the migration city, which also indicates the importance of social support. However, there are very few studies reporting the relationship between social support and BPHS utilization among rural-to-urban migrants and no study that uses a social support scale to explore the relationship between specific types of social support and BPHS utilization. Since female rural-to-urban migrants (even if married) are a unique group and are often separated from family and friends, having few links with a new community may weaken their social support network. Therefore, exploring how multi-dimensional social support affects BPHS utilization is necessary. Finally, since migrants are often unfamiliar with their working and living environments, they can be marginalized and experience both internal and external discrimination [20][21][22][23]. As a result, experiences of discrimination may further impact BPHS utilization [18]. To our knowledge, there is no study reporting the relationship between discrimination and BPHS utilization. However, Hausmann et al., in the US, found that perceived discrimination was significantly associated with lower utilization of certain preventive measures including mammograms, pap tests, and colonoscopies [24]. Without understanding the impact these factors have on BPHS utilization among married female rural-to-urban migrants, the needs of this group will remain unknown, and thus leave the women vulnerable to adverse health outcomes. Although, several studies have explored factors related to BPHS utilization in rural-to-urban migrants, most studies have included only demographic and migration factors, whereas social structural factors like social support and discrimination are rarely taken into account [10]. According to the Andersen Behavioral Model [25], social structure factors, that encompass personal, family, and community factors, affect health care services utilization. In our study, we include social support, discrimination, years of residence, length of migration, and living circumstances as social structure factors to examine its relationship with BPHS utilization. Also, there are inconsistencies in the relationship between socioeconomic status (SES) and BPHS utilization. Our model of BPHS utilization fills this gap by using Anderson's Behavioral model as a framework for considering important predisposing characteristics and enabling factors of health behavior. Therefore, the purpose of this study is to explore how demographic and social structure factors influence BPHS utilization among rural-to-urban, married migrant women. The specific aims are to: (1) describe frequency of utilization of BPHS services in rural-to-urban married migrant women, and (2) examine how social support, age, education, income, years of residence, length of migration, living circumstances, family location, and discrimination influence this utilization. --- Methods --- Study sites and recruitment This study utilized a cross-sectional method to examine the BPHS utilization of married female rural-to-urban migrant workers in Changsha, Hunan province, the People's Republic of China. Hunan Province, located in central China, has the second largest internal migrant population in China with an estimated 16.8 million in 2013, accounting for about 31% of the adult population [26]. Changsha is the capital and the most populous city of Hunan Province; in 2016, Changsha had 7,645,200 residents [26]. The city is an important commercial, manufacturing and transportation center [27]. In this study, 380 female migrant workers were originally recruited by trained, Mandarin-speaking research assistants from two medical device factories, two high-tech factories, a restaurant, a recycling factory, an automotive parts store, a textile factory and a hospital (custodial workers) in Changsha. We chose these locations because migrant women are concentrated in these labor-intensive industries. Of the 380 migrant women recruited, 343 completed a questionnaire and after data cleaning, 307 participant surveys were included in the study. Inclusion criteria included women: (1) 18-50 years of age, (2) married (basic contraceptive services are provided only for married couples), (3) with rural hukou and who had moved to an urban city for work, and (4) living in Changsha as a migrant worker for at least one month. --- Study procedure Verbal informed consent was sought from all the participants after providing a description of the study. A researcher read the details of the verbal consent information sheet including the aim, risks and benefits of the study, what will happen if they take part in this study, and letting them know they can withdrawal from the study at any time without penalty. Participants were provided a survey and pen and a private area to complete the surveys. Research assistants were present to answer questions. The survey took about 30 min to complete. A small present was given to the participants who completed the survey. Approval for this study was obtained from the Ethics Committee of the Xiangya Nursing School, Central South University. --- Measurement An author-designed survey was developed to collect data about the women's demographic and social structure information (age [in years], family location [village or county; a county is an administrative region one level higher than a village], time in Changsha as a migrant [<unk> 2 years, > 2 years], total time as migrant [<unk> 4 years, <unk> 4 years], education [primary, middle/high school, diploma, or college], monthly income [<unk> 3000 RMB or > 3000RMB] and living circumstances [separate from family or living with family]). This is provided as Additional file 1. Social support was measured using the Social Support Rate Scale (SSRS) developed by Xiao [28], which has shown good reliability among Chinese populations [29]. The SSRS is a 10-item scale measuring three dimensions of social support: subjective social support, objective social support, and utilization of social support [28]. Questions on subjective social support include four questions: (A) How many friends do you have who can provide help and support to you? (1) None, (2) 1-2, (3) 3-5, (4) 6 and above; (B) How is your relationship with your neighbors? (1) only bowing acquaintance, (2) care a little when you are in trouble, (3) some neighbors care about you, or (4) most of the neighbors care about you; (C) How is your relationship with your colleagues? (1) only bowing acquaintance, (2) care a little when you are in trouble, (3) some colleagues care about you, or (4) most of the colleagues care about you; (D) How is the support you receive from your family members (spouses, parents, children, siblings, other family members)? (1) None, (2) seldom, (3) sort of support, or (4) full support [28]. Questions on objective social support include three questions: (A) What was your living condition in the past year? (1) away from family and lives alone, (2) accommodation is constantly changing, most of the time living with strangers, (3) lives with classmates, colleagues or friends, or (4) lives with families; (B) What have been your sources of economic and practical support in case of emergency? (1) no sources, (2) the following sources (multiple choice): (a) spouse, (b) other family members, (c) relatives, (d) colleagues, (e) employer/company, (f ) official or semi-official bodies (e.g. political parties, or a labor union) (g) unofficial bodies (e.g. religious groups, social groups or other social organizations), or (h) others (please identify); (C) What have been your sources of care when you were in trouble? (same options above) [28]. Questions on the utilization of social support include three questions: (A) What is your way of confiding when you are in trouble? (1) never talk to anyone, (2) only talk to one or two intimate friends, (3) if friends ask, I will say, or (4) Take the initiative to talk about my problems in order to gain support and understanding; (B) How do you seek help when you are in trouble? (1) depend on my own and turn to no one, (2) seldom turn to others for help, (3) sometimes seeks help from others, or (4) turns to family, relatives and organizations; (C) To what extent are you involved in group (e.g. political organizations, religious organizations, labor unions and student unions) activities? (1) Never, (2) seldom, (3) often, or (4) actively involved. A higher score indicates greater social support (Cronbach's <unk> = 0.68). The possible total score of the SSRS ranges from 12 to 66 points [28]. Self-perceived discrimination was measured using a six-items scale developed by Chen [30]. The scores on the first three items (A harder time finding work than others; A harder time getting medical care; A harder time getting kids into local schools.) quantify perceived institutional discrimination (Cronbach's <unk> = 0.68) [30]. The scores on the last three items (You notice other people avoiding you; People are more impolite to you than others; People call you names or insult you.) measure perceived interpersonal discrimination (Cronbach's <unk> = 0.72) [30]. Both measures range from 1 to 5, with 1 indicating "never" and 5 indicating "very often. " [30]. The utilization of four basic women's health services was measured with dichotomous "yes/no" questions. Health care record establishment was defined as whether or not a migrant woman had completed health records in a CHC. Utilization of health education was defined as whether or not the migrant woman had received health education at least once from a CHC. Utilization of free contraceptive services was defined as whether or not a migrant woman had received at least one free condom from a CHC, and utilization of breast and cervical cancer screening was defined as whether or not a migrant woman had received at least one breast or cervical cancer screening examination. (The BPHS questionnaire developed for this study is provided as Additional file 2.) Because we were interested in the potential effects of migration factors on BPHS utilization, we eliminated prenatal diagnosis evaluation and maternal health care services as outcome criteria because these two services were not applicable to all participants in our study. We did not ask participants if they had ever been pregnant or if they had been pregnant before or after migration to Changsha. If migrants had given birth in their rural hometown, they would not have used prenatal diagnosis evaluation and maternal health care services in the CHC. --- Data analysis Frequency and descriptive statistics were obtained using percent for all dichotomous variables and means and standard error for continuous variables. Associations between family location, migration time in Changsha, migration time in total, years of education, monthly income and living circumstances and BPHS utilization (health care record establishment, health education, free contraception and cancer screening) were obtained using Chi-square tests. Associations between age, institutional discrimination, interpersonal discrimination, objective social support, subjective social support, and utilization of social support for the abovementioned BPHS utilization were conducted by univariate logistic regression with resultant odds ratios (ORs) and 95% confidence intervals (CIs). Multivariate logistic regression analyses were performed to examine factors significant for each individual BPHS in Chi-square tests and univariate logistic regression for utilization of the four BPHS while controlling for demographic variables significantly associated with BPHS. We used enter methods to select variables correlated with BPHS utilization with resultant odds ratios (ORs) and 95% confidence intervals (CIs). The inclusion P value was 0.05, and the removal P value was 0.10. The data was analyzed using SPSS 18.0. --- Results Table 1 displays descriptive statistics on measures of BPHS utilization, social support, discrimination, migration-related factors, and socio-demographic characteristics. The mean age was 35 years and participants were more likely to have completed middle or high school (68.6%) compared to primary school (4.9%) or college (10.8%). Approximately 63.5% earned less than 3,000 RMB in monthly income and 67.2% originally migrated from a rural village (compared to a county). Participants were more likely to be living separately from their families (75.6%), having worked at least two years as a migrant in Changsha (78.1%), and at least four years as a migrant worker in general (67.2%). For measures of BPHS utilization, health education among married migrant women was reported to be the lowest (24.7%), followed by breast and cervical cancer screening (26.1%), establishment of health care records (27.2%); the highest utilization was for basic contraceptive service (40.9%). Compared to the mean interpersonal discrimination score (4.45, range 3-15), female migrants perceived a higher level of institutional discrimination (5.30, range 3-15). The mean for objective social support, subjective social support and utilization of social support were 8.68 (range 1-22), 24.91 (range 8-32), 7.22 (range 3-12), respectively. Table 2 show the relationship between BPHS utilization and family location, years of residence, migration time in total, migration time in Changsha, living circumstances, income, and education using a Chi square test. Migrant women who had lived in a county (one level higher than village), having less than four years migration experience, and living with their families were more likely to establish health care records. Migrant women who had lived in a county, and living with their families were more likely to receive health education. Migrant women who had lived in a county, with a primary, middle or high school education, having more than two years residence in migration city, and living with their families were more likely to receive basic contraceptive services. Migrant women with a primary, middle or high school education, living with their families and whose monthly income was less than 3000 RMB were more likely to receive cancer screening. Table 3 shows the relationships between BPHS utilization and discrimination, social support, and age using univariate logistic regression. The study demonstrated that the more objective social support married migrant women have, the more likely they are to have received health education services (OR = 1.12; 95% CI = 1.02, 1.23; p = 0.014); however, there was no significant relationship between objective social support and health record establishment or basic contraception and cancer screening utilization. For subjective social support, there was a 9% increase in the odds for a one-unit increase in utilization of free contraceptive services (OR = 1.09; 95% CI = 1.03, 1.15; p = 0.004) and cancer screening (OR = 1.09; 95% CI = 1.02, 1.16; p = 0.009), but not significant for health record establishment and health education. Utilization of social support was significantly associated with establishment of health records (OR = 1.24; 95% CI = 1.06, 1.44; p = 0.006), basic contraceptive services (OR = 1.27; 95% CI = 1.10, 1.47; p = 0.001), and cancer screening service utilization (OR = 1.30; 95% CI = 1.11, 1.52; p = 0.001), although, not for having received health education. Discrimination and age were not significantly associated with BPHS utilization. Table 4 presents factors significantly associated with BPHS resulting from Chi square tests (living circumstances, migration time in total, migration time in Changsha, years of education, monthly income, and family location) and univariate analysis (social support) in multivariate logistic regression analyses. Living circumstances are positively associated with three BPHS services, but not with basic contraceptive service utilization. Compared with living separately from their families, married migrant women who lived with their families were more likely to establish health record (OR = 2.11; 95% CI = 1.17, 3.80), to have received health education (OR = 2.71; 95% CI = 1.51, 4.87), and to have received cancer screening (OR = 2.38; 95% CI = 1. 30, 4.36). Utilization of all BPHS services was associated with social support. The more objective social support married migrant women had, the more likely they were to have received health education (OR = 1.15; 95% CI = 1.04, 1.26). However, utilization of health record establishment, cancer screening, and basic contraceptive services were not significantly associated with objective social support. The more subjective social support married migrant women had, the more likely they were to have received basic contraceptive services (OR = 1.11; 95% CI = 1.05, 1.18) and cancer screening (OR = 1.10; 95% CI = 1.02, 1.17). However, utilization of health record establishment and health education was not significantly associated with subjective social support. Finally, the more married migrant women utilized social support, the more likely they were to establish a health care record (OR = 1.24; 95% CI = 1.06, 1.44), to have basic contraceptive tools (OR = 1.21; 95% CI = 1.04, 1.42) and cancer screening (OR = 1.29; 95% CI = 1.10, 1.51). There was no significant association between social support and health education. For education and monthly income, only education showed associations with received basic contraceptive services. Married female migrants with a diploma or college education were 64% less likely to have received basic contraceptive services (OR = 0.36; 95% CI = 0.20, 0.67) compared to those with lower levels of education. Family location and Migration time in Changsha only associated with basic contraceptive services utilization among four BPHS. Compared to married female migrants who originated from a village, those from a county were 1.96 times more likely to have received basic contraceptive services (OR = 1.96; 95% CI = 1.12, 3.44). Married female migrants who had lived in Changsha for more than two years had received significantly more basic contraceptive services (OR = 2.24; 95% CI = 1.18, 4.26) than those who had lived there less time. Overall migration time only associated with health record establishment among four BPHS. Married female migrants with more than four years of migration in total were 47% less likely to have health record establishment (OR = 0.53; 95% CI = 0.31, 0.92). --- Discussion This study examined BPHS utilization rates among rural-to-urban, married female migrants and the associations between social support, discrimination, and sociodemographic factors and BPHS utilization. Results showed that for all BPHS, rural-to-urban married female migrants had the lowest rates for health education utilization and the highest rates for basic contraceptive utilization. However, these rates are still far from sufficient. For the second study aim, results support a strong relationship between higher perceived social support and utilization of all four BPHS. Rural-to-urban married female migrants who live with their families were more likely to utilize BPHS health care records establishment, health education, and cancer screening. Overall, rural-to-urban married migrant women have inadequate BPHS utilization according to our study. The establishment of health care records is still far lower than the 2014 National Health Commission goal of 70% [31]. Importantly, establishment of a health record is a basic service offered to all individuals and the required first step to receive other medical services, for example, chronic disease or cancer screening. If migrants seek help from CHC, they need to first establish a health care record, therefore, the low rate of health record establishment in our study indicates that married female rural-tourban migrants have low medical service utilization. After univariate regression, only seven factors demonstrated significance on the utilization of one or more BPHS. First, we found that married migrant women living with their families have significantly better BPHS utilization compared with those who live separately. The same pattern was also found for migrants in other countries. In a study of Latinos in the US, Mulvaney-Day [32] found that after controlling for demographic indicators, only family support had an association with self-rated physical health, while friend support and neighborhood social cohesion showed no significant relationship with self-rated physical health. In China, a study by Chen [33] found that migrating without a spouse had a negative effect on a migrant's health, and in another study in China, migrant women's separation from their children had a significant impact on their migration stress [34]. Therefore, it is essential for health care providers to focus on migrants who migrate alone, and relevant policy should encourage co-migration to maintain migrants' health. Second, previous studies have shown that social support has a positive effect on health for female migrants [35,36]. To our knowledge, there are no studies using scales to measure social support to explore the relationship between social support and BPHS utilization in China, however, studies have included proxies for social support including social participation. Hou's study in China [10] found that migrants who participated in social activities and organizations had higher rates of heath record establishment and health education than those who had not, which is consistent with our study's finding that social support had a positive relationship with married female migrants' health record establishment, health education, free contraception utilization, and cancer screening. Subjective social support and utilization of social support showed positive associations with three BPHS (but not health education), which indicates that married female migrants' perceived social support and use of social support impacted their BPHS utilization more compared to objective social support. Even if female migrants have a great deal of social support, without a perceived sense of support or engaging in social support, the women's BPHS utilization will remain inadequate. Therefore, health care providers should focus on organizing activities that can promote female migrants use of social support. Providers should also build trust with female migrants to enhance their sense of social support, especially for those who feel lonely. Finally, our study demonstrated that higher levels of education were associated with lower utilization rates of basic contraceptive services by married female migrants. It is important to note that in this study, BPHS were provided only by CHC, which is likely the result of the National Health Commission's goal of encouraging development of BPHS in these settings. However, previous studies examining BPHS utilization often focus on specific services like reproductive health services, which may also be provided in specialty hospitals and family planning service centers [16]. It is important to note that contraceptives may also be acquired in pharmacies without having to consult a health care provider. Therefore, the association between level of education and utilization of contraceptive services may be explained by the fact that migrants with higher levels of education may self-select out of the community health system in favor of more comprehensive care medical institutions like specialty hospitals. Finally, after multivariate regression, there was no significant relationship between education and cancer screening. In our study, perceived discrimination did not account for low BPHS utilization among rural-to-urban, married female migrants. There are no studies that have examined the relationship between perceived discrimination and BPHS in China, although studies conducted in the US have corroborated that perceived discrimination is negatively related to visits for management of chronic disease, but not for receiving cancer screening [37][38][39]. Our findings are consistent with this, since we found that screening for breast and cervical cancer were unrelated to whether married migrant women perceived institutional or interpersonal discrimination. This study demonstrated that effective interventions to promote health-seeking behaviors in rural-tourban, married female migrants in China. We found that enhancing utilization of social support is an essential factor in utilization of BPHS in China. This could be accomplished by encouraging female migrants to attend social activities with friends and family members in order to promote perceived social support. It would also be helpful to encourage female migrants, who are alone and new to a city, to attend activities and thereby build their social network to enhance perceived social support. Health care providers can also enhance their communication with female migrants by offering outreach services, for example, to further increase the women's perceived social support and, as a result, increase utilization of BPHS. Stakeholders should focus on female migrants who migrate from villages, travel far to their migration city, and are recent migrants to a city. It may be necessary for neighborhood committees and CHC from various jurisdiction to collaborate and share access and contact information with female migrants. This can be accomplished by having community neighborhood committees obtain the women's migration-related information through door-to-door visits and share this information with the CHC within the jurisdiction. If female migrants are going to migrant to other jurisdiction or cities, CHC could then forward the women's health information to the corresponding jurisdiction. Besides, health care providers can also increase the frequency of phone contact with female migrants to track their mobility and inform them about BPHS in CHC. In summary, as evidenced, health care providers are essential to both identifying migrants at risk for low utilization of BPHS and implementing programs that will increase use of BPHS. It will be important to plan future studies that examine the efficacy of such programs to improve our understanding regarding use of these vital resources. --- Strengths and limitations This study has several important strengths. First, to our knowledge, this is the first study to explore the relationship between multi-dimensional social support and BPHS utilization among migrants. Rural-to-urban married female migrants perceived social support and family support as essential to influencing their BPHS utilization. We incorporated the concept of social support in an empirical framework and assessed the relationship between social support and health care utilization. Second, this is the first study to examine the relationship between perceived discrimination and BPHS utilization among married female migrants. This study also has limitations. First, the sample was not selected from a city-wide random sample, which limits the generalizability and application of its findings. Future studies should include several geographic locations and samples sizes, as well as multiple work sites. Second, this cross-sectional study design limited our ability to find true causes of underutilization. Future studies should employ longitudinal designs to explore how the experience of social support, discrimination, and migration-related factors change over time and affect BPHS utilization. Third, recall bias is inherent in this study since the women had to recall previous BPHS utilization. --- Conclusion In our study, we found an overall low utilization rate for all four BPHS among rural-to-urban, married female migrants. Most importantly, were the low health record establishment rate (necessary for migrants to receive health care services in CHC) and low health education utilization rate (vital channel for migrants to gain access to the BPHS information and policies). Therefore, focused efforts should be made to improve this process of establishing care and receiving health education. Our study found that family support and perceived social support play an important part in rural-to-urban, female married migrants' use of BPHS. Education is not associated with major BPHS utilization, which means health care providers should focus on all migrants regardless their education level. Institutional discrimination has a negative association with BPHS use although, further study to explore the significance of their relationships among rural-to-urban, married female migrants is needed. Therefore, several suggestions have been made to target rural-to-urban, married female migrants according to four specific BPHS in order to improve utilization of BPHS in CHC. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research? Choose BMC and benefit from:? Choose BMC and benefit from: --- Abbreviations BPHS: Basic Public Health Services; CHC: Community Health Center; SSRS: Social Support Rate Scale; ORs: Odds ratios; CIs: 95% Confidence intervals. --- Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12905-021-01482-3. Additional file 1. The questionnaire of women's demographic and social structure information. Additional file 2. The questionnaire of BPHS utilization. --- Authors' contributions HX: conception, design, data collection, data analysis, drafting and revision. SM: consultation in design and drafting. TSY: conception, design and drafting. LLL: consultation in drafting and critical revision. All authors read and approved the final manuscript. --- Funding Financial support was provided by the Hunan Provincial Key Laboratory of Nursing Research Fund (2017TP1004) and Hunan Women Research Association (19YB01). --- Availability of data and materials The datasets analysed during the current study are available from the corresponding author on reasonable request. --- Declarations Ethics approval and consent to participate The institutional Review Board of Central South University reviewed and approved the study protocol (2017036). The ethics committee approved the procedure for verbal consent because the survey did not involve invasive questioning. Additionally, considering the educational level of some participants, written consent may have been difficult for them to complete. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Utilization of basic public health services (BPHS) allows for disease prevention and management and is an essential component for protecting health. Disparities in utilization exist between rural-to-urban migrants and their local counterparts in China. This study sought to determine the frequency of BPHS utilization and whether social support, discrimination, and sociodemographic features were risk factors for low BPHS utilization by Chinese female migrants. Methods: Data were derived from a survey of female rural-to-urban migrants at nine work sites in Changsha, China. The association between social support, discrimination, sociodemographic factors and BPHS utilization was obtained using Chi-square and logistic regression analysis. Results: Between December 2017 and April 2018, 307 female participants completed the survey. A total of 24.7% reported having had health education, 26.1% had breast and cervical cancer screening, 27.2% had established a health care record, and 40.9% had received basic contraceptive services. Two factors were associated with the reduced likelihood of BPHS utilization: Length of migration and health record establishment (OR = 0.53; 95% CI = 0.31, 0.92) and years of education and basic contraceptive service use (OR = 0.36; 95% CI = 0.20, 0.67). The remaining six factors were associated with an increased likelihood of BPHS utilization: Living circumstances and health record establishment (OR = 2.11; 95% CI = 1.17, 3.80), health education (OR = 2.71; 95% CI = 1.51, 4.87) and cancer screening (OR = 2.38; 95% CI = 1.30, 4.36). Utilization of social support was associated with health record establishment (OR = 1.24; 95% CI = 1.06, 1.44), basic contraceptive service use (OR = 1.21; 95% CI = 1.04, 1.42) and cancer screening (OR = 1.29; 95% CI = 1.10, 1.51). Objective social support was associated with health education utilization (OR = 1.15; 95% CI = 1.04, 1.26), while subjective social support was associated with basic contraceptive service use (OR = 1.11; 95% CI = 1.05, 1.18) and cancer screening (OR = 1.10; 95% CI = 1.02, 1.17). Family location was associated with basic contraceptive service use (OR = 1.96; 95% CI = 1.12, 3.44) and migration time in Changsha was associated with basic contraceptive service use (OR = 2.24; 95% CI = 1.18, 4.27).